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TB Services

2021-09-03T10:01:53Z

VSadiki: /* PART A - Policy and service context */

='''PART A -''' '''Policy and service context'''=

==Legislation, policies and international guidance==

===Infection Prevention and Control Legislation===

<div style="color:#00000a;">The National Infection Prevention and Control Policy and Strategy makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*<span style="color:#00000a;">Constitution</span><span style="color:#00000a;">'' of the Republic of South Africa, 1996''</span>. <span style="color:#00000a;">s.2,24,27,36&39.</span>
*<span style="color:#00000a;">''The National Health Act 2003''</span>. <span style="color:#00000a;">(c.61). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''The Occupational Health and Safety Act 1993''</span>. <span style="color:#00000a;">s.8(1).</span> <span style="color:#00000a;">Cape Town South Africa: Government Gazette.</span>

Department of Labour, 2001. <span style="color:#00000a;">''Regulations for hazardous biological agents''</span>. (Government notice No. R. 1390 of the Occupational Health and Safety Act, 1993. s.43). Pretoria South Africa: Government Gazette

Department of Health, 2003. <span style="color:#00000a;">''Regulations relating to the application of the hazard analysis and critical control point system (HACCP system). ''</span><span style="color:#00000a;">(Government notice No. R. 908 of the Foodstuffs, Cosmetics and Disinfectant Act, 1972. (c.54)). Cape Town South Africa: Government Gazette.</span>

*<span style="color:#00000a;">''The Environmental Conservation Act 1989''</span>. <span style="color:#00000a;">(c.73). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''The Foodstuffs, Cosmetic and Disinfectants Act 1972.''</span> <span style="color:#00000a;">(c.45). Cape Town South Africa: Government Gazette.</span>Building legislation
</div><div style="color:#00000a;">The following legislation and regulations impact and provide guidance on the provision and design of healthcare facilities as above:

*<span style="color:#00000a;">''The Pharmacy Act 53 of 1974.''</span> <span style="color:#00000a;">(c.53). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''The National Environmental Management Act 1998.''</span> <span style="color:#00000a;">(c.107).</span> <span style="color:#00000a;">Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''Building Regulations and Building Standards Act 1977.''</span> <span style="color:#00000a;">(c.103). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">South African Bureau of Standards (SABS), 1990.</span> <span style="color:#00000a;">''SANS 10400:1990 Code of practice for the application of the national building regulations.''</span><span style="color:#00000a;">Pretoria South Africa: SABS Standards Division.</span>
*<span style="color:#00000a;">''Promotion of Equality and Prevention of Unfair Discrimination Act 2000.''</span> <span style="color:#00000a;">(c.4). Cape Town South Africa: Government Gazette.</span>
</div>
===Infection prevention and control and TB management policy and guidelines===

*<span style="color:#00000a;">National</span><span style="color:#00000a;"> Department of Health (NDoH), 2007.</span> <span style="color:#00000a;">''The draft national infection prevention and control policy for TB, MDRTB and XDRTB.''</span> <span style="color:#00000a;">South Africa: NDoH.</span>

National Department of Health, 2007. <span style="color:#00000a;">''Management of drug-resistant tuberculosis: Policy guidelines''</span>. [pdf] South Africa: NDoH. Available at: http://www.search.gov.za [Accessed 26 March 2014].<div style="color:#00000a;">National Department of Health, n.d. <span style="color:#00000a;">''Tuberculosis strategic plan for South Africa, 2007-2011.''</span> [pdf] South Africa: NDoH. Available at: http://www.search.gov.za/info/search.jsp. [Accessed 26 March 2014].

===South African building practice policy and guidelines===

*The South African Pharmacy Council, 2004. ''Good pharmacy practice. ''(Board notice 129). Cape Town South Africa: Government Gazette.
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===International design guidance===
South Africa faces one of the most devastating TB epidemics in the world. TB – with TB/HIV/Aids – is the leading cause of death

*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 1999.</span> <span style="color:#00000a;">''ANSI/ASHRAE standard 52.2-1999 Method of testing general ventilation air cleaning devices for removal efficiency by particle size.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>
*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 1989.</span> <span style="color:#00000a;">''ASHRAE standard 62 Ventilation for acceptable indoor air quality.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>
*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2003.</span> <span style="color:#00000a;">''HVAC design manual for hospitals and clinics.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>

Chartered Institution of Building Services Engineers (CIBSE), 1997. <span style="color:#00000a;">''CIBSE applications manual AM10 natural ventilation in non-domestic buildings.''</span> London: CIBSE.<div style="color:#00000a;">Chartered Institution of Building Services Engineers (CIBSE), 2000. <span style="color:#00000a;">''CIBSE applications manual AM13 mixed mode ventilation.''</span> <span style="color:#00000a;">London: CIBSE.</span></div><span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE),</span>

*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009</span>. <span style="color:#00000a;">''ANSI/ASHRAE/ASHE standard 170-2008 ventilation of health care facilities.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>
*QASA, “Know Your Rights” [Accessibility & the Built Environment]
*<span style="color:#00000a;">Department of Health and Human Services (Centre for Disease Control and Prevention), 2003.</span> <span style="color:#00000a;">''Environmental control for tuberculosis: Basic upper-room ultraviolet germicidal irradiation guidelines for healthcare setting. ''</span><span style="color:#00000a;">USA: DHHS.</span>
*<span style="color:#00000a;">World Health Organisation (WHO), 2009a.</span> <span style="color:#00000a;">''Natural ventilation for infection control in health-care settings.''</span> <span style="color:#00000a;">Geneva Switzerland: WHO</span>
*<span style="color:#00000a;">World Health Organisation (WHO), 2009b.</span> <span style="color:#00000a;">''WHO policy on TB infection control in health-care facilities, congregate settings and households''</span>. <span style="color:#00000a;">Geneva Switzerland: WHO</span>

==Service context==

<div style="color:#00000a;">South Africa faces one of the most devastating ''Mycobacterium ''tuberculosis (TB) epidemics in the world, especially in terms of number of TB cases per capita and the total numbers of drug-resistant (DR) TB cases with a prevalence of 450/100 000. It has the third-highest incidence of TB globally (WHO, 2013, p.11). TB, together with HIV/Aids, is South Africa’s leading cause of morbidity and mortality. Furthermore, healthcare workers are at six or more times increased risk of acquiring TB, compared to the background population (Joshi, et al., 2006).
The WHO reports that TB treatment success is low and treatment default rates and mortality are high. The high default from TB treatment by patients represents a major problem which, in conjunction with other factors, has led to the emergence of drug-resistant TB (DR TB). Transmission of TB, multi-drug-resistant TB (MDR TB) and extreme (or extensively) drug-resistant TB (XDR TB) in communities and congregate settings has been documented in several studies, frequently linked to HIV infection and affecting vulnerable groups such as children. MDR and XDR TB linked with HIV therefore have the potential to result in an uncontrollable epidemic with devastating economic and social consequences. The epidemiological burden co-infection in South Africa is currently estimated to be in excess of 70% of TB and HIV (WHO, 2009b).<sup> </sup>Provision of poorly designed, maintained and operated infrastructure can exacerbate transmission. Well-designed and well-maintained facilities can reduce the risk of TB infection.

''M. tuberculosis'' is an infectious disease, and is transmitted from person to person exclusively by the airborne route, usually through coughing by a patient with active pulmonary TB. MDR TB is a consequence of human error resulting from combinations of the management of drug supply, patient management, chemotherapy prescription and patient adherence. Treating MDR TB takes longer and requires drugs that are more toxic, more expensive (up to 100 times the cost of treating a drug-susceptible TB patient) and generally less effective, particularly in persons with HIV infection.

The problem of drug resistance in TB has been compounded by the emergence of XDR TB. Patients with XDR TB are extremely difficult and expensive to treat, with mortality rates between 50 and 70% (CDC, undated).<sup> </sup>In XDR TB patients with HIV co-infection, mortality rates, though improving, remain at about 90% (Neel, et al., 2010).

Owing to the District Health system, patients are intended to, and generally do, enter the healthcare system via primary healthcare services - namely the clinics and community health centres (CHCs) and private general practitioners (GPs). It is in these settings that untreated, undiagnosed infectious individuals will inevitably come into contact with susceptible individuals and the risk of transmission is produced. With the introduction of the NHI, the profile of risk in former “private” facilities may change as demographic shifts in access to these services occur. It is therefore in the interest of public health that private-sector facilities are designed, constructed and operated to meet airborne infection control requirements.

The National Department of Health (NDoH) Primary Healthcare Directorate advocates the WHO-endorsed approach in the public sector to integrated service provision (WHO, 2011). In the context of this document, this means that individuals seeking care are to receive all appropriate services and interventions at a “one-stop shop”. The common practice of provision of service by diagnosis within a facility (e.g. separation of TB, HIV/Aids, diabetes) or by vertical programmes (different clinical activities on different days) does not support integration of services. This implies that, as far as it is safe and reasonable, most services should be available in most patient/client contact spaces. The integration of services should not subject healthcare workers, clients or the public to undue exposure to airborne pathogens. In particular, when reconfiguring services in existing facilities, due diligence must be paid in ensuring that designs meet required standards for TB infection control.

Most TB patients will access services at the primary healthcare level and will require access on site to '''integrated''' services including, but not limited to:

*clinical assessment (consulting room with examination facilities, clinical scale);
*safe facilities for sample (sputum) collection;
*nutrition;
*psychosocial services (counselling); and
*pharmacy dispensary for chronic medication.
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In addition, on- or off-site access to the following services is required

*laboratory services (microscopy, culture, GeneXpert, for drug sensitivity), and
*radiology.

For a quick reference to primary healthcare services for uncomplicated building projects consult [https://iussonline.co.za/norms-standards/clinical-services/ IUSS:GNS Primary Healthcare].<div style="color:#00000a;">The majority of TB patients will be able to be treated in outpatient mode, with community-based adherence support and regular check-ups at the facility, and regular collection of chronic medication. A small number of patients, such as those who are severely ill, have more than one health concern (co-morbidity), or who are highly infectious may be admitted voluntarily to inpatient care in healthcare facilities. This may be within the general hospital population, in dedicated TB wards or in specialised dedicated facilities.
Evidence suggests that drug-susceptible TB and MDR TB, when diagnosed and under treatment, become rapidly less infectious (Dharmadhikari, forthcoming). This means that, after as little as 24 hours on '''appropriate''' treatment, TB patients - and even MDR patients - can be regarded as and accommodated with the non-infectious population. No special facilities are required for these patients (if they are short-term patients) and they can be accommodated in accordance with IUSS norms and standards (Refer to [https://iussonline.co.za/norms-standards/clinical-services/ IUSS:GNS Adult inpatient services]).

Patients recently enrolled on treatment (<24hours) who are suspected of having XDR, confirmed XDR patients, patients who interrupt treatment, and complicated cases may be considered infectious and negative-pressure isolation is strongly recommended - or, if not possible, at least patient management by respiratory isolation or, if that is not possible, by patient cohorting (patient management by clustering patients with most similar diagnoses).

The number of DR TB cases in South Africa increased from 10 085 in 2011 to 15 419 in 2012 (WHO, 2013, p.52). This is largely due to intensified case finding and investment in laboratory services. However, it represents only a portion of the estimated cases (WHO, 2013).

Since 2010 the SA National Department of Health has adopted a policy of decentralised management of Multi Drug-resistant TB. In addition to outpatient services, there is a requirement for inpatient hospital facilities:

*for all types of TB patients (pulmonary, extra-pulmonary, etc.) requiring acute treatment for TB or other comorbidities
**within patient populations of general hospitals,
**In dedicated wards at general hospitals for acute episodes, and
**at specialised hospitals (long-term accommodation) for sub-acute and palliative care for patients who are not best served by community-based care, for various reasons.
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Inpatient beds for TB services have frequently been provided by converting old wards and sanatoria as a quick solution to address at least part of the pressing need. In many instances building infrastructure has been modified or retrofitted with the intention of making it suitable. However, because beds are provided in this reactive way, the infrastructure is frequently poorly aligned with current best infection-prevention and ‑control practice and patient-centred care.<div style="color:#00000a;">South African healthcare workers are increasingly becoming aware of the need to implement and manage infection-control measures for preventing the spread of infectious diseases in healthcare settings; however, due to lack of resources, inadequate facility design and the lack of environmental controls, the means for achieving adequate infection-prevention and -control are not always found.
There have been both legal and ethical challenges posed to TB hospitalisation (Singh, Upshur and Padayatchi, 2007; London, 2009). Media have reported incidents of patients rioting and absconding (Dugger)<sup> </sup>which attested to the unpopularity of the policy and the unsuitability of the arrangements, including - though by no means limited to – the building infrastructure provided.

The NDoH has subsequently recognised the need to provide recreational, occupational and educational facilities for patients that require specialised long-term DR TB treatment (NDoH, 2007b, p.25). Social support should also be provided for all patients and their families whilst hospitalised. In the past TB facilities were simply not designed or built to address these needs. This must be recognised when assessing precedent or in identifying case study examples [[File:Centralised management of MDR TB.jpg|none|thumb|555x555px|Figure 1: Centralised management of MDR TB]]Consequently the National Department of Health expanded its approach in adopting a multi-faceted decentralisation policy in future according to the following health framework for DR TB management (see ''Decentralised Management of Multi Drug Resistant TB – a Policy Framework for South Africa''). According to this framework (see Figure 3), for a successful decentralised MDR TB programme, the following should be provided in inpatient care facilities in order to ensure adequate infrastructure and infection control measures:

*Well ventilated consulting room
*Well ventilated waiting area
*Well ventilated rooms that can accommodate from one to six patients
*Distance between beds not less than 1.2 m
*Administration control measures of infection control in place
*UVGI lights and extractors fans where possible
*Respiratory protection tools available: surgical masks, N95 respirators

These policy requirements will go some way to addressing the twin objectives of patient-centred care and effective infection prevention and control in the emerging pandemic. However, there are additional planning, design, management and maintenance considerations to reach best practice standards and these are discussed in detail below.
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='''Understanding transmission to manage risk'''=

==Transmission of M. Tuberculosis==

<div style="color:#00000a;">In healthcare settings, physicians, nurses, general hospital staff, fellow patients and visitors are at a high risk for TB infection because they share the same breathing space as infectious patients: the transmission of TB disease is through the airborne route. Varicella-zoster virus, measles virus, and smallpox virus can also be transmitted by the airborne route, and mitigated with the means described in this document, but do not currently pose a comparable public health concern.
When the droplets produced by an infected person are inhaled by a susceptible person, TB may be contracted. However, this alone does not seem to account for observable instances of transmission. There is a widely accepted theory - the droplet-nucleus hypothesis - that infectious droplet nuclei containing tubercle bacilli may remain suspended in air for prolonged periods of time, potentially long after the infector has left the room. This leads to a high risk of infection in congregate settings (shared spaces). This risk cannot be eliminated. However, expert consensus is that with adequate ventilation or air purification the risk can be reduced. Here is a brief explanation for the transmission theory<sup> </sup>(Riley and O’Grady, 1961).

The bacterium, ''M. tuberculosis'', becomes aerosolised in small droplets of water or bodily fluid when a person with the disease of the lung coughs, sneezes, laughs or sings. Many of the smallest respiratory droplets dry into “droplet nuclei” and become airborne following room air currents is described. Infection can occur when the droplet nuclei containing the bacterium are inhaled [[File:Coughing generating aerosols.jpg|none|thumb|222x222px|Figure 2: Coughing generating aerosols - Source Jennison 1942]]''M. tuberculosis'' infection is different from TB disease. People having the infection without disease (latent TB) have been infected by the ''M. tuberculosis'' bacterium. They are not symptomatic because their body’s immune system has encapsulated the infectious material in the lung, where it is held dormant. They cannot spread the bacterium or disease to others when in this phase. However, people with infection may reactivate a dormant focus in the future, leading to disease.
</div>The infection turns to disease when the body can no longer contain the infectious material in the lung. The infection then spreads, usually within the lung (where it is called pulmonary TB) and possibly to other areas of the body. This spread usually shows up as chronic respiratory symptoms such as cough and fever. People with TB disease of the lungs can therefore transmit the infectious bacterium.

===Disease status===
<div style="color:#00000a;">TB patient status could at any point:

*be actively diseased and infectious;
*be simultaneously infected by more than one strain;
*be diseased and undergoing treatment;
*be recovered after undergoing therapy;
*be developing resistance while undergoing therapy;
*have latent disease;
*have relapsed into disease;
*be re-infected;
*be immune; or
*have additional related/ unrelated medical conditions (co-morbidity)</div>
Determining the current status of any given patient or transition times between statuses is problematic (given lags in diagnosis, individual patient responses etc.).

Table 1: Drug resistance TB (CDC, 2010, slide number 28)
{| style="border-spacing:0;width:14.87cm;"
|-
| style="background-color:#009999;border-top:1.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Mono-resistant'''
| style="border-top:1.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to any one TB treatment drug
|-
| style="background-color:#009999;border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Poly-resistant'''
| style="border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to at least any 2 TB drugs (but not both isoniazid and rifampin)
|-
| style="background-color:#009999;border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Multidrug-resistant '''

'''(MDR TB)'''
| style="border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to at least isoniazid and rifampin, the 2 best first-line TB treatment drugs
|-
| style="background-color:#009999;border-top:0.5pt solid #000001;border-bottom:1.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Extensively'''

'''drug-resistant '''

'''(XDR TB)'''
| style="border-top:0.5pt solid #000001;border-bottom:1.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to isoniazid and rifampin, PLUS resistant to any fluoroquinolone AND at least 1 of the 3 injectable second-line drugs (e.g., amikacin, kanamycin, or capreomycin)
|-
|}
===Manifestations of TB===

<div style="color:#00000a;">TB is an infection caused by ''Mycobacterium tuberculosis'' also referred to as tubercle bacilli. TB most commonly affects the lungs, producing pulmonary TB. It can however spread to almost any part of the body including lymph glands, joints, kidneys and bone called extra-pulmonary TB. Pulmonary TB is the manifestation of most concern to built environment professionals as it produces greatest risk for transmission to others.</div>

====Drug-susceptible TB====

<div style="color:#00000a;">By far the majority of TB cases are susceptible to widely accessible, inexpensive drugs. It is generally curable if treatment is completed.</div>

====Pre-MDR TB====

Drug resistance [see Table 1: Drug resistance TB (CDC, 2010, slide number 28)] can only be defined through laboratory confirmation of in-vitro resistance to one or more anti-TB drugs. Results are defined as follows:

*Mono-resistant TB: in patients whose infection isolates of M. tuberculosis are confirmed to be resistant to one first line anti-TB drug.
*Poly-resistant TB: TB in patients whose infection isolates are resistant in vitro to more than one first line drug, other than isoniazid and rifampicin.

====MDR TB====

<div style="color:#00000a;">MDR TB is active TB involving ''M. tuberculosis'' organisms that are resistant to at least isoniazid and rifampicin, the two most powerful anti-TB agents. An MDR TB strain can be resistant to more than these two antibiotics and in most cases it is resistant to first line drugs. </div>

====Pre-XDR TB====

<div style="color:#00000a;">Pre-XDR TB is MDR TB which is resistant to either a fluoroquinolone or an injectable, but not both. </div>

====XDR TB====

<div style="color:#00000a;">XDR TB is defined as TB with resistance to isoniazid and rifampicin, and - in addition to any fluoroquinolone, - to at least one of the three following injectable drugs used in anti-TB treatment: capromycin, kanamicyin and amikacin. Unlike TB and MDR TB patients, XDR TB patients are infectious even when on treatment and their drug-resistant strain can be transmitted directly to susceptible individuals. In other words, infection with a drug-resistant (including an XDR) strain of TB is possible without having contracted TB previously. </div>

====Paediatric patients====

<div style="color:#00000a;">Children can contract any of the strains that adults can and manifest TB in all forms that adults present. There is consensus that whilst small children may have less lung capacity to develop velocities required for aerosolisation this has not been proven and is not universally true. Older, larger children are more likely to have transmission patterns like adults. </div>

===Origin of airborne infection===
<div style="color:#00000a;">Organism-bearing particles are liberated into the air primarily from activities involving the respiratory tract such as sneezing and coughing. In quiet breathing, very few organisms are liberated, but in talking, coughing and especially in sneezing, large numbers of droplets, many of which contain organisms, are ejected. The high velocity of air passing over the respiratory tract shears off a profusion of small droplets which are forcibly ejected into the air.
The size of the droplets swept by an air current from the surface of a liquid is determined principally by the velocity of the air and the surface tension of the liquid. As the air velocity increases, the size of the droplets decreases until above 100 m/s where the diameter of the water droplets approaches at least 10 microns (μm). In sneezing and coughing, the peak air flow in the bronchi approaches 300 m/s and the droplets are in the order of six μm in diameter.

After being expelled from the TB patient’s mouth and nose, even the smallest droplets begin to fall. Generally, the large particle droplets fall to the ground where they become mixed with dust (see Figure 11). The fate of the smaller droplets is however, quite different. Droplets below a certain aerodynamic diameter fall slowly and lose water rapidly and evaporate almost instantaneously. In this way the droplet diminishes in size until the concentration of dissolved substances is such that the vapour pressure which the droplet exerts equals that of the atmosphere.

The residue of the droplet after evaporation, which may contain the micro-organism(s) from the respiratory tract, has been called the droplet nucleus. Droplet nuclei are so light that they may not settle in the gentlest of moving air of occupied spaces and may remain suspended for extended periods of time. This poses risk to building occupants until the particles are removed by ventilation or through other air disinfection.

