Materials and finishes

Internal Ceiling Finishes in Healthcare Facilities

-  CONTEXT

1. Overview – finishes in the healthcare environment

Interior finishes play a vital role in a healthcare facility, as proper wall

treatments can contribute to the

creation and maintenance of a positive

therapeutic environment for patients

(Mayer, 2005)

Building finishes account for a large proportion of the overall cost of constructing a healthcare facility. According to Shohet et al. (2002),    interior finishing and interior construction account for 32% of the initial budget. Maintenance and cleaning of finishes add substantially to the ‘whole-life costs’ of finishes within a hospital or healthcare facility.  

Despite this, finishes are often treated as optional and purely aesthetic components of the building and the spaces within it. When budget constraints are implemented, the finishes are usually the first area to suffer. Institutions will often standardise finishes across a spectrum of rooms/facilities for economy in replacement and/or cleaning regimes.  

Interior finishes, however, play a vital role in the health care

environment, and contribute substantially to the delivery of healthcare service and the protection of staff and patients.  

In a study conducted by PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004, the comments from the majority of people who visited hospitals, including staff and patients, included “cold, depressing, dehumanising, Kafkaesque, dirty, smelly, frightening, impersonal, confusing, dull shabby, windowless, grim, stressful…” While the fact that most patients interviewed may have been negative as a result of their being ill, it does highlight a problem of the inhumane and threatening appearance of hospital environments “UNTIL THE GERM THEORY WAS DEVELOPED, (historically) where even more attention should be MORE MEN WERE DYING FROM SMALL paid to creating a caring atmosphere. WOUNDS AND DISEASES THAN FROM MAJOR

TRAUMAS ON THE FRONTLINES. BUT AS SOON It is this paradigm shift that is required when AS GERM THEORY WAS DEVELOPED A WHOLE considering and selecting finishes. The role of finishes NEW PARADIGM, A BETTER WAY OF in a healthcare facility has become as important an UNDERSTANDING WHAT WAS HAPPENING aspect of design as room sizes and relationships.  

Building finishes are usually seen as a separate and final application to the building structure (Dean, 1996). There are, however, instances where the finish is integral to the structure. These documents therefore include finishes and materials in such cases.  

2. Suite of documents

This document forms part of a series of documents addressing internal materials and finishes in health facilities, which in turn form part of the suite of documents created under the IUSS Project. The aim of the Materials and Finishes Suite of Documents is to provide guidance on design and specification for the various building components where current legislation, including the National Building Regulations does not adequately cover suitability of finishes in the healthcare facility context.

While the guidelines speak mostly of new building work, most of the principles are consistent with refurbishment projects to existing buildings as well.

 

Other IUSS HEALTH FACILITY GUIDES in this series include:

• Internal Floor Finishes (draft document rev 5)

• Internal Wall Finishes (draft document rev 4)

• Joinery and Storage Systems (to follow)

• Doors and Ironmongery (to follow)

• Sanitary Ware (to follow)

• Signage and Wayfinding (to follow)

These guidelines are updated and revised periodically, and can be accessed at www.iussonline.co.za

The primary objective of this technical guide is to assist decision-makers with the selection of ’appropriate’ ceiling finishes in the health facility context.  

The guide looks at the context (Part A), then examines various selection criteria (Part B), then summarises technical information of various ceiling finishes (Part C) to assist with assessing the best finish for the facility. Finally, the selection criteria are grouped together to form performance categories (Part D) and a matrix of rooms with the most relevant performance category is indicated.

3. Policy context

This document offers guidance on the selection of appropriate ceiling finishes in health facilities. While the aim is to inform project and design teams about the wide range of considerations to take into account when selecting finishes, it does not diminish the responsibility of the design team to comply with all applicable professional and regulatory obligations and to specify materials and finishes ‘fit for purpose’.

Some of the pertinent regulations are as follows:

• National Building Regulations and Building Standards ACT, 1977 (Act 103 of 1977) amended 30 May 2008

• SANS 10400, Code of Practice for the application of the National Building Regulations, first rev. August 1990

• R158, Government Notice dated Feb 1980 (updated March 1993) Regulation pertaining to control of Private Hospitals, (revised 05 November 1996, but not gazetted)

• R187, Regulations Governing Private Health Establishments, Western Cape, 22 June 2001

The design principles on the above documents must be taken into account alongside the recommendations of this document. For example: Clause 32 of the R158 states under general requirements in the OT Unit that the ceiling must be dustproof, of smooth impervious material, painted white or light-coloured suitable washable paint.  

Furthermore, the South African National Standards (SANS 10400) addresses numerous aspects involving materials and finishes. (Refer to, among others - Parts J, K, L and T in respect of moisture penetration, fixing

heights, structural stability and assembly.) Current South African National Standards applicable are as follows:

The Standard refers to the following definitions:

Other provincial policy documents are also applicable:

• KwaZulu-Natal, Department of Health Policy Document for the Design of Structural Installations, Rev.7, January 2013

• Eastern Cape Department of Roads and Public Works and Department of Health Hospital Design Guide, revised. August 2004

PART B -  SELECTION CRITERIA

1. Scope

in which the ceiling is finished will affect not only the acoustics, but also the aesthetics of a room. Certain materials also contribute to the thermal properties of a room.