Tubercle bacilli cannot be cultured from the air because of their low concentration and slow growth rate relative to other micro-organisms. The slow growth of tubercle bacilli and low concentrations in air require long sampling periods during which culture media, even with selective antibiotics to suppress microbial growth, become overgrown with fungi and other bacteria. Molecular amplification methods can detect nucleic acid from tubercle bacilli in the air, but cannot distinguish living from dead organisms nor quantify those with infectious potential. It is therefore not possible to measure infectiousness of TB or DR TB directly, nor can the efficacy of environmental infection control interventions to reduce or prevent transmission be measured directly.

Also, when considering airborne contagion, it is not well understood is how many infectious particles, or droplet nuclei, are required to infect. Compounding this uncertainty there are marked differences in the numbers of organisms liberated by coughing and sneezing of individual infectors. Despite these limiting factors, which are the subject of on-going speculation, investigation and scientific research, the general principles of contagious potential applies.

In any form of contagion the probability of infection increases with the degree of exposure to the infection (see Figure 3: Contagion). The factors implicated in the potential to be contagious are:

*the presence of susceptible members of the community
*the presence of infectious cases
*the effective contact rate (opportunities for transmission) influenced by variables which in the airborne example are factors such as:
**exposure time
**breathing rates of infector and susceptible
**virulence (strength) of bacteria
**environment (qualities of the room, such as humidity, air volume)
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[[File:Contagion.png|none|thumb|439x439px|Figure 3: Contagion]]
The probability of infection (1- e -Iqpt/Q) as a function of degree of exposure to infection Iqpt/Q (The point where Iqpt/Q =1 is identified by the co-ordinates).<div style="color:#00000a;">
The number of new cases occurring in an epidemic is directly related to the number of susceptible persons, the number of infectors and the effective contact rate. Respiratory droplets (for example flu), with their limited flight, range and dependence on the simultaneous presence of source and subject, behave as a form of effective contact. Droplet nuclei, with their prolonged suspension and rapid dispersion may provide an enhanced exposure and effective contact rate. It was for this reason that Wells called droplet-nucleus-borne infection, airborne contagion.

DR TB can be acquired in two different ways: primary and secondary modes. Primary transmission is caused by person-to-person transmission of a drug-resistant strain of the TB bacilli. Secondary infection develops during TB treatment, either because the patient was not treated with the appropriate treatment regimen or because the patient did not follow the treatment regimen as prescribed. Approximately 1.8% of new TB and 6.7% of retreatment cases results in MDR. DR TB can be transmitted in the same way as drug-susceptible TB.

Evidence suggests virulence of DR TB is the same as for drug-susceptible strains. However, DR TB is more difficult to treat because it can survive in a patient’s body even after treatment with the first-line drugs is started. A key challenge with current tuberculosis diagnosis technique is the delay in culturing this slow-growing organism in the laboratory. Blood or sputum culture results can take between four and twelve weeks. Because there has historically been a delay in diagnosing drug-resistant TB, these patients may be infectious for a longer period of time. Rapid screening tools for drug-resistance (GeneXpert) have been approved by the WHO, and are now in widespread use in South Africa.

The infectious droplet-nuclei which may remain suspended in air for prolonged periods of time and the respiratory droplets leads to a high risk of infection in shared spaces. This risk cannot be eliminated. However, expert consensus, based on strong circumstantial evidence, is that with adequate planning, design, management and maintenance, this risk can be reduced or managed. International best practice indicates that patients with drug-resistant TB should be closely monitored when commencing treatment and they should remain in isolation until they are no longer infectious.
</div>

The following invasive procedures should be regarded as high risk situations for transmission (Culver, Gordon and Mehta, 2003):

*bronchoscopy,

*sputum collection and induction, and
*administration of aerosolized medications

===Infection prevention and control hierarchy===

<div style="color:#00000a;">The emergence of DR TB has highlighted the need for strengthened infection prevention and control (IPC) measures to interrupt the transmission of TB in healthcare settings. There is has been no observed difference between the speed of transmission of susceptible TB and resistant MDR or XDR TB. For this reason, infection control measures apply to all TB strains irrespective of the resistant pattern.
The requirement for controls to minimise the risk of spreading this airborne disease is legislated in the ''OHS Act'' (Act 85 of 1993). ''The National Department of Health Tuberculosis Strategic Plan for South Africa, 2007-2011'', in the ''Decentralised Management of Multi Drug Resistant TB – a Policy Framework for South Africa'' and various international agencies such as the WHO, Centers for Disease Control and Prevention in the USA provide policy guidance for infection control practices. Common to the last two is the need to base these practices on the hierarchy of control measures. These are arranged from most to least important as follows:

Administrative measures such as work practices, policies and procedures, education and training, TB screening of healthcare workers, and appropriate utilisation of existing facilities, the implementation of environmental (engineering) controls, and the use of personal respiratory protection in specified areas where there is a high risk of exposure.
</div>

===Administrative IPC measures===
<div style="color:#00000a;">Appropriate architectural design to support the functional and operational processes required for the first level of the hierarchy of control, namely the administrative measures, must be investigated and ensured via the design and layout of the facility as a priority. The first and most important level of control is the use of administrative control measures is to prevent conditions for the spread of contagion, by limiting number and duration of encounters between susceptible members of the community and infectious air. Ideally, if the risk of exposure can be eliminated, no further controls are needed. Unfortunately, the risk usually cannot be eliminated, but it can be significantly reduced with proper administrative control measures. In any healthcare setting, important administrative control measures include:

*early diagnosis of potentially infectious TB patients,

*prompt separation or isolation of infectious TB patients, and
*the prompt initiation of appropriate anti-tuberculosis treatment.</div>
Other important administrative control measures include an assessment of the risk of transmission in the facility, the development of a TB infection control plan that details in writing the measures that should be taken in a given facility, and adequate training of healthcare workers to implement the plan.
[[File:CSIR generic model illustrating the functional separation.png|none|thumb|489x489px|Figure 4: CSIR generic model illustrating functional separation]]
From a facility planning and design perspective, administrative control measures can be addressed through the spatial separation techniques of functional separation, respiratory isolation, and separation for patient management. Functional separation (see Figure 4) provides for the physical separation of functionally discrete parts of the facility. Administrative functions and clinical support (admissions and discharge, accounts and finance, information services, medical records) should be substantially or exclusively reserved for staff use, and zoned separately. Nursing services, outpatient facilities, allied health services (radiology, pharmacy, rehabilitation) and visitors’ spaces may be used by both patients, staff and visitors, but should be laid out and managed so that the appropriate infection control measures are ensured. Finally patient support facilities, recreation facilities, and patient wards should be accessible to patients, but not necessarily all patients at all times, because of risk of cross-infection.<div style="color:#00000a;">
The following situations and design features have been identified as presenting the potential for increased risk of TB transmission in healthcare settings, so that when allocations of spaces are made in existing infrastructure systems the following should be borne in mind:

*Congregate settings - any setting (usually waiting areas) where large groups of patients are kept in close proximity to each other are potentially high risk areas. The highest risks are usually in admission, main outpatient, emergency or pharmacy waiting areas where undiagnosed or untreated patients congregate. Smaller waiting areas or other functional areas, such as in x-ray departments or even multi-bed patient rooms can equally pose a risk.

*Restricted / inadequate ventilation - appropriate ventilation is important, especially in congregate settings or other direct contact areas, such as dining facilities, occupational therapy areas etc. Waiting areas need to be adequately ventilated at all times in order to dilute concentrations of infectious airborne bacteria. Areas such as consulting, examination, counselling or treatment areas where staff spend long times in relatively small areas in close proximity to patients should be considered high risk areas. Minimum opening window areas are prescribed but often not complied with. The WHO guidelines (WHO, 2009a) indicate a target of 20% open window area to space floor area. The design of the window is also important to promote natural ventilation. However improved ventilation alone is usually not enough to reduce risk in that the directional flow of air to and from adjacent areas needs to be addressed.
*Shape and volume - the shape and volume of a space can also be a risk indicator. Occupied spaces with minimal floor to ceiling height (often found in multi-storey buildings) are generally higher risk areas than those with a shaped ceiling to high level clear storey windows. Shape and volume usually is linked to ventilation flow patterns and rates. The position and ease of opening of both high and low level windows is important. Staff awareness of the need to keep windows open to allow unobstructed ventilation is needed. “Open window” stickers are frequently used to provide visible reminders of open window policy.
*Adjacency - the distance between carriers and staff or other patients is a risk factor. Congregate areas where patients are sitting close together is an obvious situation and settings where close contact occurs such as during consultation, examination and treatment are risk situations. Narrow bed spacing (less than 1.2 m) presents risk for both fine droplet and droplet nuclei contamination. Multi-bed wards configurations are risk situations.
*Places where aerosol-generating procedures are undertaken- These are defined as high-risk procedures that may increase the potential of generating droplet nuclei because of the mechanical force of the procedure (e.g. intubation, cardiopulmonary resuscitation, bronchoscopy, autopsy, and surgery where high-speed devices are used) (WHO, 2007)</div>
Total respiratory isolation for TB treatment would be ideal from an infection prevention and control point of view. Several factors make this both impractical and undesirable. First there are negative social and psychological impacts to strict separation including isolation and stigmatisation of patients. Second, nursing requirements, acuity and management dictate that patients must be visible to healthcare workers and accessible to them.<div style="color:#00000a;">Whilst provision of single bed wards is advisable as far as possible, shared spaces for joint activities are required. Estate legacy constraints (the size and shape of existing rooms), affordability (single-bed wards require a higher capital investment, higher operational and maintenance costs) and nursing acuity constraints (compact configurations allow for improved nursing efficiency) mean that single-bed configurations are not always possible, and it therefore is common practice at facilities in South Africa to provide rooms with two, four, six or more patients.
TB facilities generally experience highly fluctuating patient demographics and needs. Given resource constraints and high demand, it is frequently useful to provide configurations which allow for flexible arrangements which can be administered according to prevailing needs.
</div>

Management of patients may require spatial and/ or physical separation in accordance with facility policy:

*according to gender
*ostensibly drug susceptible TB – retreatment (treatment failure)
*Mono-resistant TB (suspected-MDR)
*Poly-resistant TB (suspected-MDR)
*MDR TB
*MDR treatment failure
*Pre XDR TB
*XDR TB
*XDR treatment failure
*First sputum culture negative result, pending second result (suspected cured)
*children (with or without boarding parents)
*patients requiring isolation ( for additional infectious diseases, psychological disturbance, prisoners)

Occasionally facility policy may allow for or require additional accommodation for outpatients, visitors or patients awaiting transfer. This may be applicable to specialised facilities (Centres of Excellence), where family and patients are likely to travel great distances but will not be applicable to Satellite Facilities on the decentralised scheme.<div style="color:#00000a;">Separation of each of the cohorts described above, especially at long-term care facilities is highly desirable. Generally, at a minimum, separation of gender, paediatrics and XDR patients is required. It is highly preferable to have some accommodation for patients requiring isolation and patients with first culture negative result (suspected cured). Further refinement will be dependent on individual facility policy, size of facility (larger facilities being more complex in nature) and whether it is primarily aimed at acute or sub-acute care.
Administrative control measures must also ensure optimal operation of environmental control measures (see below). This may include assignment of a person to oversee environmental controls, to open and close windows as appropriate, change filters, test environmental control measures periodically, clean UVGI lamps if installed, perform preventative maintenance measures, etc. Whatever environmental control measures are in place, their adequate operation and maintenance should be included in the administrative control measures through the TB Infection Control Plan and their operational parameters and proper function should be evaluated regularly.
</div>

===Environmental IPC measures===
<div style="color:#00000a;">Environmental IPC protection methods should be the second- most prioritised approach, after administrative IPC measures and before personal protection measures (which should be used as measure of last resort). Two broad environmental strategies can be identified: dilution, which results in the reduction in concentration of contaminated particles in a volume of air and disinfection, which is the partial or complete destruction (sterilisation) of micro-organisms in air. Disinfection substances/ processes may be harmful to humans.
Dilution is most easily achieved through maximising air volume through design of large spaces and addressing ventilation, in particular the introduction of “fresh” air from a “safe” source (preferably outdoor air) to continually replenish indoor air as it is exposed to infected persons.

The removal of contaminated air by dilution alone requires extremely large per-occupant ventilation rates to minimise risk. Acceptable levels of room airborne contaminant removal in most South African healthcare facilities cannot be sustainably accomplished by artificial ventilation alone. Its application is limited by engineering constraints and by cost. The professional consultant team is to consider the strategy to ventilation in the following prioritised sequence and only proceed to the next option if the previous is not achievable or not feasible: natural ventilation, mixed mode ventilation and finally mechanical ventilation.

The disadvantages of reliance on natural ventilation for infection control include climate dependence and impact on patient comfort. Yet, the low cost of installation, operation and maintenance should be considered as benefits. The continuous escalation in the cost of electricity and ever-present risk of power outages further support the need to design, wherever possible, for natural rather than artificial ventilation.

The ventilation capacity of any naturally ventilated building is dependent on:

*Wind direction and profile;

*Building geometry;
*Interior obstructions and flow paths;
*Inner and outer temperature (buoyancy);
*Type and degree of envelope and building permeability;
*Adjacent structures and building location;
*Terrain; and
*Complimentary ventilation systems.</div>
The successful commissioning of the installed ventilation system depends on the successful completion of the following steps:

*Definition of performance and functional requirements as identified during the project definition stage

*Ensuring that the performance and functional requirements are met by the design and specification
*Validating that the ventilation system performs and functions as intended. An independent authority shall validate the performance and functioning of the ventilation system.

Whereas the requirements of SANS 10400 XA contemplate the limitation of infiltration and exfiltration of air from the building (sealing for energy conservation) a rational design approach must be adopted for natural and mixed mode systems.

===Dilution systems===
<div style="color:#00000a;">Dilution ventilation refers to any method of ventilation (natural, mechanical or mixed-mode) in which air is encouraged to flow into and out of a space with the aim of reducing the background concentration of airborne contaminants within that space. The complete removal of all ''M. tuberculosis'' particles cannot be accomplished by dilution ventilation alone. Its efficacy is limited by engineering constraints as well as by cost and comfort conditions. Unlike odour and temperature control functions for which ventilation and other forced-air systems are designed, the removal of diluted air (still contaminated with infectious particles air) requires extremely large ventilation rates for adequate protection.
According to the WHO Guideline ''Natural Ventilation for Infection Control in Health-Care Settings ''(WHO, 2009a), if natural ventilation alone is not able to reliably meet both the recommended ventilation and indoor comfort requirements then alternate ventilation systems, such as mixed-mode ventilation, should be sought. If that too does not meet the ventilation requirements, only then should mechanical ventilation systems be considered.

A summary of the advantages and disadvantages of natural, mechanical and mixed-mode ventilation is provided in Table 2
{| class="wikitable"
!
|'''Mechanical ventilation'''
|'''Natural ventilation '''
|'''Hybrid (mixed-mode) ventilation'''
|-
|Advantages
|Suitable for all climates and weather with air-conditioning as climate dictates
|Suitable for warm and temperate climates – moderately useful with natural ventilation possible 50% of the time
|Suitable for most climates and weather
|-
|
|More controlled and comfortable environment
|Lower capital, operational and maintenance costs for simple natural ventilation
|Energy saving
|-
|
|
|Capable of achieving high ventilation rate
|
|-
|
|Smaller range of control of environment by occupants
|Large range of control of environment by occupants
|More flexible
|-
|Disadvantages
|Expensive to install and maintain.
|Easily affected by outdoor climate and/or occupants’ behaviour
|May be expensive
|-
|
|Reported failure rate in delivering the required outdoor ventilation rate
|Reduces occupants comfort level when hot, cold or humid
|May be more difficult to design
|-
|
|Potential for noised from the equipment
|Inability to establish negative pressure in isolation areas, but may be provided by proper design; depends on situation
|
|-
|
|
|Potential for noise intrusion
|
|-
|
|
|High tech natural ventilation shares some of the disadvantages and limitations of mechanical ventilation
|}
Table 2: Summary of the advantages and disadvantages of mechanical, natural and mixed-mode ventilation systems (WHO, 2009A).
</div>
===Natural ventilation systems===
<div style="color:#00000a;">Natural ventilation is the flow of air through buildings driven by wind pressure and buoyancy forces. Natural ventilation is dependent on climate, building design, occupancy and activity in the building. Controlled natural ventilation is not limited to the strategic positioning, opening and closing of windows and doors to channel air flow in a certain direction. For natural ventilation to be effective as a ventilation solution, it must be considered from the earliest stages of the facilities design development. When developing the design concept for a naturally ventilated building, three basic steps need to be taken:

#The desired airflow patterns from inlets to outlets (windows) through the occupied spaces need to be defined. This is closely related to the form, arrangement and management of the building, which in turn depends on the use patterns and even configuration of the site.
#The principal driving forces, which enable the desired airflow patterns and ventilation rates (air changes) to be achieved, must be defined and quantified. Certain strategies tend to be wind-driven; others stack-driven. In successful designs, the principal airflow drivers are complementary to the intended flow rate and distribution.
#Size and locate the openings (windows) so that the minimum and average required flow rates can be delivered under all operating regimes.
</div>The incorporation of additional openings and devices such as solar chimneys, wind towers, turbine ventilators and wind scoops and cowls may assist the natural ventilation design by encouraging air to flow in a specified direction. These devices could also increase the ventilation rate.<div style="color:#00000a;">Naturally ventilated healthcare facilities should be designed such that the overall airflow pattern carries air from the infectious patients, to areas where there is adequate dilution, and be exhausted to the outside (WHO 2009a).
For natural ventilation, the WHO recommends the following minimum hourly ventilation rates (WHO, 2009a):

#In new healthcare facilities or renovated spaces, an hourly average of 160 l/s/patient in airborne precaution rooms, with a minimum of 80/l/s per patient.
#In general wards and outpatient departments (OPD), 60 l/s/patient. The occupancy of general wards and OPDs vary, and this should be considered in the design phase.
#In corridors and other transient spaces, a minimum of 2.5 l/s/m<sup>3</sup> is required. When emergency medical procedure are performed in these areas , an hourly average of 160 l/s/patient is required for high risk procedures, and 60 l/s/patient for all other procedures.
</div>
In these areas the airflow should be from the infectious patients, to areas where there is adequate dilution, and exhausted directly to the outside. If this is not achievable, consideration should be given to mechanical ventilation. '''Sputum booths should be provided externally if at all possible. <span style="color:#000000;">Only where this is not possible should mechanically ventilated sputum booth options be considered.'''<div style="color:#00000a;"><span style="color:#000000;">See below for requirements of mechanical ventilation and Annex 1 for mechanically ventilated sputum booths.</span>It is important in natural ventilation design to consider:

#the fluctuation rates due to changes in weather in the design of natural ventilation systems (including extremes of wind speed);
#building performance in inclement weather;
#patient comfort; and
#control of drafts in the occupied zone- Air currents in excess of 0.8 m/s in the occupied zone can cause disturbance and discomfort.
</div>

====Mixed-mode systems====
<div style="color:#00000a;">The terms “mixed-mode” and “hybrid” ventilation are used synonymously. They refer to mechanically assisted natural ventilation strategies. Mixed-mode systems essentially extend the capacity of naturally ventilated systems. The two major types of mixed-mode ventilation are:

#Complementary mixed-mode ventilation
#Zoned mixed-mode ventilation
</div>
Complementary mixed-mode ventilation uses natural ventilation and mechanical ventilation strategies at different times of the day, or different seasons of the year, i.e. natural ventilation is used when wind conditions are favourable, and mechanical ventilation is extreme conditions. Complementary mixed-mode ventilation can further be classified as concurrent or changeover. In concurrent operation, the mechanical ventilation system works in the background to the natural ventilation system, assisting where temperature, airflow, or indoor air quality parameters are not met. In changeover strategies, the natural and mechanical ventilation systems work alternately. Seasonal and night-day changeovers are the most common.<div style="color:#00000a;">Zoned mixed-mode ventilation implies that certain parts of the building use natural ventilation, and other parts, usually specialised areas within the building, use mechanical ventilation. Brown and Huang (2006, p.47) recommends that energy zoning be employed for naturally ventilated buildings. Activities or spaces having similar cooling and occupancy schedules should be located close to each other, so that the same energy strategies can be used in those areas. In this way it is also possible to cluster the areas which will be naturally ventilated and the areas which will be mechanically ventilated. By clustering all the mechanically ventilated areas, air-conditioned air can be distributed more efficiently.
Mixed-mode ventilation systems may benefit from control strategies. These control strategies may be manual or automatic. Automatic controls usually include sensors, actuators and controllers. The control strategy should be triggered if the required ventilation rates are not met. When this happens, the system switches from natural to mechanical. Once climatic conditions are able to deliver the required ventilation rate, the system should be set back to natural ventilation. Control strategies may also be temperature-based, or rain-based, but the required ventilation rates should be met if these controls are employed.
</div>

====Mechanical ventilation systems====

<div style="color:#00000a;">There are certain instances where the use of mechanical ventilation is the only feasible option, an example of which is deep-planned buildings.
In high risk areas, the mechanical ventilation system should, at least, meet the following minimum ventilation requirements:

#A ventilation rate of 12 ACH, or
#A ventilation rate of 80 l/s/patient of outside or sterilised air.
</div>Criteria 2 is required when considering congregate settings, such as waiting areas and dining halls. Criteria 1 is not relevant where option 2 is achieved. Criteria 1 is not relevant in high volume spaces (>3.5m AFFL).<div style="color:#00000a;">The system should preferably be a full fresh air system. All air should be exhausted directly to the outside. In the event of a partially recirculating system, HEPA filtration or in-duct UVGI should be considered should there be risk of airborne transmission (patient areas).
Where neither of the points above can be sustainably achieved, the occupancy levels in high risk indoor spaces should be managed to remain below a level that which can be effectively served by the considered ventilation system.

The use of exhaust air filtration in single pass ventilation systems as a means of removing hazardous infectious particles from the room should be restricted to “in-room” filtration. “In-duct” filtration, will not lower the concentration of infectious airborne particles in the occupied zone in which they are being expelled by infectious persons. “In-duct” filtration can only remove the infectious particles present in the incoming air or in air being redistributed to other areas served by the recirculating system. “In-room” filtration can be achieved using portable air cleaners (PAC). PACs may therefore serve as an effective extension to the dilution process provided by controlled ventilation, where the ventilation rates required for IPC cannot be achieved. PACs can be used as a means to increase the contaminant removal effectiveness of the ventilation system (at the cost of increased energy consumption). The law of diminishing returns is applicable to any common intervention applied to reduce the probability of airborne cross-infection. For this reason it is important to quantify the expected gains before renovating, adjusting or augmenting systems.

Given the maintenance requirements for HEPA filtration and in-duct UVGI systems and the inherent occupational health risks associated with their maintenance, these systems should only be used as a measure of last resort in airborne precaution areas.

Where mechanical ventilation systems are used, consider the failure-mode fall-back option of reverting to natural ventilation.

For more detail on airborne contamination control concepts refer to the <span style="color:#00000a;"><u>'' [https://www.iussonline.co.za/norms-standards/healthcare-environment/ IUSS:GNS Building Engineering Services]''</u></span>.
</div>

===Disinfection systems===

====Upper-room air UVGI====
<div style="color:#00000a;">According to the CSIR Guidance document: ''UVGI Disinfection of Room Air: an Evidence Based Guideline for Design, Implementation and Maintenance, 2015 https://www.tb-ipcp.co.za/tools-resources/documents-paper-and-articles , the following irradiance and dose factors must be considered when evaluating the ability of an upper-room UVGI system to kill or inactivate airborne microorganisms:''
*include the sensitivity of the microorganisms to UVGI

*and the dose of UVGI received by a microorganism
*the room occupancy levels
*or population of microorganisms.</div>
'''UVGI dose''' is the ultraviolet (UV) irradiance multiplied by the time of exposure and is usually expressed as μW·s/cm2. A appropriatly-designed upper-room UVGI system may be effective in killing or inactivating most airborne droplet nuclei containing mycobacteria if designed to provide an average '''UV fluence rate''' in the room in the range of 15 mW/m³ to-20 mW/m³ and provided the other elements stipulated in these guidelines are met. In addition, the fixtures should be installed to provide as uniform a UVGI distribution in the upper room as possible without losing too much fluence to the walls. There is likely an upper threshold where adding more UVGI will not achieve significant increases in inactivation (Xu, et al., 2003).<div style="color:#00000a;">As the mechanical ventilation rate in a room is increased, the total number of microorganisms removed from the room via this system is increased. However, when mechanical ventilation is increased in a room where an upper-room UVGI system has been deployed, the effectiveness of the UVGI system may be reduced because the residence time of the bacteria in the irradiated zone decreases. Under experimental laboratory conditions with mechanical ventilation rates up to six air changes per hour (ACH), the rate that microorganisms are killed or inactivated by UVGI systems appears to be additive with mechanical ventilation systems in well-mixed rooms. Similarly laboratory studies that UVGI effectiveness changes with modifications to mechanical ventilation rates. Exceeding 6 ACH may reduce UVGI effectiveness although the overall contaminant removal rate may still increase (Xu, et al., 2003).
Upper-room UVGI systems rely on air movement between the lower portion of the room where droplet nuclei are generated and the upper irradiated portion of the room. Once in the upper portion, droplet nuclei containing ''M. tuberculosis'' may be exposed to a sufficient dose of UVGI to kill or inactivate them.

When upper-room UVGI systems are installed, general ventilation systems should be designed to provide optimal airflow patterns within rooms and prevent air stagnation or short circuiting of air from the supply diffusers to the exhaust grilles. Also, heating and cooling seasons should be considered and the system designed to provide for optimal convective air movement. Consideration of the drop and throw parameters of selected ventilation air terminals is critical to ensure good mixing under all seasonal conditions.

Most rooms or areas with properly installed supply diffusers and exhaust grilles should have adequate mixing. If f air stagnation is possible, air mixing should be improved by the considered addition of vertical air mixing fans or repositioning the supply diffusers and/or exhaust grills. If there is any question about vertical air mixing between the lower and upper portions of the room due to environmental or other factors, a fan(s) should be used to continually mix the air. In a room without adequate air mixing under experimental laboratory conditions, UVGI system effectiveness increased by up to 72% when a mixing fan was used.

A number of studies have indicated that the effectiveness of upper-room UVGI systems decreases as humidity increases. The reason for the decrease in UVGI effectiveness is not clearly understood. However, the effect needs to be considered in the general context of upper-room UVGI systems.

For optimal efficiency, relative humidity (RH) should be controlled to between 25% and 60% where upper room UVGI systems are installed. This is consistent with American Institute of Architects (AIA) and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) recommendations that the RH affecting patient care areas in hospitals and outpatient facilities range from 30% RH to 60% RH. If high humidity conditions are normal, it may be necessary to install a system with greater than normal upper-room irradiance levels.

Recommendations developed by ASHRAE and AIA stipulate that the design temperature for most areas affecting patient care in hospitals and outpatient facilities range from 20 °C to 24 °C. This temperature range is consistent with the optimal use of low pressure mercury lamps that are used in upper-room UVGI systems.

The most common way to generate germicidal UV radiation in lamps used in well-designed upper-room UVGI systems is to pass an electrical charge through low-pressure mercury vapour that has been enclosed in selected glass tubes that transmit only certain UV wavelengths. Care must be used in selecting the correct UVGI lamp for use in upper room UVGI systems. Typically, the optimal wavelength for UV germicidal radiation is 254 nanometres (nm) in the UVC range. UV lamps are made for a variety of purposes that may have a negligible consequence in killing airborne microorganisms. Some UV lamps (such as those used for tanning) radiate energy in the UVA and/or UVB range and over extended periods may have adverse health consequences for exposed persons. Other UV lamps are designed to emit radiation at 184.9nm and produce ozone, which is hazardous to humans even at low concentrations. Low-pressure mercury lamps should be rated for low or no ozone generation. Since all lamps must eventually be discarded, each lamp should contain only a relatively small quantity of mercury (i.e., 5mg or less).

In upper-room UV irradiation, fixtures containing UVGI lamps are suspended from the ceiling or installed on walls. The base of the lamp is shielded to direct the radiation upward and outward to create an intense zone of UVGI in the upper air while minimizing the level of UVGI in the lower (occupied) portion of the room or area. The height of the room must be considered in the design of an effective system.

A professional who is knowledgeable in upper-room UVGI systems design and installation should be consulted before procurement and installation of the system. The number of persons competent in the design of upper-room UVGI systems is normally limited.

Persons who may be consulted include engineers, industrial hygienists, and radiation/ health physicists. A mechanism to provide training certification for system designers should be developed and based on the guidance document ''UVGI Disinfection of Room Air: an Evidence Based Guideline for Design, Implementation and Maintenance.''

Once the number and types of UVGI fixtures appropriate for the room or area have been determined, the fixtures need to be appropriately installed. Installation guidelines are provided in the ''Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings'' document and the guidance document ''UVGI Disinfection of Room Air: an Evidence Based Guideline for Design, Implementation and Maintenance''. Only qualified service technicians who have received training on the installation and placement of UVGI lamp fixtures should install the systems. Following installation UV lamps require on-going maintenance and frequent replacement, by suitably skilled technicians. This consideration may be a limiting factor in the use of the solution.
</div>

====Personal protection measures====

<div style="color:#00000a;">In addition to administrative and environmental control measures, the recommended personal control measure for protection of the healthcare worker, from inhaling infectious droplets in high-risk DR TB settings, is the use of respiratory protective devices. These are designed to fit over the mouth and nose and filter out infectious TB particles.
Respiratory protective devices for healthcare workers that are capable of adequately filtering out infectious particles are more expensive than surgical or procedure masks. Nevertheless, their use in high-risk DR TB settings is strongly recommended, particularly in high burden HIV settings where many healthcare workers may be HIV infected. Respiratory protection should be used only when all other administrative and/or environmental control measures are fully implemented. Acceptable respirator types meet the performance requirements outlined in table 7, and include:

*SANS 50149 FFP2/3 respirators

*CDC - NIOSH N95 respirators</div>
The use of N95 respirators should be used with caution in South Africa as there is no framework of compulsory standards and regulations controlling their use. The user may therefore not be adequetly protected from fake devices. The National Regulator for Compulsory Specification (NRCS) has published a homologated database of FFP2/3 devices compliant with SANS 50149.

http://www.nrcs.org.za/siteimgs/CMM/Homologation%20Database%20-%20PPE.pdf<div style="color:#00000a;">Surgical (also called procedure) masks, in accordance with SANS 1866, may be worn by patients in order to prevent the dispersion of respiratory droplets and to reduce formation of droplet nuclei. Surgical masks do not adequately prevent airborne particles from being inhaled by the wearer. SANS 1866 Type 2 surgical masks should be used with caution as they resemble N95 or FFP2/3 respirators and may be easily confused with the latter.
An analysis of the facility design should be made in respect of where provision for personal protective equipment PPE should be made available. These include:

*protective eyewear (for UV device maintenance)
*respiratory protection (typically respirators for healthcare workers, cleaning and maintenance staff, visitors), and
*surgical masks (for patient use).</div>
Dry, secure storage of bulk PPE supplies conveniently located close to points of use should be provided. As respirators are costly and personalised (respirators cannot be shared) secure hanging/ drying facilities clearly marked to avoid confusion are recommended. Stations are required for daily PPE supplies and for disposal facilities (bins) for discarded masks and respirators.

='''Planning and design principles'''=
<div style="color:#00000a;">For specialised TB services long-term accommodation, the project planning, design, construction and commissioning should aim to provide:

*a safe, secure and functional environment for patients and staff;

*optimal accommodation and support for long term patient stay;
*low capital and on-going operating costs (service, staffing and maintenance);
*an environmentally appropriate design solution; and
*a fully accessible, inclusive environment.</div>
==Patient profile==

<div style="color:#00000a;">There are known risk factors associated with an increased likelihood of contracting TB, including DR TB and increased risk of latent disease manifesting in active TB. Patient profile and demographic data are not systematically kept in South Africa, though there appears to be an uneven and fluctuating distribution. Relatively poor socioeconomic groups may be more vulnerable to DR TB infection, but it can (and does) affect anyone regardless of age, gender, race or socioeconomic circumstance. The strong correlation between HIV and TB has been noted. In addition, globally, an increased risk is associated with malnutrition, heavy smoking, silicosis, diabetes mellitus, Hodgkin lymphoma, end-stage renal disease, chronic lung disease, and alcoholism.[[File:Changes in the number of TB notifications in a sample South African community, stratified by age.png|none|thumb|473x473px|Figure 5: Changes in the number of TB notifications in a sample South African community, stratified by age, 1996 - 2004 (Lawn, et al., 2006, p.1043)]][[File:Total number of TB notifications between 1996 - 2004 in a sample South African community, stratified by age and sex .png|none|thumb|473x473px|Figure 6: Total number of TB notifications between 1996 - 2004 in a sample South African community, stratified by age and sex (Lawn, et al., 2006, p.1043)]]Isolated research studies (whose findings may not be generalizable) in South Africa found that TB incidence and prevalence per gender varies with age (see Figure 5). TB incidence was highest in the population group aged 30-49 years, which is the economically productive age group with highest number of dependants. 11% of cases were in children. In the study there was a significant increase in TB among adolescents, especially girls, between 1996 and 2004 (see Figure 6: Total number of TB notifications between 1996 - 2004 in a sample South African community, stratified by age and sex Reflecting the global situation, TB affects more men than women.

Some population groups, such as prisoners and miners are at increased risk of contracting TB.
</div>

==Patient-centred care==
<div style="color:#00000a;">Hospitalisation for DR TB places a unique demand on infrastructure. During their stay patients may become either very ill and in need of hospital acute care, to being well or feel quite well only requiring supervised medication. In order to support patient care, part step-down quasi residential-type accommodation should be provided, so that patients who are feeling well can feel “at home”; and part hospital-type accommodation should be provided, in areas where direct staff supervision is possible.
There is strong evidence from research studies which describe the importance of health facility design as a means to improve health outcomes (Ulrich, et al., 2008). The more supportive the environment is, the less chance there will be of admitted patients absconding and infecting others in the community while still in an infectious stage of the disease. Environmental factors such as large windows with high levels of daylight, views of nature, low noise levels all reduce stress and depression and promote healing. Some visual and acoustic privacy (screening for confidential/ personal activities in counselling, consulting and ward areas) promotes patient dignity. Personal choice and control over heating, lighting and furniture layout instils a sense of empowerment.
</div>

===Safety===
<div style="color:#00000a;">There are several aspects of risk that should be addressed by the consultant team. They include: infection prevention and control (for airborne and other modes of transmission) slips and falls, fire, and UV exposure. Only the most likely and critical of risks have been addressed in this document.

===Isolation===
Distinction can be made between five types of segregation:

*Separation – patients are housed in single room accommodation though they may not be self-harming or violent.

*Negative pressure room applied to infectious patients, with airlock ante-chamber (e.g. TB patients).
*Positive pressure isolation room applied to immuno-compromised/ susceptible patients, with airlock (e.g. burns patients).
*Duel-function isolation – with controls to convert from positive to negative pressure according to current room occupancy, with airlock. This is discouraged due to complexities in designing and operating these and due to increase risk in accidental incorrect use.
*Seclusion (Social isolation) – for patients who are self-harming or violent. A room with high level of security which complies with national norms and standards for psychiatric care facilities. Airlock not required.
*Barrier isolation – patients are housed within a chamber constructed of an impermeable barrier and typically ventilated through HEPA filters. Decontamination airlocks and material transfer chambers are included in the system. These types of systems are exclusively used for suspected P4 level pathogens, and are not indicated for use with TB patients.
</div>
When briefing professional consultant teams, it is important to convey where each of the above is required. For TB, infection control is useful and usually all that is provided. For further information on Isolation rooms, the reader is referred to the IUSS Adult In-patient Services guidance document. https://iussonline.co.za/norms-standards/clinical-services

===Infection prevention and control===
<div style="color:#00000a;">The most critical aspect of risk in the design is from the point of view of airborne infection control. This aspect has been addressed in detail in previous sections (for airborne infection) and in the. Refer to <span style="color:#00000a;"><u>''IUSS:GNS Infection prevention and control''</u></span>. </div>

===Slips, trips and falls===
<div style="color:#00000a;">Slippery floor surfaces should be avoided, particularly externally. Contrasting colours should be used at changes in floor level to assist visually impaired persons. Adequate lighting, handrails and guardrails should be provided. External paving areas should be well drained.</div>

===Alarms and fire alarms===
In addition to the usual compliance requirements, it should be noted that as deafness is a common side-effect of TB treatment regimes, all sounding alarms including fire alarms should be supplemented with visible alarms in patient areas e.g. red or yellow flashing lights to accompany fire or emergency evacuation alarms.

===UV exposure risk===
<div style="color:#00000a;">Where ultraviolet radiation germicidal irradiation (UVGI) is contemplated, due consideration must be made to potential adverse health effects on patients, staff (including maintenance staff) and visitors. For convenience the UV spectrum is described in three different wavelength bands: UVA (long wave lengths, range: 320–400 nm), UVB (midrange wavelengths, range: 290–320 nm) and UVC (short wave lengths, range: 100–290 nm).
UVC is unlike UVA and UVB, as it has extremely low penetrating ability. It is nearly completely absorbed by the outer layer of the skin (stratum corneum), where little or no harm is experienced. Although listed as a potential carcinogen for man, UVC is unlikely to be carcinogenic or to cause skin or eye irritation (keratoconjunctivitis) if applied correctly within exposure limits as set out by the International Radiation Protection Agency (IRPA) and other international health bodies.
</div>
Since open UVGI devices are principally designed to emit a certain amount of UV-c radiation, these devices cannot be considered to be intrinsically safe. The UVGI system should be designed to achieve the maximum system output and maintain the lowest reasonable exposure levels in the occupied zone of the room.<div style="color:#00000a;">The primary safety concern with UVGI in controlling eye exposure to prevent irritation, limits the irradiance limits achievable in the occupied room.</div>

====Safe Exposure Limit====
<div style="color:#00000a;">The occupied rooms considered for UVGI should not exceed an exposure dose below 6 mJ/cm² (for mercury vapour lamps at 254 nm 15) and 3.8 mJ/cm² (at 265nm) per 8h.
Therefore, in the typical application of 254nm devices, occupant exposure shall not exceed 0.40µW/cm² for a period of time equivalent to 4 hours per work day. If exceeded, steps must be taken to reduce the effective irradiance dose to less than 6.0mJ/cm2 for the total duration per day.

It becomes important to consider the actual nature and usage of these spaces to determine appropriate safe exposure rates. In determining these rates, occupancy factors such as the eye level of regular occupants, position of occupants (seated, standing, lying down), frequency and duration of exposure, need to be determined and incorporated. Therefore different areas or rooms will require different safety limits.

Areas such as passages and wards would therefore demand vastly different safety limits from each other.

The economic considerations of infection control suggest that high risk areas be given priority for air disinfection. These areas will be determined through the outcome of a comprehensive risk assessment of the facility. Installation of open UVGI devices in stairwells is not considered safe practice as there is seldom sufficient soffit height for an effective upper room zone. Where passages are used as return air plenums in recirculating ventilation systems, these passages shall be considered for air disinfection.
</div>

====Reflections into the Lower Room====
<div style="color:#00000a;">The potential of high UV intensities being reflected into the occupied room must be considered by designers and users. Certain materials and surfaces that reflect visible light might also reflect UV-c light; for example consider reflectors of regular open luminaires, windows, exposed ducting and metallic or high gloss architectural finishes in the upper room.</div>

===Security===
<div style="color:#00000a;">In the South African context, there is considerable store in balancing security needs, so that patients and staff feel that their person and their personal belongings are protected from harm. Detailed guidance is provided in [https://iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Security].</div>

===Inclusive design===
<div style="color:#00000a;">In accordance with the Constitution of South Africa, Occupational Health and Safety Act, the Promotion of Equality and Prevention of Unfair Discrimination Act and the UN Convention on Rights of People with Disabilities, Universal Design is a key requirement for all public buildings in South Africa. Refer to [https://iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Inclusive environments].</div>

===Holistic care===
<div style="color:#00000a;">DR TB facilities must accommodate patient care, dignity and wellbeing. Medical and accommodation needs are clearly the minimum and most critical aspect that must be addressed by the facility. However the accommodation needs for long-term care must address patients’ needs in a more holistic way. </div>

===Balanced service provision===
<div style="color:#00000a;">Some of the identified problems related to long-term patient needs are isolation of economically active sufferers from their working environment, and interruption of schoolwork in children. The provision of education and development programmes for adults and children alike (library and multi-media facilities have the potential to reduce isolation, stigmatisation, and to contribute to a positive frame of mind) are therefore just some of the issues that can be addressed via facility design. A small business hub with information communications technology (ICT) connectivity may be provided to assist patients who may need to keep their businesses running while under treatment. Both indoor and outdoor recreational activities and other opportunities for physiological, psychological and spiritual needs during this extended stay should be provided in the facility. The provision of patient support accommodation and social counselling and support (visits from relatives and friends) is essential to promote a sense of wellbeing and purpose. Allied health services such as pharmacy, and rehabilitation therapy (occupational therapy, physiotherapy, and social work) play a critical role in supporting whole-patient care. Treatment side effects may include hearing loss, so that provision of audiology booth for regular testing is useful. Screened, covered and well-ventilated sputum booths should be provided in close proximity to clinical areas for production of sputum samples. These may be equipped with a hand-wash basin, a shelf and a plug point, to allow for nebulisation. Chest (and other) x-rays need to be taken, therefore provision of x-ray facilities with appropriate radiation protection should be provided.
Given resource constraints, it is not always possible to invest in the full complement of these facilities at DR TB centres in one capital investment. However, as each potentially adds to quality of care that can be delivered, which leads both directly and indirectly (say, through preventing absconding) to improved health outcomes, best practice recommends that these aspects be addressed as fully as practicable. It is useful to produce master-plan proposals, within a phasing framework so that a full complement of services can be provided over time, and so that short term development does not compromise medium and long term development potential.

Patients in some DR TB settings are permitted to prepare their own meals, but this is unusual practice and is usually optional and reserved for patients who are pending discharge. Policies in terms of meal presentation and delivery vary between institutions. Three basic modes of delivery include a pre-plated service delivered to the patient bed. The second mode is a tray served at a dining table and the third is a buffet-style service. As meal preparation services are frequently outsourced, the first two modes of delivery are most commonly found in South Africa. Dedicated dining facilities are not always available, so that meals must be served at patients’ bedsides or lounge areas (if provided). Bedridden and ill patients may be unable to use formal dining facilities. International studies in long-term care facilities have shown that there are increased appetite, nutrition and patient satisfaction in communal dining settings, and particularly with buffet-style eating. However these studies have primarily been undertaken for the elderly. Similar studies have not been undertaken in South Africa or for TB patients. To complicate matters, patients in communal dining settings are unable to use personal protective equipment, raising risk at these encounters. Nevertheless it is recommended that patient formal dining facilities be provided for and that they are treated as high risk areas in terms of infection control.