Although ceilings are for the most part out of reach of hands and feet of everyday staff and patient traffic, and the microbial burden would seem to be somewhat reduced, airborne dust particles and fine moisture dispersal can still allow pathogens to gather on ceiling surfaces.  The ceiling can therefore have a role to play in infection prevention and control.

Ceilings are often the membrane onto which services such as lighting or air-conditioning, and a host of other fittings, are fixed, while obscuring unsightly services behind. These and other criteria will be discussed in more detail under Selection Criteria.  

Generally, the ceiling type falls into one of three types in terms of installation:

1. Actual Soffit of structure overhead – for example a concrete slab

While this type of installation will limit the flexibility of service outlets, it provides a solid structure where heavier fittings need to be attached to the ceiling. The finishes can range from off-shutter smooth concrete to plastered and painted surface treatment.

2. Membrane fixed directly to the structure overhead – for example a nail-up ceiling board

The compliance with SANS fire requirements for a noncombustible ceiling/roof structure will be paramount in determining what ceiling types (and subsequent structure) can be used here. There is the usefulness of the ceiling void above

in this type of installation, with more flexibility here for service outlets to be changed if the ceiling is skimmed and painted on completion. Certain nail-up ceilings also have thermal properties in themselves and would not require a separate application of insulation.  

3. Membrane suspended from the structure overhead allowing a ceiling void above – for example a suspended grid ceiling

The suspended ceiling, especially if consisting of modular tiles – available in varying types, allows the most flexibility for positioning lights, ventilation and other services. Replacement of damaged areas is simple and there is easy access to the services running in the void making this option a common choice.

Each type gives rise to different options in terms of finishes and materials and each has its place in healthcare facilities.  

2. Environmental aspects in the choice of finishes

A guide of finishes would be incomplete without highlighting the environmental aspects in the choice of finishes.  

This is an extremely broad factor covering:

• Embodied energy of materials

• Life cycle costing/sustainability

• Toxicity and effects of indoor environment quality

2.1. Embodied energy of materials

The term embodied energy refers to the total energy measure required to manufacture a product. This includes:

• Harvesting/mining of the raw material

• Processing the material

• Manufacturing the product

• Transport/delivery of the product to the manufacturing plant, retail outlets and finally the end user

• Labour or mechanical energy spent on placing the product in its finished position  

Buying locally-produced materials is an easy and achievable way to lower embodied energy of a building. The table below gives an indication of the embodied energy of various typical building materials.  

Embodied energy of common ceiling materials (finish and substrates

While health facility design may limit your selection of materials in terms of other performance factors, which are more critical, every opportunity to reduce the embodied energy of materials should be pursued. Manufacturers are increasingly aiming at reducing embodied energy, as well as the carbon footprint in the manufacture of their products.  

Life cycle costs are described as the social, economic and environmental costs of a material or product from cradle to grave – that is, from the

extraction of the raw ore needed to

make it, through the manufacturing, to the end use to disposal or

recycling. (Daniel D. Chiras. The

New Ecological Home, 2004)

This is driven by the market demand and designers can contribute by choosing materials that support green initiatives in this regard.  

3. Life cycle costing and sustainability

The durability of materials is a key element in the life cycle cost assessment. A product may have a low embodied energy, but requires more frequent replacement in the building.  

Specifiers should investigate the service life of materials with the respective manufacturers, to establish its life span. This element should also be highlighted to funders who often place more emphasis on reducing the capital cost of a facility, without considering the long-term cost.   

The graph below indicates how capital outlay costs compare to life span costs – emphasising

The Green Building Council of South Africa has developed Green Star TM rating tools which will credit materials with the following:

• Reuse of existing material

• Recycling properties

• Local sourcing

As a practical example, and to indicate the benefit of comparing life cycle costing, the table alongside shows the comparative life cycle costs of various floor finishes - in this instance demonstrating the low life cycle costs of a rubber product, even though the installation cost for this product was the highest at the outset.

3.1. Toxicity and effect on indoor environment

Indoor Environment Quality (IEQ) is one of the nine categories of the Green Building Council of South Africa’s Green Star TM Rating Tools. These rating tools are used to assess environmental performance of a building and/or materials and through improvement in IEQ, the wellbeing of the occupant is protected.  

VOCs can cause irritation and odour annoyance and could lead to behavioral,

neurotoxic, hemotoxic and genotoxic effects (Meininghaus et al., 2000;

Hoskins, 2003; Hodgson et al., 2000)

IEQ is measured in terms of:

• Internal noise levels (this is discussed in more detail under Selection Criteria: Acoustics)  

• Mould prevention (this is discussed in more detail under Section Criteria: Humidity)

• Volatile Organic Compounds (VOCs)

Materials such as paints and polyvinylchlorides can emit VOCs (gasses) when finishes are new and these reduce over the life span of the product. Sealants and adhesives also give off VOCs, having a negative effect on indoor air quality.  