Facility policy may provide that patients in long-term care facilities are encouraged to participate in cleaning, laundry and gardening activities.
</div>

===Healing environments===
<div style="color:#00000a;">International research into evidence-based design has concluded that well designed built environments can play a critical role in improving healing outcomes. Infrastructure has an important role to play in this respect. Long-term DR TB care facilities should not only address the needs of patients and their families, but also the needs of healthcare workers.</div>

===Occupant comfort===
<div style="color:#00000a;">While ventilation is of significant importance to maintain effective infection control within the healthcare buildings, one of the most critical aspects of patient recovery is adherence and completion of their treatment regime.
Buildings should be designed so that comfort conditions in indoor environments can be achieved irrespective of climate conditions, bearing in mind that TB sufferers are typically very underweight and may have little tolerance for cold. The climate may require supplemental heating to achieve comfort conditions in winter without compromising the ventilation requirements. The operational constraints of the hospital (in terms of maintenance and operational costs as well as environmental impact) mean that fully air-conditioned or heated wards are usually not desirable either.The ISO standard 7730 provides a measure of thermal comfort based on the predicted mean vote (PMV) method. The ASHRAE 55 ''Thermal environmental conditions for human occupancy'' guide provides methodology for measuring comfort conditions, including provision for naturally ventilated buildings. It is proposed that these form the basis of the design assessment relating to thermal comfort.

The ventilation and comfort control design must weigh up these competing requirements to provide an optimal indoor environment (ventilation and thermal comfort) while bearing in mind the operational impacts on the hospital in the long term. As such, the following metrics should be used to demonstrate an optimal balance of ventilation, thermal comfort and operational costs:

*Proportion of hours where the targeted ACH rate is achieved (currently 160 l/s per person for naturally ventilated areas)

*Proportion of hours where either:
*PMV levels between -1.0 and 1.0 are achieved; or
*Acceptability limits of ASHRAE Standard 55, 2004 are achieved within 80% of acceptability limit 1
*Predicted operational costs (energy use and maintenance)</div>
The decision-making with respect to the mechanical or naural ventilation system or other systems relating to thermal comfort should take all these into account.

==Staff: patient ratios==
<div style="color:#00000a;">According to the ''Decentralised Management of Multi Drug Resistant TB – a Policy Framework for South Africa'', a provincial/ centralised MDR TB unit requires the following minimum staffing levels. This should be cross-referenced against the WHO Document “Workload Indicators of Staffing Need” (WHO, 2010) which has been formally adopted by the NDoH:
{| class="wikitable"
|Doctor
|1/40 beds
|-
|Professional nurse / Staff nurse or Nursing Assistant
|4/ 11 per 40 beds
|-
|Pharmacist
|1 per 100- 200 beds
|-
|Social worker
|1 for > 40 beds
|-
|Dietician
|1 for > 40 beds
|-
|Clinical Psychologist
|1 for > 40 beds
|-
|OT
|1 for > 40 beds
|-
|Audiologist
|1 for > 40 beds
|-
|Physiotherapist
|1 for > 40 beds
|-
|Data Capturer/ Admin Clerk
|1 for 100- 200 beds
|-
|Driver
|1 for > 40 beds
|}
Table 3: Sample Organisational Development Investigation the following staffing complement per 30 bed functional unit (''courtesy Brooklyn Chest Hospital'')
{| class="wikitable"
|'''OFFICE: ADMINISTRATION'''
|'''NUMBER OF POSTS'''
|'''COMMENTS'''
|-
|Administration clerk
|1
|
|-
|CLINICAL SERVICES
|
|
|-
|Medical officer
|1
|
|-
|MEDICAL AUXILLARY SERVICES
|
|
|-
|Physiotherapist
|
|Central services
|-
|Occupational therapist
|
|Central services
|-
|Social work
|
|Central services
|-
|Dietician
|
|Central services
|-
|Audio/speech therapist
|
|Central services
|-
|Clinical Psychologist
|
|Central services
|-
|Radiographer
|
|Central services
|-
|Pharmacist
|
|Central services
|-
|Counsellor
|
|Central services
|-
|NURSING SERVICES
|
|
|-
|ASD nursing area
|
|Central services
|-
|Operational manager nursing
|1
|
|-
|Professional nurse
|4
|
|-
|Staff nurse
|4
|
|-
|Auxiliary nurse
|8
|
|-
|Housekeeping supervisor
|1
|
|-
|Household aid
|6
|
|-
|NIGHT DUTY MANAGEMENT
|
|
|-
|Night duty manager
|1
|Central services
|-
|Professional nurse
|1
|
|-
|Staff nurse
|3
|
|-
|Auxiliary nurse
|2
|
|-
|Household aid
|1
|}

==Supporting the caregiver==
</div>
===Recruitment, retention and productivity in staff===

<div style="color:#00000a;">International research has shown that infrastructure has a part to play in staff recruitment, retention and productivity. South Africa has been experiencing an extended challenge in respect of attracting and retaining qualified healthcare professionals. This challenge is particularly marked in TB–specialist skills because of the additional risk. This risk is not merely perceived. Healthcare workers generally and TB-specialists specifically are exposed to higher risk of infection and higher infection rates than the general population.
Staff is thus a critical factor to take into consideration when DR TB planning facilities. In particular the provision of safe working environments:

*which address risk from an IPC perspective in a way which is explicit and reassuring;

*which provides for physical safety against violent/ disturbed patients; and
*which allow adequate safe storage for personal belongings.

Provision of staff housing, recreation facilities and other staff amenities may be an attractive benefit.
</div>
===Additional personnel considerations===
<div style="color:#00000a;">From an infrastructure point of view, it is critical that maintenance posts are established and filled with incumbents who are appropriately skilled to address the specialised needs of DR TB facilities, infection control and healing environments. As with healthcare workers, there are challenges in attracting and retaining skilled artisans, engineers, and health facility specialist maintenance staff, particularly in environments perceived to be high-risk.
While the most significant factor in staff recruitment and retention is salaries and benefits, especially in relation to many overseas destinations, many experts emphasize that pay is not the sole motive for leaving the South African public service. Other factors include poor work environments characterized by heavy workloads, lack of supervision, and limited organizational capacity. There are also environmental considerations; workplaces may be dangerous due to condition, functional or environmental design, or there may be a lack of supplies to protect workers from occupational exposure to diseases like tuberculosis.
</div>

==Site appraisal==
<div style="color:#00000a;">Where feasible the principle of redevelopment and reuse of existing buildings should be investigated before building new buildings. As a first stage in providing a comprehensive appraisal of the site, the consultant team should collect, collate and prepare a full assessment of accommodation and engineering services at the existing site including:</div>

===Building layouts===

*existing buildings with measured footprint and scaled spatial layout on site plan;
*current functional allocation (use) of existing buildings;
*level of utilisation of buildings;
*national monument status;
*building condition assessment (high level and quick professional estimate on scale one condemn to five as new);
*evaluate of the level of accessibility of proposed new structures and linkages to existing buildings; and
*evaluation of existing pedestrian and vehicular routes (i.e. staff, visitors, and service vehicular and pedestrian routes) to determine optimum layout of proposed new buildings.
<div style="color:#00000a;">A coloured site map should be prepared by the consultant team using the coding provided below to visualise the suitability of the existing building stock (see figure 8) and the condition of the existing building stock (see figure 9).[[File:Condition assessment coding.png|none|thumb|499x499px|Figure 7: Recommended suitability coding for site appraisal]][[File:Recommended Condition Assessment Coding For Site Appraisal.png|none|thumb|499x499px|Figure 8: Recommended Condition Assessment Coding For Site Appraisal]]

===Site Information===

*Major landscaping, trees and features;
*Site access points for staff, patients and service personnel and access constraints;
*Existing fencing and level of security provided;
*Service connection points, main service runs, water tanks (as they are currently being constructed), transformers, substations, generators, etc.; and
*Flood lines, water table levels, site storm water drainage and general potential for flooding.</div>

===Engineering and bulk services===

<div style="color:#00000a;">Engineering services

*Power: Analysis of existing power supply – types, current load, reliability, capacity, potential for expansion,

*Water supply: Analysis of existing water supply – source/s, storage, condition, current and projected demand,
*Sewage: Analysis of existing sewage reticulation and disposal system, connections, capacity, condition, current and projected load,
*ICT services: Telephones, internet connectivity, intranet connectivity. Analysis of existing supply – types, load, reliability, capacity, potential for expansion,
*Other services as identified by consultant team (gas, steam etc.)</div>
It is recommended that the photographic survey of existing infrastructure be compiled by the consultants.

===Climatic and sustainability considerations===
Prevailing climate conditions should be taken into consideration during the design process. The closest freely available (open source/ public domain) or alternate annual and diurnal temperature, rainfall, wind-speed and direction data should be collected, analysed and used in addressing building performance and patient comfort objectives (see Figure 10). Material specifications and details should address corrosive attributes associated with proximity to the sea.

Rational peak demand of electricity use and demand management systems should be considered in the design and specification. There should be a split between essential and non-essential electricity use, and emergency backup should be provided for essential services. Separate metering for water and electricity should be provided for the new unit. Refer to [https://www.iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Sustainability and the environment].

===Future development===
Future development for the site should be studied. The consultant team is to provide evidence that a very high level study has been undertaken to ascertain whether or not the proposed facility will likely compromise, limit or enable the proposed development through appropriate means (such as crude scale block positioning on site). The implications of the project on future development should be discussed in an open forum with stakeholders. Consideration should be given to the optimal positioning and size of central services to satisfy the future demand of the hospital site.

==Additional Project Studies, Approvals and Requirements==

===Environmental Impact Assessment (EIA)===
An Environmental impact assessment (EIA) may be required.

===Local authority submissions===
The following approvals must be provided, as stipulated by the local authority:

*A site development plan (SDP);
* A copy of a set of working drawings;
*A traffic engineer’s report; and
* A fire department.

===Phasing and decanting===
Where the project calls for a construction project to be conducted within an existing functional healthcare environment, phasing and decanting plans are required. The appropriate precautionary measures should be taken. Refer to [https://www.iussonline.co.za/norms-standards/procurement-and-operation IUSS:GNS Decommissioning]. The services currently provided for at the hospital must continue with as little disruption as is reasonably possible. Phased construction and/ or temporary decanting of functions may be required. Should decanting activities be required to accommodate the construction project, then this activity should be planned timeously with all stakeholders’ involvement under the leadership of the briefing authority (or if defined as extraordinary scope of services, principal agent, contractor or other clearly identified party).

===Commissioning and validation===
Refer to [https://www.iussonline.co.za/norms-standards/procurement-and-operation IUSS:GNS Commissioning].

===Post-occupancy evaluation===
At one year from practical completion date a post-occupancy evaluation is recommended. All participants in the planning, design, construction and commissioning of the new facility will be required to participate in a half day on-site assessment on whether the project objectives where met. Feedback should be provided to the briefing authority and custodial agent to inform future building projects.

===Operation and maintenance manual (O&M)===
The consultant team is required to prepare an operations and maintenance manual for the hospital management and the custodial agent for presentation at practical completion. The requirements regarding the content of this document will be determined by consensus at a focus meeting with stakeholders to be convened by the principal agent during the construction phase of the project. As a recommendation these manuals may contain the following information:

General information

*Description, make, model number of all equipment installed; and
*Contact details of suppliers and /or manufacturers etc.

Design information

*Design data sheets, containing all design and selection parameters, calculations, selection curves, etc.;
*Settings and values recorded during commissioning;
*Manufacturer's brochures and pamphlets;
*Maintenance data and schedules;
*The lapse of time between services and the description of the service required of each part, lubrication requirements, etc.;
*Schedule of spares; and
*A complete electrical equipment schedule.

These will include the description, make, model number, rating and other performance criteria, commissioned (default) settings, including all brochures, pamphlets and maintenance requirements. Names and contact details of supplier and manufacturer.

Detail description of the operation of the electrical, mechanical and control systems including the design information, manufacturer’s brochures and pamphlets, settings and values recorded during commissioning, maintenance data and schedules. Complete sets of:

*as built drawings";
*architectural work drawing;
*structural drawings;
*site works drawings;
*electrical reticulation drawings;
*mechanical installation drawings (i.e. all workshop and equipment layout drawings required for the manufacture and erection of the installations); and
*instrumentation/control drawings, such as schematic control diagrams and electronic/ electrical layout drawings.

='''Operational narrative and user room requirements'''=

==Daily Schedule==
Table 4: Sample: Current daily activities at long-term care facility
{| class="wikitable"
|TIME
|ACTIVITY
|VENUE
|DESIGN IMPLICATION
|-
|5:00
|Patients are woken up, urged to complete ablutions, and dress.

<br />
|Wards
|Each patient will have his own bedroom and adjoining bathroom.

Each bed will have an adjacent cupboard for clothes and possessions, and space for a bedside table.
<br />
|-
|
|Patients to produce sputum
|Sputum booth
|1.Monthly sputum samples taken from relevant patients
|-
|07:00
|Nursing on day shift attend a handover meeting with night staff. This includes discussing problems, and planning activities for the day.
|Nursing station
|The nursing station is a general area where much clinical information is shared between staff and between disciplines and is a separate area in the ward. Secure cupboards (and a safe), under desk shelving and notice board space are required.

The location of the nursing station should allow for a clear view of most of the ward (through transparent barriers/windows) and it should be as centrally placed as possible. It should accommodate up to 6 people, and be accessible to the offices of the other members of the team. Lock-up cupboards, computer points, telephone; nurse call control panels should be operated from here. In this ward the nursing station should provide a central place in terms of staff efficiencies.
|-
|
|
|Matron’s office
|While office should be separate from nursing station due to space requirements, easy communication and visible access should be available. Built-in office furniture with network points, plugs, telephone, filing space, lockable cupboards, enough space for at least three filing cabinets, appropriate storage and availability for ward stationery (some open and others locked), additional filing workspace, provision of pigeon holes for each for each patient file board, key cupboard.
|-
|7:30
|Daily injection given to patients
|Procedure room
|Nurses prepare injections according to medicine chart per individual patient.

The room requires a clinical hand-wash basin with clinical taps, lock-up cupboards, worktops, a patient couch, good lighting
|-
|08:30
|Breakfast and issuing of medication
|Dining hall
|This adjoins the kitchen and food delivery area. The nursing station should be nearby so that medication and general nursing tasks can be co-ordinated efficiently.

Food will be brought from a central kitchen located elsewhere in the hospital, but facilities for re-heating and to make hot beverages need to be available.

As patients mostly will proceed to the dining area from various other activity areas (sleeping, clinic, recreational, OT etc.) it will have to be in a central location, easily accessible from other patient areas.

Food must be delivered through a dedicated staff access point that allows for minimal patient contact.
<br />
|-
|09:30 – 12:30
|Therapeutic activities
|
|
|-
|
|Medical officer

The ward will have at least one medical officer.
|Consulting room
<br />
|These should have enough space for interviewing at least 3 people, as well as a desk, examining coach and x-ray box.
<br />
|-
|
|Occupational Therapy (OT)
|Games room and lounge
|During the day most patients will be allowed to attend the OT programme.
|-
|
|Psychologists & Social Workers

Interviews, psychotherapy and counselling with patients or their families (often together) occur daily, usually by appointment.
|Counselling rooms
<br />
|Each office will need built-in desks, computer and telephone points, and secure storage space.
|-
|12:30 – 13:30
|Lunch and using of medication
|Dining hall
|
|-
|13:30 – 14:00
|Rest period
<br />
|General rest areas
|Some patients may retire to their rooms for a brief period, but most will be in general areas (lounge, restricted outdoor areas).
|-
|14:00 – 16:30
|Continuation of many morning activities
|
|
|-
|
|Sport and Recreation
|Outdoor field
|These patients will have easier access to outdoor areas.
<br />
|-
|
|
|Indoor group area
|For use for group leisure.
|-
|
|
|Lounge
|A comfortable furnished area containing a TV, board games (such as Kerem). This area has to be fully visible from the nursing station. Public telephones should be situated nearby. It may be helpful if this was close to the dining area.
|-
|
|Visiting

Families, friends (and occasionally others) are allowed to visit during two afternoons per week and each evening between 19:00 to 20:00
|Visitors area
|Although visiting times are regulated, families here have easier access to the patients, and there does not have to be a strict separation between patients and visitors.
|-
|16:30 – 17:30
|Supper
<br />
|Dining area
|Activities as for other mealtimes.
|-
|17:30 – 19:00
|Leisure time
|Lounge
|Access to enclosed courtyards allows patients to smoke and relax in the restricted outdoors before retiring to sleep.
|-
|18:00
|Nursing handover to night staff
<br />
|Nursing station
|The same as in the morning
|-
|19:00 – 21:30
|Preparation for sleep

Dispensing of night medication
|Lounge and sleeping areas
|Usually a snack and hot drink is given to patients. Many watch TV, others socialise or smoke (the latter activity will take place in designated courtyard areas that adjoin onto the ward, but without direct access to the general campus area).
|-
|22:00 – 07:00
|Night activities
<br />
|Sleeping areas,

Nursing station
|
|}

==User room requirements==
Refer to [https://www.iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Generic room requirements] and [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Primary healthcare].

===TB outpatient services===
Discharged patients need to be seen for follow-up visits in their communities or at facility-based outpatients department (OPD) usually every two months or so. Treatment for newly diagnosed and uncomplicated MDR TB and TB patients is typically initiated by clinical staff at OPD, and in accordance with policy decentralised management of TB treated in the community. Complicated cases and XDR patients may be admitted into the inpatient accommodation units through the OPD unless a dedicated admissions facility is provided.

Paediatric patients may be seen for follow-up at paediatric wards or at the general OPD, depending on organisational structure. In small facilities the outpatient department can share clinical support services for inpatient care. Depending on patient loads and institutional preference, a dedicated OPD can be provided with similar facilities to clinical inpatient and support services.

Care should be taken to avoid enclosed congregate settings (such as waiting areas) where possible. Where these are required, they should be regarded as high risk for airborne contamination.

====Consulting room====
The consulting room is used by doctors and nursing staff for interviewing and examining patients, and to prescribe treatment for their condition. The doctor or certified nurse practitioner discusses the patients’ symptoms and records her case history. The patient sits on a chair during this stage and if a physical examination is necessary, lies on an examination couch. Once on the couch, the doctor or certified nurse practitioner examines the patient standing on the patients’ right hand side using medical supplies and instruments on an instrument trolley placed next to the head of the examination couch. The doctor or certified nurse practitioner may dispense medicine or instruct the patient to proceed to the treatment room for further medical treatment. Privacy is required during the consultation.

One consulting room should be provided per 30 patient beds or part thereof. The consulting rooms should be standard size. The consulting rooms requires a clinical hand-wash basin with a soap dispenser and paper towel holder, a desk and chair, two patient chairs, an examination couch with a curtain screen, a place to hang clothing, examination lights, access to shared x-ray viewing facility, wall mounted blood pressure monitors, telephone and computer and network connectivity. The room must have a desk with cupboard for the nurse/clinicians’ own personal belongings and a cupboard for standard forms. A separate cupboard must be in this room to provide for equipment and medicine necessary for procedures. Each room must be provided with a pinning board 900 x 900. An examination couch with an exam lamp is to be provided. Provide space next to the couch for a medicine and instrument trolley. Curtain tracks should be provided around the examination couch for visual privacy for patient being examined, if appropriate.

====Counselling room====
The counselling rooms must be the same size as the consulting rooms and correctly handed for use as consulting rooms should the need arise. The counselling rooms require a desk and chair, with telephone, shelves, IT and a network point, clinical hand-wash basin, soap dispenser and two easy chairs for counselling purposes.

====Diagnostic radiology services====
Diagnostic radiology services (chest x-rays) of all patients may be routinely required for diagnosis, during treatment and in follow-up. Baseline x-rays of all the staff and annually as part of the hospital’s infection prevention and control programme. Diagnostic radiology should be provided on-site or at a nearby referral facility. Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Diagnostic radiology]. Mobile x-ray services are a suitable alternative where fixed radiology equipment is not available and if not provided at a nearby referral facility.

====Sputum collection and induction====
Sputum collection is a process whereby a specimen of sputum, liberated from the lungs, is collected. In many adults this process is readily achieved, however, in younger children and adults who cannot liberate sputum spontaneously, sputum induction is performed. Sputum induction is a process whereby sputum is liberated from the lungs using sterile water or hypertonic saline to irritate the airway, which promotes coughing, to produce a sputum specimen (Francis J Curry National Tuberculosis Centre, 1999).

It is advised that sputum collection be conducted in an area which provides privacy, for patient dignity, but also conducted under observation of a clinician, should the patient go require support and in order to ensure sample integrity (that the sputum is from the individual). As sputum collection is a high risk procedure, good administrative and environmental control measures for the designated sputum collection area is essential for the safety of healthcare workers and patients.

The functional area for sputum collection should comprise a covered area, clinical hand-wash basin, soap dispenser and counter top and, if sputum induction is performed in the same space, a splash-proof power point for a nebulizer.

Sputum collection should be performed in a designated area. At naturally ventilated primary healthcare clinics and community healthcare centres, or any other single-storey naturally ventilated healthcare establishment, sputum collection should preferably be performed in a designated '''outside''' area. The “sputum booth” should be positioned within view of the nurse’s station, but should be at least four meters away from the nearest building. '''Sputum should not be collected in patient toilets or consulting/counselling rooms'''. Details of an outdoor sputum booth are available in ANNEXURE 2.

In a mechanically ventilated healthcare facility, rooms having characteristics of airborne infection isolation rooms (AIIR) can be used for sputum collection. These rooms should be ventilated with 80 L per second per person of outside air or the requirements of the National Building Regulations, whichever is greater (SANS 10400 Part O, Table 2, as amended) and are to be maintained at negative pressure relative to the adjacent space, with a pressure differential in the order of -5 Pa. These rooms should preferably be served by full fresh air systems, or in the case of recirculating systems, the exhaust air should be HEPA filtered (EN1822 H13).

Special, purpose-built sputum booths, also referred to as Local Exhaust Ventilation (LEV) devices can also be used for sputum collection. These devices may be portable, where they are beneficial in multi-storey healthcare facilities, where a single sputum booth can be used for the whole facility. Details of a mechanically ventilated sputum booth are available in ANNEXURE 1.

A patient is seated in a chamber where he/she produces a sputum specimen. Fresh air, preferably filtered, is supplied overhead, and exhausted from the chamber at low level. The exhaust air is passed through an H13 HEPA filter to remove the airborne contaminant, and is passed back to the room. To ensure the chamber is safe for the next patient, a time-lag between one patient and the next should be calculated and stipulated, based on the validated clean-up rate of the sputum booth (SANS 14644-3). Downflow booths are preferred as this provides the most efficient contaminant removal. For reliable operation, downflow velocities of 0.35-0.45 m/s should be maintained in the booth with the door closed.
[[File:An illustration of local exhaust ventilation device .png|none|thumb|346x346px|Figure 9: An illustration of local exhaust ventilation device (sputum booth)]]
To ensure that AIIRs and LEVs operate as designed, a good maintenance plan is essential. This involves maintenance of pre-filters and HEPA filters, general ventilation maintenance, and standard daily checks to ensure downward and inward airflow is maintained. These checks are simple, and may be performed with incense sticks or smoke /vapour generating ventilation tubes. Maintenance is critical in LEVs, as failure to maintain the device operating as designed could result in contaminated air being passed into occupied zones. Since ducted UV lights can fail catastrophically without any indication, it is not recommended that the HEPA filters considered for LEV systems be substituted with only in-duct UV lights.

Where sputum collection or induction is performed, signage informing patients about the associated procedure should be considered. This should include:

#Instructions inside the sputum collection booth about the sputum collection procedure.
#Time-lags between patients producing a sputum specimen in the same booth.
#Reminders to healthcare workers to wear respirators in the sputum collection area.

====Pharmacy====
Pharmacist and assistants pharmacists are required to prepare and dispense medication, and manage medicine stock for inpatient and outpatients services. Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Pharmacy]. The pharmacy may be responsible for community outreach programmes for community-based care and may be responsible for distributing medication to downstream referral facilities.

====Laboratory services====
Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Clinical and specialised diagnostic laboratory guidelines]

===Patient accommodation===
Table 5: Patient accommodation cohorts for short-term accommodation
{| class="wikitable"
|Service type
|Accommodation
|Occupancy
|Notes
|-
|Paediatric

(unisex)
|
|
|
|-
|TB and MDR TB (female)
|
|
|
|-
|TB and MDR TB (male)
|
|
|
|-
|XDR (male/unisex)
|
|
|
|-
|XDR (female/unisex)
|
|
|
|-
|XDR paediatrics (unisex)
|
|
|
|-
|Former correctional services/(unisex isolation)
|
|
|
|-
|Psychiatric TB patients/ (unisex isolation)
|
|
|
|}

===Clinical support services for inpatient care===
Nursing support is to be located centrally to serve several bed functional units (for sub-acute services) or dedicated per unit for acute services to ensure supervision and control of the department. Alternatively if functional units are physically separate, these nursing support facilities are to be duplicated. In addition to the inpatient facilities described here, TB patients will need access to facilities described in 2.1 above either as a dedicated facility or where appropriate, shared with outpatients.

====Duty station/ nurse’s station====
The duty station should be provided with a built-in worktop (desk height), a telephone, computer and network points, cupboards and a clinical hand-wash basin.

====Clean linen area====
A locked linen store with slatted racks to support the airing and safe storage of clean linen should be provided.

====Dirty utility room====
The dirty linen store near the sluice and a dirty utility service door with direct access to waste collection points for easy removal and disposal. Space for separate refuse bins for paper, medical waste and general waste.

====Sluice room====
A standard sluice room with bedpan, urinal racks, storage cupboards and a worktop should be provided.

====Surgery services (operating theatre)====
Surgical services are commonly required by TB patients so should be readily available in nearby referral facilities or for stand-alone TB-services minor procedures room may be provided on site. Support infrastructure such as CSSD is required in accordance with.

====Staff facilities====
A cluster of staff facilities should be provided for exclusive use by staff. These include a lounge/tea area/room; a kitchen area/room; staff locker area/room and staff ablutions. Staff facilities should be located remotely from patient areas to allow for:

*airborne infection control
*a “break-away” venue to rest following patient contact periods away from the demands of the work environment

Staff facilities should be readily accessible to the duty areas. The purpose of this kitchen is to prepare beverages for members of the staff at tea breaks and lunch breaks, and to provide a place for washing and storing crockery and stocks of tea, coffee, sugar, milk and cleaning materials under lock and key. The kitchen area/room should be equipped with a sink, lock-up cupboards, bar fridge, and an instant boiling water dispenser (“Hydroboil” or similar approved).

Staff lockers should be provided for each non-central service member of staff for storing personal belongings.

====Procedure room====
The procedure room can be provided for the taking of blood and other specimens (except sputum). Clinical hand-wash basin with elbow taps to be provided. Work tops at standing height. Lock-up cupboards and a patient couch with good lighting. The electrocardiogram and the emergency trolley can be stored in this room.

====Store rooms====
Store rooms for provisions and consumables, surgical stores, equipment (such as wheelchairs, crutches and health technology) should be provided. These stores must be ventilated and fitted with shelves selected for appropriate storage of goods. Where electrical equipment is stored, electrical socket points may be required to ensure battery charging.

====Medical store====
A lockable room for store for the safekeeping of ward stock and scheduled drugs, infusions etc. is required. This must room must be cool (as close to 18 °C with passive means as possible), dry and dark (that is its electrical lighting should be independently controlled). It should be provided with a cabinet, worktop and adjustable shelving.

====Matron’s office====
The office should be a standard office with the normal requirements (desk, telephone, computer and network points, cupboards and a clinical hand-wash basin).

====Mortuary====
If a nearby referral healthcare establishment is available, a bier room may suffice. Alternatively a small mortuary may be provided. Refer to <u> [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Mortuary Services]''.''</u>

===Patient Support===
Care should be taken to avoid enclosed congregate settings (such as waiting areas) where possible. Where these are required, they should be regarded as high risk for airborne contamination.

====Visitor’s area====
This area must be separate from the ward, should have a meeting room for several families, veranda and garden. Seating and tables must be built in. The visitor facility can be shared between male and female patients. Access control must be provided for visitors.

====Visitor’s ablution====
To be attached to visitor’s area. At least one unisex accessible toilet is to be provided.

====Dining facilities====
In acute settings, patients may be served meals in bed. A hall to accommodate patients is recommended in long-term care facilities. This room should provide tables and chairs for all patients, a small kitchenette, fridge, microwave, stove and an instant boiling water dispenser (“Hydroboil” or similar approved). These areas should have ample access to the outside. This room can be interlinked with games and TV rooms (if provided).

====Business centre====
This room should provide access to computers with Internet connectivity, space and chairs.

====Resource centre/ media room/ library====
This room should be like a small lounge providing space for books easy chairs and big table and chairs for occupational therapy activities.

====Games room====
This room should provide space for e.g. snooker, table tennis, and board games. This can be interlinked with other patient support areas (e.g. dining and TV room).

====TV room====
Separate from dining and games room, this room should have a TV, DVD and lounge suites. To be interlinked with Games and Dining Rooms.

====Kitchenette====
In addition to central kitchen services, an area may be provided in which patients can prepare their own meals and wash dishes. This area should be provided with a stove/oven, microwave, fridge, an instant boiling water dispenser (“Hydroboil” or similar approved), double sink, dishwasher. Lock-up cupboards and counter top working areas. Lock-up cupboards will provide store space for crockery and consumables.

====Patient laundry====
In addition to the central laundry services, provision may be made for a laundry for patient use only. This room should provide a washing machine and washing trough, and have direct access to a drying yard.

====Other recreation====
Patients are encouraged to spend much time outdoors during convalescence. Consideration should be made to providing pleasant garden and planting areas, possible vegetable gardens, and permanent weather-proof seats. An outdoor covered patio with braai facilities connected to dining area should be provided. An outdoor uncovered patio connected to the games/ TV room area may be provided. Storm-water management around the proposed building and affected grounds should be considered.

===Allied healthcare services===
National policy recognises the importance of have a holistic psycho-social approach to patient care. Therefor provision should be made for allied health services preferably by practitioners on site, visiting practitioners or, alternatively at a nearby referral facility. Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Adult rehabilitation services for further guidance].

====Occupational therapy====
Occupational therapists (OTs) and assistant OTs deliver a service to TB patients. It may be challenging to motivate patients especially when they are sick and are treated with many drugs, which have severe side effects. OT aims to increase skills by training in several crafts, cooking classes etc.

====Audiology====
Audiology services are required as a common side-effect of TB treatment is hearing loss. A baseline hearing test ought to be performed upon patient admission and followed up with regular tests to determine the effects of the drugs on hearing. If hearing is affected, drugs regimens can be adapted. Sharing of audiology equipment with referral facilities may be problematic as conventionally audio booths are enclosed to control noise and may be inadequately adapted for airborne infection risk. It is highly recommended that dedicated mobile audiometers which do not require booths (see KUDUwave, or equivalent) are secured for TB facilities. These can be supported by telemedicine so that reduced on-site involvement of audiologist is possible. Where the use of mobile audiometers is not possible or appropriate, it is recommended that the audiology test booth used be ventilated and flushed with fresh air for 20 minutes between uses.

====Physiotherapy====
Physiotherapists and assistant physiotherapists deliver services to patients as required. This typically includes lung function tests, mobility exercises and assistance in sputum production where patients have difficulty.

====Clinical psychology====
Clinical psychologist sees patients on an individual basis, have climate groups and supervise the six lay counsellors in their work.

====Social services====
Social workers assist patients with social and economic issues which include the obtaining of grants, identity documents and family counselling.

===Support services===

====School====
Provision of school services may be negotiated with the relevant Provincial Department of Basic Education. Separate teaching and learning facilities may be provided.

====Kitchen====
Kitchen services may be outsourced or prepared on site. Refer to ''IUSS: GNS Catering Services''

====Laundry====
General laundry services can be provided on site, off site or can be shared (where co-located). Refer to [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Laundry and linen]. In addition to general laundry services some TB institutions encourage patients to wash their own clothing. Where this is the case, hand washing, washing machine, drying machines and/or drying yards should be provided.

===Facilities management===

====Waste management====
On-site disposal, storage and collection of waste need consideration. Refer to [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Waste disposal].

====Maintenance services - building====
Building maintenance services for both planned and unplanned maintenance (for example works foreman, electrician, painter, plumber, and carpenter) will be needed to provide service on site either on a full-time, part time or visiting basis depending on the size of the facility and institutional arrangement. Maintenance workshops and storage space may be required for this.

====Clinical engineering====

====Gardening services====
Gardening and grounds maintenance services may be provided on-site or outsourced. It is recommended that planting and landscaping is arranged near to building openings to discourage loitering nearby for infection prevention and control.

====Cleaning services====
Cleaning services may be outsourced. However storage of cleaning equipment, materials and staff facilities for cleaners is required to be provided on site.

===Administration===
Office accommodation is to be provided in accordance with the following reference: Department of Public Works, 2005. Space planning norms and standards for office accommodation used by organs of state. (Government notice 1665). Cape Town South Africa: Government Gazette.

===Other===

====Co-located institutions/ activities====
Medical researchers, NGOs and other organisations may provide services to and be co-located with the facility.

====Overnight stay====
Family member overnight accommodation is not routinely provided but may be desirable, particularly in rural settings.

====Commercial support (tuck shop, ATM)====
Tuck shop facilities and banking services may be provided - if viable - on site for staff and patients. This is highly recommended as otherwise infectious patients leave the site in order to attend to these requirements.

====Staff accommodation====
Staff accommodation for nursing and or/clinical staff may be required by provincial policy, and may be recommended in most cases, especially in rural settings. Separation on site of staff quarters and patient facilities on site should allow for staff safety and privacy, whilst remaining within comfortable walking distance of the patient facilities. Refer to [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Health facility residential]

='''Case studies'''=

==List of case studies==

* Areas comparison of long-term XDR TB care facilities at:
**Bongani Hospital, Mpumalanga
**Tshepong Hospital, North West
**Modimolle Hospital, Limpopo
*Modimolle TB Hospital
**site layout
**patient rooms
**natural ventilation design
*Catherine Booth TB Hospital, KwaZulu-Natal
**Roof ventilation and windows concept drawings
**Two-bed patient rooms plan

[[File:Case study A and B.jpg|none|thumb|535x535px|Case study A - Bongani Hospital, Case study B - Tshepong Hospital]]
[[File:Case study C and BCH proposal.jpg|none|thumb|536x536px|Case study C - MDR TB Unit, Modimolle and BCH proposal - Brooklyn chest Hospital]]
[[File:Modimolle TB hospital iite layout .png|none|thumb|537x537px|Modimolle TB Hospital (site layout)]]
[[File:Modimolle TB hospital patient rooms.png|none|thumb|537x537px|Modimolle TB Hospital (patient rooms)]]
[[File:Natural ventilation design principles.png|none|thumb|535x535px|Modimolle TB Hospital (Natural ventilation design principles)]]
[[File:Catherine Booth construction, windows and ventilation.png|none|thumb|536x536px|Catherine Booth TB Hospital, KwaZulu-NatalRoof (ventilation and windows concept drawings)]]
[[File:Two-bed patient rooms plan.png|none|thumb|537x537px|Catherine Booth TB Hospital, KwaZulu-Natal (Two-bed patient rooms plan)]]

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World Health Organisation (WHO), 2010. Workload indicators of staffing need: User’s manual. Geneva: WHO.

World Health Organisation (WHO), 2013. Global tuberculosis report. Geneva: WHO.

Xu Peng [et al.] Efficacy of ultraviolet germicidal irradiation of upper-room air in inactivatingairborne bacterial spores and mycobacteria in full-scale studies [Journal] // Athmospheric Environment 37. - 2003. - pp. 405-419.

Xu, P., Peccia, J., Fabian, P., Martyny, J.W., Fennelly, K.P., Hernandez, M. and Miller, S.L., 2003. Efficacy of ultraviolet germicidal irradiation of upper-room air in inactivating airborne bacterial spores and mycobacteria in full-scale studies. Atmospheric Environment, 37 (2003), pp.405–419.

='''Abbreviations'''=
{| class="wikitable"
|ACGIH
|American Conference of Governmental Hygienists
|-
|ACH
|Air changes per hour
|-
|AIA
|American Institute of Architects
|-
|AIIR
|Airborne infection isolation room
|-
|ASHRAE
|American Society of Heating, Refrigerating and Air-Conditioning Engineers
|-
|CDC
|Centers for Disease Control and Prevention (US agency)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|CSSD
|central sterile supply department
|-
|DR
|drug-resistant
|-
|DR TB
|drug-resistant TB
|-
|EIA
|environmental impact assessment
|-
|IAQ
|indoor air quality
|-
|ICT
|information communications technology
|-
|IPC
|infection prevention and control
|-
|IRPA
|International Radiation Protection Agency
|-
|LEV
|local exhaust ventilation
|-
|MDR TB
|multi-drug-resistant TB
|-
|NDoH
|National Department of Health
|-
|NGO
|non-governmental organisation
|-
|NHLS
|National Health Laboratory Service (SA agency)
|-
|NHI
|National Health Insurance
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|OHS
|occupational health and safety
|-
|OPD
|outpatient department
|-
|OT
|occupational therapy / occupational therapist
|-
|PAC
|Portable air cleaner
|-
|PHC
|primary healthcare
|-
|PMV
|predicted mean vote
|-
|PPE
|personal protective equipment
|-
|QASA
|Quadra-para Association of South Africa
|-
|REL
|recommended exposure limit
|-
|RH
|relative humidity
|-
|RSE
|relative spectral effectiveness
|-
|SAHNORMS
|South African hospital norms
|-
|SDP
|site development plan
|-
|TB
|tuberculosis
|-
|TLV
|threshold limit values
|-
|UVA
|ultraviolet “A” (wavelength 400 nm–315 nm)
|-
|UVB
|ultraviolet “B” (wavelength 315 nm–280 nm)
|-
|UVC
|ultraviolet “C” (wavelength 280 nm–100 nm)
|-
|UVGI
|ultraviolet germicidal irradiation
|-
|WHO
|World Health Organisation
|-
|XDR TB
|extreme (or extensively) drug-resistant TB
|}

='''Annexure 1. Indoor sputum booth'''=

==Application==
This document contains a set of drawings and specifications presenting prototype concept of a Sputum Booth developed at the CSIR. These are intended for the clinical applications. Further information can be obtained from the Architectural Engineering Group of the Building Scient and Technology Unit of the CSIR'''''.'''''

==Background==
This document presents technical drawings and specifications of the concept a sputum induction and collection booth designed for TB infection control in clinical settings. The prototype was developed by the Architectural Engineering Group, Building Science & Technology Programme, Division of Built Environment, CSIR. The development process of this facility was described in a separate report: ''“Development of a prototype of the Sputum Booth; CDC project”'', November 2013.

The related work was carried out in terms of the international research project funded by the Centre for Disease Control (CDC).
[[File:Sputum booth, rear view.jpg|none|thumb|Figure 10: Sputum booth, rear view]]

==Suggestions improvements on concept booth==
Upon the completion of the prototype unit, a few areas were identified for further improvements. These relate to the following:

*The mass of the unit is still too high for safe and resiliant transport. Solutions for weight reduction should be soughtExternal fold away handels could be included in the design for easier handling of the unit.
*The overall length of the booth could be reduced by about 150 mm. This would still provide enough space to accommodate a person in a wheelchair.
*The costs and mass of future units could be reduced by replacing the aluminium sandwich panelling with polymer sheeting
*The fan-filter unit could be constructed such that is an integral structural component of the booth, reducing size and weight of the overall unit.
*Incorporating an additional flexible one-way membrane behind the screen of the pre filter would limit the reversed airflow back into the booth when the booth is non-operational or during transportation.

==Arduino wiring code for door interlock timer==
/*Begin*/

/*

Sputum booth door lock control Sample code 08/11/2013

Written by: Tobias van Reenen (CSIR)

This Arduino Uno sketch controls a 12V magnetic door lock for a mechanically ventilated sputum booth

The door in this sketch remains normally locked and is released on the press of the external and internal door release buttons

The internal door release button will always unlock the door while the external button will only release the door after it has remained locked

for the predetermined length of time. This is in order to allow the booth ventilation system to adequately flush the booth between occupants.

The following wiring connections are made:

Arduino________Interface

GND ------------------ gnd

5.0v------------------ Vcc

Magnet power---------- +12V & -12V

8 -------------------- Release Button (Internal)

9 -------------------- Unlock Button (External)

10 ------------------- Unlock LED (Green)

11 ------------------- Locked LED (Red)

12 ------------------- Door Magnet Relay

<nowiki>*</nowiki>/

//Initiate variables

int doorLOCK = 12;    //5v relay pin, switching 12V Magnet

int lockedLED = 11;    //redLED

int unlockLED = 10;    //greenLED

int unlockButton = 9;    //External Button requesting an door unlock. Cannot override timer --requires 10k pull-up resistor & 5V Vcc

int releaseButton = 8; //Internal button requesting a door release. Overrides timer --requires 10k pull-up resistor & 5V Vcc

float unlockDELAY = 3000; //3 seconds

float lockDELAY = 30000;    //30 seconds

float unlockTimeStamp;

float lockTimeStamp;

int pressed = 0;

int unpressed = 1;

int UNLOCK = 1;

int LOCK = 0; //using normally closed relay config

int ON = 1;

int OFF = 0;

void setup() {

pinMode(doorLOCK,OUTPUT);

pinMode(lockedLED,OUTPUT);

pinMode(unlockLED,OUTPUT);

pinMode(unlockButton,INPUT);

pinMode(releaseButton,INPUT);

Serial.begin(9600);

Serial.println("restart");

digitalWrite(unlockLED,OFF);

digitalWrite(lockedLED,ON);

}

void loop() {

Serial.print("unlock: ");

Serial.print(digitalRead(unlockButton));

Serial.print(" release: ");

Serial.print(digitalRead(releaseButton));

Serial.print(" unlockLED: ");

Serial.println(digitalRead(unlockLED));

if (digitalRead(releaseButton) == pressed){ //check for release button press

while (digitalRead(releaseButton) == pressed){    //holds code until button released

unlockDOOR();    // unlock door function

}

}

if (digitalRead(unlockButton) == pressed){ //check for unlock button press

   if (digitalRead(unlockLED) == ON){ //only unlocks door if unlock LED is lit

while (digitalRead(unlockButton) == pressed){//holds code until button released

   unlockDOOR();

}

} //unlock door function

   }

if (millis()> (unlockTimeStamp+unlockDELAY)){    //counts down unlock delay and then locks door again

   Serial.print("CountDown: "); Serial.println((lockDELAY+unlockTimeStamp+unlockDELAY-millis())/1000);

   if ((digitalRead(unlockButton) == unpressed)&&(digitalRead(releaseButton) == unpressed)){

if (digitalRead(doorLOCK)!=LOCK){ //checks for unlock button hold before locking door

   lockDOOR(); //lock door function

}

   }

}

if (millis()> (lockTimeStamp+lockDELAY)){

   digitalWrite(unlockLED, ON);

   }

}

void unlockDOOR(){

Serial.println("unlocking...");

unlockTimeStamp = millis();    // initiate unlock counter

digitalWrite(lockedLED,OFF);

digitalWrite(unlockLED,OFF);

digitalWrite(doorLOCK,UNLOCK);

}

void lockDOOR(){

Serial.print("locking... ");

lockTimeStamp = millis();

digitalWrite(doorLOCK,LOCK);

digitalWrite(lockedLED,ON);

digitalWrite(unlockLED,OFF);

Serial.print("unlockLED: ");

Serial.println(digitalRead(unlockLED));

}

/*end*/

==Drawings==
[[File:Sputum booth, left view.jpg|none|thumb|490x490px|Figure 11: Sputum booth, left view]]
[[File:Sputum booth, front view.png|none|thumb|484x484px|Figure 12: Sputum booth, front view]]
[[File:Sputum booth, Isometric view.png|none|thumb|498x498px|Figure 13: Sputum booth, Isometric view]]
[[File:Sputum booth, door control logic.png|none|thumb|547x547px|Figure 14: Sputum booth, door control logic]]
[[File:Sputum booth, door controller wiring.png|none|thumb|Figure 15: Sputum booth, door controller wiring]]
[[File:Sputum booth, door controller PCB (NTS).png|none|thumb|Figure 16: Sputum booth, door controller PCB (NTS)]]
='''Annexure 2.    Pre-fabricated outdoor sputum booth'''=
[[File:Sputum Booth Isometric view.png|none|thumb|Figure 17: Sputum booth Isometric view]]
[[File:Sputum Booth front view.png|none|thumb|Figure 18: Sputum booth front view]]
[[File:Sputum booth, side view..png|none|thumb|Figure 19: Sputum booth, side view.]]