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. When considering the toxic impact on the environment in which the various ceiling finishes will be installed, the finish as a whole - complete with painted or surface finish, substrate material and any adhesives used – must be taken into account.

A further important aspect to consider is the use of non-toxic materials in mental health facilities, where patients are prone to chew and ingest any materials that can be uplifted off surfaces, from paint to flooring, to ceiling panels where these are within reach.

Every effort must be made when specifying materials and finishes in these facilities to ensure that materials and their junctions are wellsecured and cannot be peeled back or picked off by patients. The toxicity of the material content should also be clarified with manufacturers to ensure that these materials are safe and fit for this purpose.

4. Evidence-based design  

Determining which criteria to apply when selecting finishes appropriate for health facilities could be very subjective. However, in recent years, there have been substantial advances made by various researchers in providing scientific evidence for the impact of the healthcare environment on healthcare outcomes. Many studies, such as Ulrich et al. (2008) demonstrated connections between the design of facilities and the effect on patients, staff and the public utilising healthcare buildings. This has led to a growing understanding of what are priorities in designing health facilities:

Extensive research by The Centre for Health Design (CHD) Research Coalition on Evidence-based Design literature led to the Evidence-based Design Glossary, (Phase 1 Report Healthcare Environmental Terms and Outcome Measures) November 2011.

Various unrelated research papers were gathered with interesting results. These included the following:

• Environmental factors influencing the contamination of inanimate surfaces (including interior finish materials of flooring and furniture as well as surface cleaning methods) Anderson, Mackle, Stoler and Mallison 1982, and Lankford, Collins, Youngberg, Rooney, Warren and Noskin 2006)

• Reducing background noise in operating theatres and the impact on surgical errors (Moorthy, Munz, Dosis, Bann and Darzi, 2003)

• Multiple environmental factors affecting patient fall rates (Calkins, Biddle and Biesan, 2011 and Becker et al., 2003)

• Patient satisfaction with quality of care when sound-reflecting ceiling tiles were replaced with sound-absorbing tiles to reduce noise (Hagerman and Colleagues, 2005)

• Positive visual distractions including windows, nature photographs, etc. and the effect on patients restless behaviour in waiting rooms (Nanda, 2010, Pati and Nanda, 2011)

• Nurses’ exposure to daylight correlating to job satisfaction (Alimoglu and Donmez, 2005)

• Noise as a source of stress and its negative impact on staff (Morrison, Haas, Shaffner, Garett and Fackler, 2003)

• Textile materials containing microbial agents (Takai et al., 2002)

• Aesthetic appeal and its effect on patient and staff satisfaction and patient waiting (Becker and Douglass, 2008)

Arising out of an overview of these studies, the following selection criteria have been identified:

• Infection prevention

• Cleaning and maintenance

• Safety

• Indoor air quality -  humidity

• Indoor air quality - emissions

• Acoustics

• Aesthetics

Although all these factors are important, the specific functions of each space or room will re-order the priority of fulfilling each aspect. To assist with establishing these priorities and assessing the effects of each criterion, these are examined in more detail in the next section.  

5. Selection criteria

5.1. Infection prevention

The South African Patients’ Rights Charter (1997) states: “Everyone has the right to a healthy and safe environment that will ensure their physical and mental health or well-being including … protection from all forms of environmental danger, such as pollution, ecological degradation or infection.”

According to a survey conducted by Rohde (2002), materials and finishes have in the past been selected according to the following characteristics in declining order of importance: Aesthetics, durability, ease of maintenance, client preference, initial cost, cost of maintenance, infection control, ease of installation and life cycle cost.

“Ideal features of surfaces that satisfy sustainability, infection prevention and safe patient outcomes include

cleanability, resistance to moisture and reducing the risk of fungal contamination.” (Bartley, 2010 based on

CDC and HICPAC Guidelines 2003)

The selection of a suspended ceiling must be approved by the infection control team so that it does not

become a microbiological hazard.

(Scottish R & D Project: B (04)02)

Selecting the correct finish is a complex process with many aspects to consider, and the many and varied room types in a health facility extend the options. However, in healthcare facilities, the importance of the effect of a particular finish on the prevention of infection control must be prioritised.  

While it is understood that not every area of a hospital or health facility

will carry infection prevention as the highest priority, this aspect remains the most pressing issue in selection of finishes in health facilities.  

The rising incidence of healthcare-associated infections (HAIs) in hospital and medical facilities supports the view that the selection of materials must first address infection prevention. This impacts the choice of materials in two aspects. The first is whether the surfaces are likely to become reservoirs for infectious agents. This is a function of the surface conditions and structure of the ceiling material. The second is the ability to clean the finish, and this is discussed further in the next section.

The Centre for Disease Control in the United States quoted statistics in 2010 of one out of every 20 hospitalised patients contracting HAIs, particularly in relation to sepsis and pneumonia.  

Although there is no known direct evidence linking HAIs in patients to particular finishes, there have been numerous studies conducted on microbial counts on floor finishes – particularly in soft textiles such as carpets. Beyer and Belsito (2000) proved that carpet acted as a reservoir for fungi and bacteria.

Anderson et al. (1982) also carried