='''Annexure 3. Brickwork outdoor sputum booth'''=
[[File:Brickwork sputum booth-layout and detail.png|none|thumb|502x502px|Figure 20: Brickwork sputum booth-layout and detail]]

<br />
[[Category:Clinical Services]]

TB Services

2021-09-03T09:58:16Z

VSadiki: /* Policy and service context */

='''PART A -''' '''Policy and service context'''=

==1. Legislation, policies and international guidance==

===1.1. Infection Prevention and Control Legislation===

<div style="color:#00000a;">The National Infection Prevention and Control Policy and Strategy makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*<span style="color:#00000a;">Constitution</span><span style="color:#00000a;">'' of the Republic of South Africa, 1996''</span>. <span style="color:#00000a;">s.2,24,27,36&39.</span>
*<span style="color:#00000a;">''The National Health Act 2003''</span>. <span style="color:#00000a;">(c.61). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''The Occupational Health and Safety Act 1993''</span>. <span style="color:#00000a;">s.8(1).</span> <span style="color:#00000a;">Cape Town South Africa: Government Gazette.</span>

Department of Labour, 2001. <span style="color:#00000a;">''Regulations for hazardous biological agents''</span>. (Government notice No. R. 1390 of the Occupational Health and Safety Act, 1993. s.43). Pretoria South Africa: Government Gazette

Department of Health, 2003. <span style="color:#00000a;">''Regulations relating to the application of the hazard analysis and critical control point system (HACCP system). ''</span><span style="color:#00000a;">(Government notice No. R. 908 of the Foodstuffs, Cosmetics and Disinfectant Act, 1972. (c.54)). Cape Town South Africa: Government Gazette.</span>

*<span style="color:#00000a;">''The Environmental Conservation Act 1989''</span>. <span style="color:#00000a;">(c.73). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''The Foodstuffs, Cosmetic and Disinfectants Act 1972.''</span> <span style="color:#00000a;">(c.45). Cape Town South Africa: Government Gazette.</span>
</div>
===1.2. Building legislation===

<div style="color:#00000a;">The following legislation and regulations impact and provide guidance on the provision and design of healthcare facilities as above:

*<span style="color:#00000a;">''The Pharmacy Act 53 of 1974.''</span> <span style="color:#00000a;">(c.53). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''The National Environmental Management Act 1998.''</span> <span style="color:#00000a;">(c.107).</span> <span style="color:#00000a;">Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">''Building Regulations and Building Standards Act 1977.''</span> <span style="color:#00000a;">(c.103). Cape Town South Africa: Government Gazette.</span>
*<span style="color:#00000a;">South African Bureau of Standards (SABS), 1990.</span> <span style="color:#00000a;">''SANS 10400:1990 Code of practice for the application of the national building regulations.''</span><span style="color:#00000a;">Pretoria South Africa: SABS Standards Division.</span>
*<span style="color:#00000a;">''Promotion of Equality and Prevention of Unfair Discrimination Act 2000.''</span> <span style="color:#00000a;">(c.4). Cape Town South Africa: Government Gazette.</span>
</div>
===1.3. Infection prevention and control and TB management policy and guidelines===

*<span style="color:#00000a;">National</span><span style="color:#00000a;"> Department of Health (NDoH), 2007.</span> <span style="color:#00000a;">''The draft national infection prevention and control policy for TB, MDRTB and XDRTB.''</span> <span style="color:#00000a;">South Africa: NDoH.</span>

National Department of Health, 2007. <span style="color:#00000a;">''Management of drug-resistant tuberculosis: Policy guidelines''</span>. [pdf] South Africa: NDoH. Available at: http://www.search.gov.za [Accessed 26 March 2014].<div style="color:#00000a;">National Department of Health, n.d. <span style="color:#00000a;">''Tuberculosis strategic plan for South Africa, 2007-2011.''</span> [pdf] South Africa: NDoH. Available at: http://www.search.gov.za/info/search.jsp. [Accessed 26 March 2014].

===1.4. South African building practice policy and guidelines===

*The South African Pharmacy Council, 2004. ''Good pharmacy practice. ''(Board notice 129). Cape Town South Africa: Government Gazette.
</div>
===1.5. International design guidance===
South Africa faces one of the most devastating TB epidemics in the world. TB – with TB/HIV/Aids – is the leading cause of death

*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 1999.</span> <span style="color:#00000a;">''ANSI/ASHRAE standard 52.2-1999 Method of testing general ventilation air cleaning devices for removal efficiency by particle size.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>
*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 1989.</span> <span style="color:#00000a;">''ASHRAE standard 62 Ventilation for acceptable indoor air quality.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>
*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2003.</span> <span style="color:#00000a;">''HVAC design manual for hospitals and clinics.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>

Chartered Institution of Building Services Engineers (CIBSE), 1997. <span style="color:#00000a;">''CIBSE applications manual AM10 natural ventilation in non-domestic buildings.''</span> London: CIBSE.<div style="color:#00000a;">Chartered Institution of Building Services Engineers (CIBSE), 2000. <span style="color:#00000a;">''CIBSE applications manual AM13 mixed mode ventilation.''</span> <span style="color:#00000a;">London: CIBSE.</span></div><span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE),</span>

*<span style="color:#00000a;">American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009</span>. <span style="color:#00000a;">''ANSI/ASHRAE/ASHE standard 170-2008 ventilation of health care facilities.''</span> <span style="color:#00000a;">Atlanta USA: ASHRAE.</span>
*QASA, “Know Your Rights” [Accessibility & the Built Environment]
*<span style="color:#00000a;">Department of Health and Human Services (Centre for Disease Control and Prevention), 2003.</span> <span style="color:#00000a;">''Environmental control for tuberculosis: Basic upper-room ultraviolet germicidal irradiation guidelines for healthcare setting. ''</span><span style="color:#00000a;">USA: DHHS.</span>
*<span style="color:#00000a;">World Health Organisation (WHO), 2009a.</span> <span style="color:#00000a;">''Natural ventilation for infection control in health-care settings.''</span> <span style="color:#00000a;">Geneva Switzerland: WHO</span>
*<span style="color:#00000a;">World Health Organisation (WHO), 2009b.</span> <span style="color:#00000a;">''WHO policy on TB infection control in health-care facilities, congregate settings and households''</span>. <span style="color:#00000a;">Geneva Switzerland: WHO</span>

==2. Service context==

<div style="color:#00000a;">South Africa faces one of the most devastating ''Mycobacterium ''tuberculosis (TB) epidemics in the world, especially in terms of number of TB cases per capita and the total numbers of drug-resistant (DR) TB cases with a prevalence of 450/100 000. It has the third-highest incidence of TB globally (WHO, 2013, p.11). TB, together with HIV/Aids, is South Africa’s leading cause of morbidity and mortality. Furthermore, healthcare workers are at six or more times increased risk of acquiring TB, compared to the background population (Joshi, et al., 2006).
The WHO reports that TB treatment success is low and treatment default rates and mortality are high. The high default from TB treatment by patients represents a major problem which, in conjunction with other factors, has led to the emergence of drug-resistant TB (DR TB). Transmission of TB, multi-drug-resistant TB (MDR TB) and extreme (or extensively) drug-resistant TB (XDR TB) in communities and congregate settings has been documented in several studies, frequently linked to HIV infection and affecting vulnerable groups such as children. MDR and XDR TB linked with HIV therefore have the potential to result in an uncontrollable epidemic with devastating economic and social consequences. The epidemiological burden co-infection in South Africa is currently estimated to be in excess of 70% of TB and HIV (WHO, 2009b).<sup> </sup>Provision of poorly designed, maintained and operated infrastructure can exacerbate transmission. Well-designed and well-maintained facilities can reduce the risk of TB infection.

''M. tuberculosis'' is an infectious disease, and is transmitted from person to person exclusively by the airborne route, usually through coughing by a patient with active pulmonary TB. MDR TB is a consequence of human error resulting from combinations of the management of drug supply, patient management, chemotherapy prescription and patient adherence. Treating MDR TB takes longer and requires drugs that are more toxic, more expensive (up to 100 times the cost of treating a drug-susceptible TB patient) and generally less effective, particularly in persons with HIV infection.

The problem of drug resistance in TB has been compounded by the emergence of XDR TB. Patients with XDR TB are extremely difficult and expensive to treat, with mortality rates between 50 and 70% (CDC, undated).<sup> </sup>In XDR TB patients with HIV co-infection, mortality rates, though improving, remain at about 90% (Neel, et al., 2010).

Owing to the District Health system, patients are intended to, and generally do, enter the healthcare system via primary healthcare services - namely the clinics and community health centres (CHCs) and private general practitioners (GPs). It is in these settings that untreated, undiagnosed infectious individuals will inevitably come into contact with susceptible individuals and the risk of transmission is produced. With the introduction of the NHI, the profile of risk in former “private” facilities may change as demographic shifts in access to these services occur. It is therefore in the interest of public health that private-sector facilities are designed, constructed and operated to meet airborne infection control requirements.

The National Department of Health (NDoH) Primary Healthcare Directorate advocates the WHO-endorsed approach in the public sector to integrated service provision (WHO, 2011). In the context of this document, this means that individuals seeking care are to receive all appropriate services and interventions at a “one-stop shop”. The common practice of provision of service by diagnosis within a facility (e.g. separation of TB, HIV/Aids, diabetes) or by vertical programmes (different clinical activities on different days) does not support integration of services. This implies that, as far as it is safe and reasonable, most services should be available in most patient/client contact spaces. The integration of services should not subject healthcare workers, clients or the public to undue exposure to airborne pathogens. In particular, when reconfiguring services in existing facilities, due diligence must be paid in ensuring that designs meet required standards for TB infection control.

Most TB patients will access services at the primary healthcare level and will require access on site to '''integrated''' services including, but not limited to:

*clinical assessment (consulting room with examination facilities, clinical scale);
*safe facilities for sample (sputum) collection;
*nutrition;
*psychosocial services (counselling); and
*pharmacy dispensary for chronic medication.
</div>
In addition, on- or off-site access to the following services is required

*laboratory services (microscopy, culture, GeneXpert, for drug sensitivity), and
*radiology.

For a quick reference to primary healthcare services for uncomplicated building projects consult [https://iussonline.co.za/norms-standards/clinical-services/ IUSS:GNS Primary Healthcare].<div style="color:#00000a;">The majority of TB patients will be able to be treated in outpatient mode, with community-based adherence support and regular check-ups at the facility, and regular collection of chronic medication. A small number of patients, such as those who are severely ill, have more than one health concern (co-morbidity), or who are highly infectious may be admitted voluntarily to inpatient care in healthcare facilities. This may be within the general hospital population, in dedicated TB wards or in specialised dedicated facilities.
Evidence suggests that drug-susceptible TB and MDR TB, when diagnosed and under treatment, become rapidly less infectious (Dharmadhikari, forthcoming). This means that, after as little as 24 hours on '''appropriate''' treatment, TB patients - and even MDR patients - can be regarded as and accommodated with the non-infectious population. No special facilities are required for these patients (if they are short-term patients) and they can be accommodated in accordance with IUSS norms and standards (Refer to [https://iussonline.co.za/norms-standards/clinical-services/ IUSS:GNS Adult inpatient services]).

Patients recently enrolled on treatment (<24hours) who are suspected of having XDR, confirmed XDR patients, patients who interrupt treatment, and complicated cases may be considered infectious and negative-pressure isolation is strongly recommended - or, if not possible, at least patient management by respiratory isolation or, if that is not possible, by patient cohorting (patient management by clustering patients with most similar diagnoses).

The number of DR TB cases in South Africa increased from 10 085 in 2011 to 15 419 in 2012 (WHO, 2013, p.52). This is largely due to intensified case finding and investment in laboratory services. However, it represents only a portion of the estimated cases (WHO, 2013).

Since 2010 the SA National Department of Health has adopted a policy of decentralised management of Multi Drug-resistant TB. In addition to outpatient services, there is a requirement for inpatient hospital facilities:

*for all types of TB patients (pulmonary, extra-pulmonary, etc.) requiring acute treatment for TB or other comorbidities
**within patient populations of general hospitals,
**In dedicated wards at general hospitals for acute episodes, and
**at specialised hospitals (long-term accommodation) for sub-acute and palliative care for patients who are not best served by community-based care, for various reasons.
</div>
Inpatient beds for TB services have frequently been provided by converting old wards and sanatoria as a quick solution to address at least part of the pressing need. In many instances building infrastructure has been modified or retrofitted with the intention of making it suitable. However, because beds are provided in this reactive way, the infrastructure is frequently poorly aligned with current best infection-prevention and ‑control practice and patient-centred care.<div style="color:#00000a;">South African healthcare workers are increasingly becoming aware of the need to implement and manage infection-control measures for preventing the spread of infectious diseases in healthcare settings; however, due to lack of resources, inadequate facility design and the lack of environmental controls, the means for achieving adequate infection-prevention and -control are not always found.
There have been both legal and ethical challenges posed to TB hospitalisation (Singh, Upshur and Padayatchi, 2007; London, 2009). Media have reported incidents of patients rioting and absconding (Dugger)<sup> </sup>which attested to the unpopularity of the policy and the unsuitability of the arrangements, including - though by no means limited to – the building infrastructure provided.

The NDoH has subsequently recognised the need to provide recreational, occupational and educational facilities for patients that require specialised long-term DR TB treatment (NDoH, 2007b, p.25). Social support should also be provided for all patients and their families whilst hospitalised. In the past TB facilities were simply not designed or built to address these needs. This must be recognised when assessing precedent or in identifying case study examples [[File:Centralised management of MDR TB.jpg|none|thumb|555x555px|Figure 1: Centralised management of MDR TB]]Consequently the National Department of Health expanded its approach in adopting a multi-faceted decentralisation policy in future according to the following health framework for DR TB management (see ''Decentralised Management of Multi Drug Resistant TB – a Policy Framework for South Africa''). According to this framework (see Figure 3), for a successful decentralised MDR TB programme, the following should be provided in inpatient care facilities in order to ensure adequate infrastructure and infection control measures:

*Well ventilated consulting room
*Well ventilated waiting area
*Well ventilated rooms that can accommodate from one to six patients
*Distance between beds not less than 1.2 m
*Administration control measures of infection control in place
*UVGI lights and extractors fans where possible
*Respiratory protection tools available: surgical masks, N95 respirators

These policy requirements will go some way to addressing the twin objectives of patient-centred care and effective infection prevention and control in the emerging pandemic. However, there are additional planning, design, management and maintenance considerations to reach best practice standards and these are discussed in detail below.
</div>

='''PART B - Understanding transmission to manage risk'''=

==1. Transmission of M. Tuberculosis==

<div style="color:#00000a;">In healthcare settings, physicians, nurses, general hospital staff, fellow patients and visitors are at a high risk for TB infection because they share the same breathing space as infectious patients: the transmission of TB disease is through the airborne route. Varicella-zoster virus, measles virus, and smallpox virus can also be transmitted by the airborne route, and mitigated with the means described in this document, but do not currently pose a comparable public health concern.
When the droplets produced by an infected person are inhaled by a susceptible person, TB may be contracted. However, this alone does not seem to account for observable instances of transmission. There is a widely accepted theory - the droplet-nucleus hypothesis - that infectious droplet nuclei containing tubercle bacilli may remain suspended in air for prolonged periods of time, potentially long after the infector has left the room. This leads to a high risk of infection in congregate settings (shared spaces). This risk cannot be eliminated. However, expert consensus is that with adequate ventilation or air purification the risk can be reduced. Here is a brief explanation for the transmission theory<sup> </sup>(Riley and O’Grady, 1961).

The bacterium, ''M. tuberculosis'', becomes aerosolised in small droplets of water or bodily fluid when a person with the disease of the lung coughs, sneezes, laughs or sings. Many of the smallest respiratory droplets dry into “droplet nuclei” and become airborne following room air currents is described. Infection can occur when the droplet nuclei containing the bacterium are inhaled [[File:Coughing generating aerosols.jpg|none|thumb|222x222px|Figure 2: Coughing generating aerosols - Source Jennison 1942]]''M. tuberculosis'' infection is different from TB disease. People having the infection without disease (latent TB) have been infected by the ''M. tuberculosis'' bacterium. They are not symptomatic because their body’s immune system has encapsulated the infectious material in the lung, where it is held dormant. They cannot spread the bacterium or disease to others when in this phase. However, people with infection may reactivate a dormant focus in the future, leading to disease.
</div>The infection turns to disease when the body can no longer contain the infectious material in the lung. The infection then spreads, usually within the lung (where it is called pulmonary TB) and possibly to other areas of the body. This spread usually shows up as chronic respiratory symptoms such as cough and fever. People with TB disease of the lungs can therefore transmit the infectious bacterium.

===1.1. Disease status===
<div style="color:#00000a;">TB patient status could at any point:

*be actively diseased and infectious;
*be simultaneously infected by more than one strain;
*be diseased and undergoing treatment;
*be recovered after undergoing therapy;
*be developing resistance while undergoing therapy;
*have latent disease;
*have relapsed into disease;
*be re-infected;
*be immune; or
*have additional related/ unrelated medical conditions (co-morbidity)</div>
Determining the current status of any given patient or transition times between statuses is problematic (given lags in diagnosis, individual patient responses etc.).

Table 1: Drug resistance TB (CDC, 2010, slide number 28)
{| style="border-spacing:0;width:14.87cm;"
|-
| style="background-color:#009999;border-top:1.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Mono-resistant'''
| style="border-top:1.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to any one TB treatment drug
|-
| style="background-color:#009999;border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Poly-resistant'''
| style="border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to at least any 2 TB drugs (but not both isoniazid and rifampin)
|-
| style="background-color:#009999;border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Multidrug-resistant '''

'''(MDR TB)'''
| style="border-top:0.5pt solid #000001;border-bottom:0.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to at least isoniazid and rifampin, the 2 best first-line TB treatment drugs
|-
| style="background-color:#009999;border-top:0.5pt solid #000001;border-bottom:1.5pt solid #000001;border-left:1.5pt solid #000001;border-right:0.5pt solid #000001;padding:0cm;" |'''Extensively'''

'''drug-resistant '''

'''(XDR TB)'''
| style="border-top:0.5pt solid #000001;border-bottom:1.5pt solid #000001;border-left:0.5pt solid #000001;border-right:1.5pt solid #000001;padding:0cm;" |Resistant to isoniazid and rifampin, PLUS resistant to any fluoroquinolone AND at least 1 of the 3 injectable second-line drugs (e.g., amikacin, kanamycin, or capreomycin)
|-
|}
===1.2. Manifestations of TB===

<div style="color:#00000a;">TB is an infection caused by ''Mycobacterium tuberculosis'' also referred to as tubercle bacilli. TB most commonly affects the lungs, producing pulmonary TB. It can however spread to almost any part of the body including lymph glands, joints, kidneys and bone called extra-pulmonary TB. Pulmonary TB is the manifestation of most concern to built environment professionals as it produces greatest risk for transmission to others.</div>

====Drug-susceptible TB====

<div style="color:#00000a;">By far the majority of TB cases are susceptible to widely accessible, inexpensive drugs. It is generally curable if treatment is completed.</div>

====Pre-MDR TB====

Drug resistance [see Table 1: Drug resistance TB (CDC, 2010, slide number 28)] can only be defined through laboratory confirmation of in-vitro resistance to one or more anti-TB drugs. Results are defined as follows:

*Mono-resistant TB: in patients whose infection isolates of M. tuberculosis are confirmed to be resistant to one first line anti-TB drug.
*Poly-resistant TB: TB in patients whose infection isolates are resistant in vitro to more than one first line drug, other than isoniazid and rifampicin.

====MDR TB====

<div style="color:#00000a;">MDR TB is active TB involving ''M. tuberculosis'' organisms that are resistant to at least isoniazid and rifampicin, the two most powerful anti-TB agents. An MDR TB strain can be resistant to more than these two antibiotics and in most cases it is resistant to first line drugs. </div>

====Pre-XDR TB====

<div style="color:#00000a;">Pre-XDR TB is MDR TB which is resistant to either a fluoroquinolone or an injectable, but not both. </div>

====XDR TB====

<div style="color:#00000a;">XDR TB is defined as TB with resistance to isoniazid and rifampicin, and - in addition to any fluoroquinolone, - to at least one of the three following injectable drugs used in anti-TB treatment: capromycin, kanamicyin and amikacin. Unlike TB and MDR TB patients, XDR TB patients are infectious even when on treatment and their drug-resistant strain can be transmitted directly to susceptible individuals. In other words, infection with a drug-resistant (including an XDR) strain of TB is possible without having contracted TB previously. </div>

====Paediatric patients====

<div style="color:#00000a;">Children can contract any of the strains that adults can and manifest TB in all forms that adults present. There is consensus that whilst small children may have less lung capacity to develop velocities required for aerosolisation this has not been proven and is not universally true. Older, larger children are more likely to have transmission patterns like adults. </div>

===1.3. Origin of airborne infection===
<div style="color:#00000a;">Organism-bearing particles are liberated into the air primarily from activities involving the respiratory tract such as sneezing and coughing. In quiet breathing, very few organisms are liberated, but in talking, coughing and especially in sneezing, large numbers of droplets, many of which contain organisms, are ejected. The high velocity of air passing over the respiratory tract shears off a profusion of small droplets which are forcibly ejected into the air.
The size of the droplets swept by an air current from the surface of a liquid is determined principally by the velocity of the air and the surface tension of the liquid. As the air velocity increases, the size of the droplets decreases until above 100 m/s where the diameter of the water droplets approaches at least 10 microns (μm). In sneezing and coughing, the peak air flow in the bronchi approaches 300 m/s and the droplets are in the order of six μm in diameter.

After being expelled from the TB patient’s mouth and nose, even the smallest droplets begin to fall. Generally, the large particle droplets fall to the ground where they become mixed with dust (see Figure 11). The fate of the smaller droplets is however, quite different. Droplets below a certain aerodynamic diameter fall slowly and lose water rapidly and evaporate almost instantaneously. In this way the droplet diminishes in size until the concentration of dissolved substances is such that the vapour pressure which the droplet exerts equals that of the atmosphere.

The residue of the droplet after evaporation, which may contain the micro-organism(s) from the respiratory tract, has been called the droplet nucleus. Droplet nuclei are so light that they may not settle in the gentlest of moving air of occupied spaces and may remain suspended for extended periods of time. This poses risk to building occupants until the particles are removed by ventilation or through other air disinfection.

Tubercle bacilli cannot be cultured from the air because of their low concentration and slow growth rate relative to other micro-organisms. The slow growth of tubercle bacilli and low concentrations in air require long sampling periods during which culture media, even with selective antibiotics to suppress microbial growth, become overgrown with fungi and other bacteria. Molecular amplification methods can detect nucleic acid from tubercle bacilli in the air, but cannot distinguish living from dead organisms nor quantify those with infectious potential. It is therefore not possible to measure infectiousness of TB or DR TB directly, nor can the efficacy of environmental infection control interventions to reduce or prevent transmission be measured directly.

Also, when considering airborne contagion, it is not well understood is how many infectious particles, or droplet nuclei, are required to infect. Compounding this uncertainty there are marked differences in the numbers of organisms liberated by coughing and sneezing of individual infectors. Despite these limiting factors, which are the subject of on-going speculation, investigation and scientific research, the general principles of contagious potential applies.

In any form of contagion the probability of infection increases with the degree of exposure to the infection (see Figure 3: Contagion). The factors implicated in the potential to be contagious are:

*the presence of susceptible members of the community
*the presence of infectious cases
*the effective contact rate (opportunities for transmission) influenced by variables which in the airborne example are factors such as:
**exposure time
**breathing rates of infector and susceptible
**virulence (strength) of bacteria
**environment (qualities of the room, such as humidity, air volume)
</div>
[[File:Contagion.png|none|thumb|439x439px|Figure 3: Contagion]]
The probability of infection (1- e -Iqpt/Q) as a function of degree of exposure to infection Iqpt/Q (The point where Iqpt/Q =1 is identified by the co-ordinates).<div style="color:#00000a;">
The number of new cases occurring in an epidemic is directly related to the number of susceptible persons, the number of infectors and the effective contact rate. Respiratory droplets (for example flu), with their limited flight, range and dependence on the simultaneous presence of source and subject, behave as a form of effective contact. Droplet nuclei, with their prolonged suspension and rapid dispersion may provide an enhanced exposure and effective contact rate. It was for this reason that Wells called droplet-nucleus-borne infection, airborne contagion.

DR TB can be acquired in two different ways: primary and secondary modes. Primary transmission is caused by person-to-person transmission of a drug-resistant strain of the TB bacilli. Secondary infection develops during TB treatment, either because the patient was not treated with the appropriate treatment regimen or because the patient did not follow the treatment regimen as prescribed. Approximately 1.8% of new TB and 6.7% of retreatment cases results in MDR. DR TB can be transmitted in the same way as drug-susceptible TB.

Evidence suggests virulence of DR TB is the same as for drug-susceptible strains. However, DR TB is more difficult to treat because it can survive in a patient’s body even after treatment with the first-line drugs is started. A key challenge with current tuberculosis diagnosis technique is the delay in culturing this slow-growing organism in the laboratory. Blood or sputum culture results can take between four and twelve weeks. Because there has historically been a delay in diagnosing drug-resistant TB, these patients may be infectious for a longer period of time. Rapid screening tools for drug-resistance (GeneXpert) have been approved by the WHO, and are now in widespread use in South Africa.

The infectious droplet-nuclei which may remain suspended in air for prolonged periods of time and the respiratory droplets leads to a high risk of infection in shared spaces. This risk cannot be eliminated. However, expert consensus, based on strong circumstantial evidence, is that with adequate planning, design, management and maintenance, this risk can be reduced or managed. International best practice indicates that patients with drug-resistant TB should be closely monitored when commencing treatment and they should remain in isolation until they are no longer infectious.
</div>

The following invasive procedures should be regarded as high risk situations for transmission (Culver, Gordon and Mehta, 2003):

*bronchoscopy,

*sputum collection and induction, and
*administration of aerosolized medications

===1.4. Infection prevention and control hierarchy===

<div style="color:#00000a;">The emergence of DR TB has highlighted the need for strengthened infection prevention and control (IPC) measures to interrupt the transmission of TB in healthcare settings. There is has been no observed difference between the speed of transmission of susceptible TB and resistant MDR or XDR TB. For this reason, infection control measures apply to all TB strains irrespective of the resistant pattern.
The requirement for controls to minimise the risk of spreading this airborne disease is legislated in the ''OHS Act'' (Act 85 of 1993). ''The National Department of Health Tuberculosis Strategic Plan for South Africa, 2007-2011'', in the ''Decentralised Management of Multi Drug Resistant TB – a Policy Framework for South Africa'' and various international agencies such as the WHO, Centers for Disease Control and Prevention in the USA provide policy guidance for infection control practices. Common to the last two is the need to base these practices on the hierarchy of control measures. These are arranged from most to least important as follows:

Administrative measures such as work practices, policies and procedures, education and training, TB screening of healthcare workers, and appropriate utilisation of existing facilities, the implementation of environmental (engineering) controls, and the use of personal respiratory protection in specified areas where there is a high risk of exposure.
</div>

===1.5. Administrative IPC measures===
<div style="color:#00000a;">Appropriate architectural design to support the functional and operational processes required for the first level of the hierarchy of control, namely the administrative measures, must be investigated and ensured via the design and layout of the facility as a priority. The first and most important level of control is the use of administrative control measures is to prevent conditions for the spread of contagion, by limiting number and duration of encounters between susceptible members of the community and infectious air. Ideally, if the risk of exposure can be eliminated, no further controls are needed. Unfortunately, the risk usually cannot be eliminated, but it can be significantly reduced with proper administrative control measures. In any healthcare setting, important administrative control measures include:

*early diagnosis of potentially infectious TB patients,

*prompt separation or isolation of infectious TB patients, and
*the prompt initiation of appropriate anti-tuberculosis treatment.</div>
Other important administrative control measures include an assessment of the risk of transmission in the facility, the development of a TB infection control plan that details in writing the measures that should be taken in a given facility, and adequate training of healthcare workers to implement the plan.
[[File:CSIR generic model illustrating the functional separation.png|none|thumb|489x489px|Figure 4: CSIR generic model illustrating functional separation]]
From a facility planning and design perspective, administrative control measures can be addressed through the spatial separation techniques of functional separation, respiratory isolation, and separation for patient management. Functional separation (see Figure 4) provides for the physical separation of functionally discrete parts of the facility. Administrative functions and clinical support (admissions and discharge, accounts and finance, information services, medical records) should be substantially or exclusively reserved for staff use, and zoned separately. Nursing services, outpatient facilities, allied health services (radiology, pharmacy, rehabilitation) and visitors’ spaces may be used by both patients, staff and visitors, but should be laid out and managed so that the appropriate infection control measures are ensured. Finally patient support facilities, recreation facilities, and patient wards should be accessible to patients, but not necessarily all patients at all times, because of risk of cross-infection.<div style="color:#00000a;">
The following situations and design features have been identified as presenting the potential for increased risk of TB transmission in healthcare settings, so that when allocations of spaces are made in existing infrastructure systems the following should be borne in mind:

*Congregate settings - any setting (usually waiting areas) where large groups of patients are kept in close proximity to each other are potentially high risk areas. The highest risks are usually in admission, main outpatient, emergency or pharmacy waiting areas where undiagnosed or untreated patients congregate. Smaller waiting areas or other functional areas, such as in x-ray departments or even multi-bed patient rooms can equally pose a risk.

*Restricted / inadequate ventilation - appropriate ventilation is important, especially in congregate settings or other direct contact areas, such as dining facilities, occupational therapy areas etc. Waiting areas need to be adequately ventilated at all times in order to dilute concentrations of infectious airborne bacteria. Areas such as consulting, examination, counselling or treatment areas where staff spend long times in relatively small areas in close proximity to patients should be considered high risk areas. Minimum opening window areas are prescribed but often not complied with. The WHO guidelines (WHO, 2009a) indicate a target of 20% open window area to space floor area. The design of the window is also important to promote natural ventilation. However improved ventilation alone is usually not enough to reduce risk in that the directional flow of air to and from adjacent areas needs to be addressed.
*Shape and volume - the shape and volume of a space can also be a risk indicator. Occupied spaces with minimal floor to ceiling height (often found in multi-storey buildings) are generally higher risk areas than those with a shaped ceiling to high level clear storey windows. Shape and volume usually is linked to ventilation flow patterns and rates. The position and ease of opening of both high and low level windows is important. Staff awareness of the need to keep windows open to allow unobstructed ventilation is needed. “Open window” stickers are frequently used to provide visible reminders of open window policy.
*Adjacency - the distance between carriers and staff or other patients is a risk factor. Congregate areas where patients are sitting close together is an obvious situation and settings where close contact occurs such as during consultation, examination and treatment are risk situations. Narrow bed spacing (less than 1.2 m) presents risk for both fine droplet and droplet nuclei contamination. Multi-bed wards configurations are risk situations.
*Places where aerosol-generating procedures are undertaken- These are defined as high-risk procedures that may increase the potential of generating droplet nuclei because of the mechanical force of the procedure (e.g. intubation, cardiopulmonary resuscitation, bronchoscopy, autopsy, and surgery where high-speed devices are used) (WHO, 2007)</div>
Total respiratory isolation for TB treatment would be ideal from an infection prevention and control point of view. Several factors make this both impractical and undesirable. First there are negative social and psychological impacts to strict separation including isolation and stigmatisation of patients. Second, nursing requirements, acuity and management dictate that patients must be visible to healthcare workers and accessible to them.<div style="color:#00000a;">Whilst provision of single bed wards is advisable as far as possible, shared spaces for joint activities are required. Estate legacy constraints (the size and shape of existing rooms), affordability (single-bed wards require a higher capital investment, higher operational and maintenance costs) and nursing acuity constraints (compact configurations allow for improved nursing efficiency) mean that single-bed configurations are not always possible, and it therefore is common practice at facilities in South Africa to provide rooms with two, four, six or more patients.
TB facilities generally experience highly fluctuating patient demographics and needs. Given resource constraints and high demand, it is frequently useful to provide configurations which allow for flexible arrangements which can be administered according to prevailing needs.
</div>

Management of patients may require spatial and/ or physical separation in accordance with facility policy:

*according to gender
*ostensibly drug susceptible TB – retreatment (treatment failure)
*Mono-resistant TB (suspected-MDR)
*Poly-resistant TB (suspected-MDR)
*MDR TB
*MDR treatment failure
*Pre XDR TB
*XDR TB
*XDR treatment failure
*First sputum culture negative result, pending second result (suspected cured)
*children (with or without boarding parents)
*patients requiring isolation ( for additional infectious diseases, psychological disturbance, prisoners)

Occasionally facility policy may allow for or require additional accommodation for outpatients, visitors or patients awaiting transfer. This may be applicable to specialised facilities (Centres of Excellence), where family and patients are likely to travel great distances but will not be applicable to Satellite Facilities on the decentralised scheme.<div style="color:#00000a;">Separation of each of the cohorts described above, especially at long-term care facilities is highly desirable. Generally, at a minimum, separation of gender, paediatrics and XDR patients is required. It is highly preferable to have some accommodation for patients requiring isolation and patients with first culture negative result (suspected cured). Further refinement will be dependent on individual facility policy, size of facility (larger facilities being more complex in nature) and whether it is primarily aimed at acute or sub-acute care.
Administrative control measures must also ensure optimal operation of environmental control measures (see below). This may include assignment of a person to oversee environmental controls, to open and close windows as appropriate, change filters, test environmental control measures periodically, clean UVGI lamps if installed, perform preventative maintenance measures, etc. Whatever environmental control measures are in place, their adequate operation and maintenance should be included in the administrative control measures through the TB Infection Control Plan and their operational parameters and proper function should be evaluated regularly.
</div>

===1.6. Environmental IPC measures===
<div style="color:#00000a;">Environmental IPC protection methods should be the second- most prioritised approach, after administrative IPC measures and before personal protection measures (which should be used as measure of last resort). Two broad environmental strategies can be identified: dilution, which results in the reduction in concentration of contaminated particles in a volume of air and disinfection, which is the partial or complete destruction (sterilisation) of micro-organisms in air. Disinfection substances/ processes may be harmful to humans.
Dilution is most easily achieved through maximising air volume through design of large spaces and addressing ventilation, in particular the introduction of “fresh” air from a “safe” source (preferably outdoor air) to continually replenish indoor air as it is exposed to infected persons.

The removal of contaminated air by dilution alone requires extremely large per-occupant ventilation rates to minimise risk. Acceptable levels of room airborne contaminant removal in most South African healthcare facilities cannot be sustainably accomplished by artificial ventilation alone. Its application is limited by engineering constraints and by cost. The professional consultant team is to consider the strategy to ventilation in the following prioritised sequence and only proceed to the next option if the previous is not achievable or not feasible: natural ventilation, mixed mode ventilation and finally mechanical ventilation.

The disadvantages of reliance on natural ventilation for infection control include climate dependence and impact on patient comfort. Yet, the low cost of installation, operation and maintenance should be considered as benefits. The continuous escalation in the cost of electricity and ever-present risk of power outages further support the need to design, wherever possible, for natural rather than artificial ventilation.

The ventilation capacity of any naturally ventilated building is dependent on:

*Wind direction and profile;

*Building geometry;
*Interior obstructions and flow paths;
*Inner and outer temperature (buoyancy);
*Type and degree of envelope and building permeability;
*Adjacent structures and building location;
*Terrain; and
*Complimentary ventilation systems.</div>
The successful commissioning of the installed ventilation system depends on the successful completion of the following steps:

*Definition of performance and functional requirements as identified during the project definition stage

*Ensuring that the performance and functional requirements are met by the design and specification
*Validating that the ventilation system performs and functions as intended. An independent authority shall validate the performance and functioning of the ventilation system.

Whereas the requirements of SANS 10400 XA contemplate the limitation of infiltration and exfiltration of air from the building (sealing for energy conservation) a rational design approach must be adopted for natural and mixed mode systems.

===1.7. Dilution systems===
<div style="color:#00000a;">Dilution ventilation refers to any method of ventilation (natural, mechanical or mixed-mode) in which air is encouraged to flow into and out of a space with the aim of reducing the background concentration of airborne contaminants within that space. The complete removal of all ''M. tuberculosis'' particles cannot be accomplished by dilution ventilation alone. Its efficacy is limited by engineering constraints as well as by cost and comfort conditions. Unlike odour and temperature control functions for which ventilation and other forced-air systems are designed, the removal of diluted air (still contaminated with infectious particles air) requires extremely large ventilation rates for adequate protection.
According to the WHO Guideline ''Natural Ventilation for Infection Control in Health-Care Settings ''(WHO, 2009a), if natural ventilation alone is not able to reliably meet both the recommended ventilation and indoor comfort requirements then alternate ventilation systems, such as mixed-mode ventilation, should be sought. If that too does not meet the ventilation requirements, only then should mechanical ventilation systems be considered.

A summary of the advantages and disadvantages of natural, mechanical and mixed-mode ventilation is provided in Table 2
{| class="wikitable"
!
|'''Mechanical ventilation'''
|'''Natural ventilation '''
|'''Hybrid (mixed-mode) ventilation'''
|-
|Advantages
|Suitable for all climates and weather with air-conditioning as climate dictates
|Suitable for warm and temperate climates – moderately useful with natural ventilation possible 50% of the time
|Suitable for most climates and weather
|-
|
|More controlled and comfortable environment
|Lower capital, operational and maintenance costs for simple natural ventilation
|Energy saving
|-
|
|
|Capable of achieving high ventilation rate
|
|-
|
|Smaller range of control of environment by occupants
|Large range of control of environment by occupants
|More flexible
|-
|Disadvantages
|Expensive to install and maintain.
|Easily affected by outdoor climate and/or occupants’ behaviour
|May be expensive
|-
|
|Reported failure rate in delivering the required outdoor ventilation rate
|Reduces occupants comfort level when hot, cold or humid
|May be more difficult to design
|-
|
|Potential for noised from the equipment
|Inability to establish negative pressure in isolation areas, but may be provided by proper design; depends on situation
|
|-
|
|
|Potential for noise intrusion
|
|-
|
|
|High tech natural ventilation shares some of the disadvantages and limitations of mechanical ventilation
|}
Table 2: Summary of the advantages and disadvantages of mechanical, natural and mixed-mode ventilation systems (WHO, 2009A).
</div>
===1.8. Natural ventilation systems===
<div style="color:#00000a;">Natural ventilation is the flow of air through buildings driven by wind pressure and buoyancy forces. Natural ventilation is dependent on climate, building design, occupancy and activity in the building. Controlled natural ventilation is not limited to the strategic positioning, opening and closing of windows and doors to channel air flow in a certain direction. For natural ventilation to be effective as a ventilation solution, it must be considered from the earliest stages of the facilities design development. When developing the design concept for a naturally ventilated building, three basic steps need to be taken:

#The desired airflow patterns from inlets to outlets (windows) through the occupied spaces need to be defined. This is closely related to the form, arrangement and management of the building, which in turn depends on the use patterns and even configuration of the site.
#The principal driving forces, which enable the desired airflow patterns and ventilation rates (air changes) to be achieved, must be defined and quantified. Certain strategies tend to be wind-driven; others stack-driven. In successful designs, the principal airflow drivers are complementary to the intended flow rate and distribution.
#Size and locate the openings (windows) so that the minimum and average required flow rates can be delivered under all operating regimes.
</div>The incorporation of additional openings and devices such as solar chimneys, wind towers, turbine ventilators and wind scoops and cowls may assist the natural ventilation design by encouraging air to flow in a specified direction. These devices could also increase the ventilation rate.<div style="color:#00000a;">Naturally ventilated healthcare facilities should be designed such that the overall airflow pattern carries air from the infectious patients, to areas where there is adequate dilution, and be exhausted to the outside (WHO 2009a).
For natural ventilation, the WHO recommends the following minimum hourly ventilation rates (WHO, 2009a):

#In new healthcare facilities or renovated spaces, an hourly average of 160 l/s/patient in airborne precaution rooms, with a minimum of 80/l/s per patient.
#In general wards and outpatient departments (OPD), 60 l/s/patient. The occupancy of general wards and OPDs vary, and this should be considered in the design phase.
#In corridors and other transient spaces, a minimum of 2.5 l/s/m<sup>3</sup> is required. When emergency medical procedure are performed in these areas , an hourly average of 160 l/s/patient is required for high risk procedures, and 60 l/s/patient for all other procedures.
</div>
In these areas the airflow should be from the infectious patients, to areas where there is adequate dilution, and exhausted directly to the outside. If this is not achievable, consideration should be given to mechanical ventilation. '''Sputum booths should be provided externally if at all possible. <span style="color:#000000;">Only where this is not possible should mechanically ventilated sputum booth options be considered.'''<div style="color:#00000a;"><span style="color:#000000;">See below for requirements of mechanical ventilation and Annex 1 for mechanically ventilated sputum booths.</span>It is important in natural ventilation design to consider:

#the fluctuation rates due to changes in weather in the design of natural ventilation systems (including extremes of wind speed);
#building performance in inclement weather;
#patient comfort; and
#control of drafts in the occupied zone- Air currents in excess of 0.8 m/s in the occupied zone can cause disturbance and discomfort.
</div>

====Mixed-mode systems====
<div style="color:#00000a;">The terms “mixed-mode” and “hybrid” ventilation are used synonymously. They refer to mechanically assisted natural ventilation strategies. Mixed-mode systems essentially extend the capacity of naturally ventilated systems. The two major types of mixed-mode ventilation are:

#Complementary mixed-mode ventilation
#Zoned mixed-mode ventilation
</div>
Complementary mixed-mode ventilation uses natural ventilation and mechanical ventilation strategies at different times of the day, or different seasons of the year, i.e. natural ventilation is used when wind conditions are favourable, and mechanical ventilation is extreme conditions. Complementary mixed-mode ventilation can further be classified as concurrent or changeover. In concurrent operation, the mechanical ventilation system works in the background to the natural ventilation system, assisting where temperature, airflow, or indoor air quality parameters are not met. In changeover strategies, the natural and mechanical ventilation systems work alternately. Seasonal and night-day changeovers are the most common.<div style="color:#00000a;">Zoned mixed-mode ventilation implies that certain parts of the building use natural ventilation, and other parts, usually specialised areas within the building, use mechanical ventilation. Brown and Huang (2006, p.47) recommends that energy zoning be employed for naturally ventilated buildings. Activities or spaces having similar cooling and occupancy schedules should be located close to each other, so that the same energy strategies can be used in those areas. In this way it is also possible to cluster the areas which will be naturally ventilated and the areas which will be mechanically ventilated. By clustering all the mechanically ventilated areas, air-conditioned air can be distributed more efficiently.
Mixed-mode ventilation systems may benefit from control strategies. These control strategies may be manual or automatic. Automatic controls usually include sensors, actuators and controllers. The control strategy should be triggered if the required ventilation rates are not met. When this happens, the system switches from natural to mechanical. Once climatic conditions are able to deliver the required ventilation rate, the system should be set back to natural ventilation. Control strategies may also be temperature-based, or rain-based, but the required ventilation rates should be met if these controls are employed.
</div>

====Mechanical ventilation systems====

<div style="color:#00000a;">There are certain instances where the use of mechanical ventilation is the only feasible option, an example of which is deep-planned buildings.
In high risk areas, the mechanical ventilation system should, at least, meet the following minimum ventilation requirements:

#A ventilation rate of 12 ACH, or
#A ventilation rate of 80 l/s/patient of outside or sterilised air.
</div>Criteria 2 is required when considering congregate settings, such as waiting areas and dining halls. Criteria 1 is not relevant where option 2 is achieved. Criteria 1 is not relevant in high volume spaces (>3.5m AFFL).<div style="color:#00000a;">The system should preferably be a full fresh air system. All air should be exhausted directly to the outside. In the event of a partially recirculating system, HEPA filtration or in-duct UVGI should be considered should there be risk of airborne transmission (patient areas).
Where neither of the points above can be sustainably achieved, the occupancy levels in high risk indoor spaces should be managed to remain below a level that which can be effectively served by the considered ventilation system.

The use of exhaust air filtration in single pass ventilation systems as a means of removing hazardous infectious particles from the room should be restricted to “in-room” filtration. “In-duct” filtration, will not lower the concentration of infectious airborne particles in the occupied zone in which they are being expelled by infectious persons. “In-duct” filtration can only remove the infectious particles present in the incoming air or in air being redistributed to other areas served by the recirculating system. “In-room” filtration can be achieved using portable air cleaners (PAC). PACs may therefore serve as an effective extension to the dilution process provided by controlled ventilation, where the ventilation rates required for IPC cannot be achieved. PACs can be used as a means to increase the contaminant removal effectiveness of the ventilation system (at the cost of increased energy consumption). The law of diminishing returns is applicable to any common intervention applied to reduce the probability of airborne cross-infection. For this reason it is important to quantify the expected gains before renovating, adjusting or augmenting systems.

Given the maintenance requirements for HEPA filtration and in-duct UVGI systems and the inherent occupational health risks associated with their maintenance, these systems should only be used as a measure of last resort in airborne precaution areas.

Where mechanical ventilation systems are used, consider the failure-mode fall-back option of reverting to natural ventilation.

For more detail on airborne contamination control concepts refer to the <span style="color:#00000a;"><u>'' [https://www.iussonline.co.za/norms-standards/healthcare-environment/ IUSS:GNS Building Engineering Services]''</u></span>.
</div>

===1.9. Disinfection systems===

====Upper-room air UVGI====
<div style="color:#00000a;">According to the CSIR Guidance document: ''UVGI Disinfection of Room Air: an Evidence Based Guideline for Design, Implementation and Maintenance, 2015 https://www.tb-ipcp.co.za/tools-resources/documents-paper-and-articles , the following irradiance and dose factors must be considered when evaluating the ability of an upper-room UVGI system to kill or inactivate airborne microorganisms:''
*include the sensitivity of the microorganisms to UVGI

*and the dose of UVGI received by a microorganism
*the room occupancy levels
*or population of microorganisms.</div>
'''UVGI dose''' is the ultraviolet (UV) irradiance multiplied by the time of exposure and is usually expressed as μW·s/cm2. A appropriatly-designed upper-room UVGI system may be effective in killing or inactivating most airborne droplet nuclei containing mycobacteria if designed to provide an average '''UV fluence rate''' in the room in the range of 15 mW/m³ to-20 mW/m³ and provided the other elements stipulated in these guidelines are met. In addition, the fixtures should be installed to provide as uniform a UVGI distribution in the upper room as possible without losing too much fluence to the walls. There is likely an upper threshold where adding more UVGI will not achieve significant increases in inactivation (Xu, et al., 2003).<div style="color:#00000a;">As the mechanical ventilation rate in a room is increased, the total number of microorganisms removed from the room via this system is increased. However, when mechanical ventilation is increased in a room where an upper-room UVGI system has been deployed, the effectiveness of the UVGI system may be reduced because the residence time of the bacteria in the irradiated zone decreases. Under experimental laboratory conditions with mechanical ventilation rates up to six air changes per hour (ACH), the rate that microorganisms are killed or inactivated by UVGI systems appears to be additive with mechanical ventilation systems in well-mixed rooms. Similarly laboratory studies that UVGI effectiveness changes with modifications to mechanical ventilation rates. Exceeding 6 ACH may reduce UVGI effectiveness although the overall contaminant removal rate may still increase (Xu, et al., 2003).
Upper-room UVGI systems rely on air movement between the lower portion of the room where droplet nuclei are generated and the upper irradiated portion of the room. Once in the upper portion, droplet nuclei containing ''M. tuberculosis'' may be exposed to a sufficient dose of UVGI to kill or inactivate them.

When upper-room UVGI systems are installed, general ventilation systems should be designed to provide optimal airflow patterns within rooms and prevent air stagnation or short circuiting of air from the supply diffusers to the exhaust grilles. Also, heating and cooling seasons should be considered and the system designed to provide for optimal convective air movement. Consideration of the drop and throw parameters of selected ventilation air terminals is critical to ensure good mixing under all seasonal conditions.

Most rooms or areas with properly installed supply diffusers and exhaust grilles should have adequate mixing. If f air stagnation is possible, air mixing should be improved by the considered addition of vertical air mixing fans or repositioning the supply diffusers and/or exhaust grills. If there is any question about vertical air mixing between the lower and upper portions of the room due to environmental or other factors, a fan(s) should be used to continually mix the air. In a room without adequate air mixing under experimental laboratory conditions, UVGI system effectiveness increased by up to 72% when a mixing fan was used.

A number of studies have indicated that the effectiveness of upper-room UVGI systems decreases as humidity increases. The reason for the decrease in UVGI effectiveness is not clearly understood. However, the effect needs to be considered in the general context of upper-room UVGI systems.

For optimal efficiency, relative humidity (RH) should be controlled to between 25% and 60% where upper room UVGI systems are installed. This is consistent with American Institute of Architects (AIA) and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) recommendations that the RH affecting patient care areas in hospitals and outpatient facilities range from 30% RH to 60% RH. If high humidity conditions are normal, it may be necessary to install a system with greater than normal upper-room irradiance levels.

Recommendations developed by ASHRAE and AIA stipulate that the design temperature for most areas affecting patient care in hospitals and outpatient facilities range from 20 °C to 24 °C. This temperature range is consistent with the optimal use of low pressure mercury lamps that are used in upper-room UVGI systems.

The most common way to generate germicidal UV radiation in lamps used in well-designed upper-room UVGI systems is to pass an electrical charge through low-pressure mercury vapour that has been enclosed in selected glass tubes that transmit only certain UV wavelengths. Care must be used in selecting the correct UVGI lamp for use in upper room UVGI systems. Typically, the optimal wavelength for UV germicidal radiation is 254 nanometres (nm) in the UVC range. UV lamps are made for a variety of purposes that may have a negligible consequence in killing airborne microorganisms. Some UV lamps (such as those used for tanning) radiate energy in the UVA and/or UVB range and over extended periods may have adverse health consequences for exposed persons. Other UV lamps are designed to emit radiation at 184.9nm and produce ozone, which is hazardous to humans even at low concentrations. Low-pressure mercury lamps should be rated for low or no ozone generation. Since all lamps must eventually be discarded, each lamp should contain only a relatively small quantity of mercury (i.e., 5mg or less).

In upper-room UV irradiation, fixtures containing UVGI lamps are suspended from the ceiling or installed on walls. The base of the lamp is shielded to direct the radiation upward and outward to create an intense zone of UVGI in the upper air while minimizing the level of UVGI in the lower (occupied) portion of the room or area. The height of the room must be considered in the design of an effective system.

A professional who is knowledgeable in upper-room UVGI systems design and installation should be consulted before procurement and installation of the system. The number of persons competent in the design of upper-room UVGI systems is normally limited.

Persons who may be consulted include engineers, industrial hygienists, and radiation/ health physicists. A mechanism to provide training certification for system designers should be developed and based on the guidance document ''UVGI Disinfection of Room Air: an Evidence Based Guideline for Design, Implementation and Maintenance.''

Once the number and types of UVGI fixtures appropriate for the room or area have been determined, the fixtures need to be appropriately installed. Installation guidelines are provided in the ''Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings'' document and the guidance document ''UVGI Disinfection of Room Air: an Evidence Based Guideline for Design, Implementation and Maintenance''. Only qualified service technicians who have received training on the installation and placement of UVGI lamp fixtures should install the systems. Following installation UV lamps require on-going maintenance and frequent replacement, by suitably skilled technicians. This consideration may be a limiting factor in the use of the solution.
</div>

====Personal protection measures====

<div style="color:#00000a;">In addition to administrative and environmental control measures, the recommended personal control measure for protection of the healthcare worker, from inhaling infectious droplets in high-risk DR TB settings, is the use of respiratory protective devices. These are designed to fit over the mouth and nose and filter out infectious TB particles.
Respiratory protective devices for healthcare workers that are capable of adequately filtering out infectious particles are more expensive than surgical or procedure masks. Nevertheless, their use in high-risk DR TB settings is strongly recommended, particularly in high burden HIV settings where many healthcare workers may be HIV infected. Respiratory protection should be used only when all other administrative and/or environmental control measures are fully implemented. Acceptable respirator types meet the performance requirements outlined in table 7, and include:

*SANS 50149 FFP2/3 respirators

*CDC - NIOSH N95 respirators</div>
The use of N95 respirators should be used with caution in South Africa as there is no framework of compulsory standards and regulations controlling their use. The user may therefore not be adequetly protected from fake devices. The National Regulator for Compulsory Specification (NRCS) has published a homologated database of FFP2/3 devices compliant with SANS 50149.

http://www.nrcs.org.za/siteimgs/CMM/Homologation%20Database%20-%20PPE.pdf<div style="color:#00000a;">Surgical (also called procedure) masks, in accordance with SANS 1866, may be worn by patients in order to prevent the dispersion of respiratory droplets and to reduce formation of droplet nuclei. Surgical masks do not adequately prevent airborne particles from being inhaled by the wearer. SANS 1866 Type 2 surgical masks should be used with caution as they resemble N95 or FFP2/3 respirators and may be easily confused with the latter.
An analysis of the facility design should be made in respect of where provision for personal protective equipment PPE should be made available. These include:

*protective eyewear (for UV device maintenance)
*respiratory protection (typically respirators for healthcare workers, cleaning and maintenance staff, visitors), and
*surgical masks (for patient use).</div>
Dry, secure storage of bulk PPE supplies conveniently located close to points of use should be provided. As respirators are costly and personalised (respirators cannot be shared) secure hanging/ drying facilities clearly marked to avoid confusion are recommended. Stations are required for daily PPE supplies and for disposal facilities (bins) for discarded masks and respirators.

='''PART C - Planning and design principles'''=
<div style="color:#00000a;">For specialised TB services long-term accommodation, the project planning, design, construction and commissioning should aim to provide:

*a safe, secure and functional environment for patients and staff;

*optimal accommodation and support for long term patient stay;
*low capital and on-going operating costs (service, staffing and maintenance);
*an environmentally appropriate design solution; and
*a fully accessible, inclusive environment.</div>
==1. Patient profile==

<div style="color:#00000a;">There are known risk factors associated with an increased likelihood of contracting TB, including DR TB and increased risk of latent disease manifesting in active TB. Patient profile and demographic data are not systematically kept in South Africa, though there appears to be an uneven and fluctuating distribution. Relatively poor socioeconomic groups may be more vulnerable to DR TB infection, but it can (and does) affect anyone regardless of age, gender, race or socioeconomic circumstance. The strong correlation between HIV and TB has been noted. In addition, globally, an increased risk is associated with malnutrition, heavy smoking, silicosis, diabetes mellitus, Hodgkin lymphoma, end-stage renal disease, chronic lung disease, and alcoholism.[[File:Changes in the number of TB notifications in a sample South African community, stratified by age.png|none|thumb|473x473px|Figure 5: Changes in the number of TB notifications in a sample South African community, stratified by age, 1996 - 2004 (Lawn, et al., 2006, p.1043)]][[File:Total number of TB notifications between 1996 - 2004 in a sample South African community, stratified by age and sex .png|none|thumb|473x473px|Figure 6: Total number of TB notifications between 1996 - 2004 in a sample South African community, stratified by age and sex (Lawn, et al., 2006, p.1043)]]Isolated research studies (whose findings may not be generalizable) in South Africa found that TB incidence and prevalence per gender varies with age (see Figure 5). TB incidence was highest in the population group aged 30-49 years, which is the economically productive age group with highest number of dependants. 11% of cases were in children. In the study there was a significant increase in TB among adolescents, especially girls, between 1996 and 2004 (see Figure 6: Total number of TB notifications between 1996 - 2004 in a sample South African community, stratified by age and sex Reflecting the global situation, TB affects more men than women.

Some population groups, such as prisoners and miners are at increased risk of contracting TB.
</div>

==2. Patient-centred care==
<div style="color:#00000a;">Hospitalisation for DR TB places a unique demand on infrastructure. During their stay patients may become either very ill and in need of hospital acute care, to being well or feel quite well only requiring supervised medication. In order to support patient care, part step-down quasi residential-type accommodation should be provided, so that patients who are feeling well can feel “at home”; and part hospital-type accommodation should be provided, in areas where direct staff supervision is possible.
There is strong evidence from research studies which describe the importance of health facility design as a means to improve health outcomes (Ulrich, et al., 2008). The more supportive the environment is, the less chance there will be of admitted patients absconding and infecting others in the community while still in an infectious stage of the disease. Environmental factors such as large windows with high levels of daylight, views of nature, low noise levels all reduce stress and depression and promote healing. Some visual and acoustic privacy (screening for confidential/ personal activities in counselling, consulting and ward areas) promotes patient dignity. Personal choice and control over heating, lighting and furniture layout instils a sense of empowerment.
</div>

===2.1. Safety===
<div style="color:#00000a;">There are several aspects of risk that should be addressed by the consultant team. They include: infection prevention and control (for airborne and other modes of transmission) slips and falls, fire, and UV exposure. Only the most likely and critical of risks have been addressed in this document.

===2.2. Isolation===
Distinction can be made between five types of segregation:

*Separation – patients are housed in single room accommodation though they may not be self-harming or violent.

*Negative pressure room applied to infectious patients, with airlock ante-chamber (e.g. TB patients).
*Positive pressure isolation room applied to immuno-compromised/ susceptible patients, with airlock (e.g. burns patients).
*Duel-function isolation – with controls to convert from positive to negative pressure according to current room occupancy, with airlock. This is discouraged due to complexities in designing and operating these and due to increase risk in accidental incorrect use.
*Seclusion (Social isolation) – for patients who are self-harming or violent. A room with high level of security which complies with national norms and standards for psychiatric care facilities. Airlock not required.
*Barrier isolation – patients are housed within a chamber constructed of an impermeable barrier and typically ventilated through HEPA filters. Decontamination airlocks and material transfer chambers are included in the system. These types of systems are exclusively used for suspected P4 level pathogens, and are not indicated for use with TB patients.
</div>
When briefing professional consultant teams, it is important to convey where each of the above is required. For TB, infection control is useful and usually all that is provided. For further information on Isolation rooms, the reader is referred to the IUSS Adult In-patient Services guidance document. https://iussonline.co.za/norms-standards/clinical-services

===2.3. Infection prevention and control===
<div style="color:#00000a;">The most critical aspect of risk in the design is from the point of view of airborne infection control. This aspect has been addressed in detail in previous sections (for airborne infection) and in the. Refer to <span style="color:#00000a;"><u>''IUSS:GNS Infection prevention and control''</u></span>. </div>

===2.4. Slips, trips and falls===
<div style="color:#00000a;">Slippery floor surfaces should be avoided, particularly externally. Contrasting colours should be used at changes in floor level to assist visually impaired persons. Adequate lighting, handrails and guardrails should be provided. External paving areas should be well drained.</div>

===Alarms and fire alarms===
In addition to the usual compliance requirements, it should be noted that as deafness is a common side-effect of TB treatment regimes, all sounding alarms including fire alarms should be supplemented with visible alarms in patient areas e.g. red or yellow flashing lights to accompany fire or emergency evacuation alarms.

===UV exposure risk===
<div style="color:#00000a;">Where ultraviolet radiation germicidal irradiation (UVGI) is contemplated, due consideration must be made to potential adverse health effects on patients, staff (including maintenance staff) and visitors. For convenience the UV spectrum is described in three different wavelength bands: UVA (long wave lengths, range: 320–400 nm), UVB (midrange wavelengths, range: 290–320 nm) and UVC (short wave lengths, range: 100–290 nm).
UVC is unlike UVA and UVB, as it has extremely low penetrating ability. It is nearly completely absorbed by the outer layer of the skin (stratum corneum), where little or no harm is experienced. Although listed as a potential carcinogen for man, UVC is unlikely to be carcinogenic or to cause skin or eye irritation (keratoconjunctivitis) if applied correctly within exposure limits as set out by the International Radiation Protection Agency (IRPA) and other international health bodies.
</div>
Since open UVGI devices are principally designed to emit a certain amount of UV-c radiation, these devices cannot be considered to be intrinsically safe. The UVGI system should be designed to achieve the maximum system output and maintain the lowest reasonable exposure levels in the occupied zone of the room.<div style="color:#00000a;">The primary safety concern with UVGI in controlling eye exposure to prevent irritation, limits the irradiance limits achievable in the occupied room.</div>

====Safe Exposure Limit====
<div style="color:#00000a;">The occupied rooms considered for UVGI should not exceed an exposure dose below 6 mJ/cm² (for mercury vapour lamps at 254 nm 15) and 3.8 mJ/cm² (at 265nm) per 8h.
Therefore, in the typical application of 254nm devices, occupant exposure shall not exceed 0.40µW/cm² for a period of time equivalent to 4 hours per work day. If exceeded, steps must be taken to reduce the effective irradiance dose to less than 6.0mJ/cm2 for the total duration per day.

It becomes important to consider the actual nature and usage of these spaces to determine appropriate safe exposure rates. In determining these rates, occupancy factors such as the eye level of regular occupants, position of occupants (seated, standing, lying down), frequency and duration of exposure, need to be determined and incorporated. Therefore different areas or rooms will require different safety limits.

Areas such as passages and wards would therefore demand vastly different safety limits from each other.

The economic considerations of infection control suggest that high risk areas be given priority for air disinfection. These areas will be determined through the outcome of a comprehensive risk assessment of the facility. Installation of open UVGI devices in stairwells is not considered safe practice as there is seldom sufficient soffit height for an effective upper room zone. Where passages are used as return air plenums in recirculating ventilation systems, these passages shall be considered for air disinfection.
</div>

====Reflections into the Lower Room====
<div style="color:#00000a;">The potential of high UV intensities being reflected into the occupied room must be considered by designers and users. Certain materials and surfaces that reflect visible light might also reflect UV-c light; for example consider reflectors of regular open luminaires, windows, exposed ducting and metallic or high gloss architectural finishes in the upper room.</div>

===Security===
<div style="color:#00000a;">In the South African context, there is considerable store in balancing security needs, so that patients and staff feel that their person and their personal belongings are protected from harm. Detailed guidance is provided in [https://iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Security].</div>

===Inclusive design===
<div style="color:#00000a;">In accordance with the Constitution of South Africa, Occupational Health and Safety Act, the Promotion of Equality and Prevention of Unfair Discrimination Act and the UN Convention on Rights of People with Disabilities, Universal Design is a key requirement for all public buildings in South Africa. Refer to [https://iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Inclusive environments].</div>

===Holistic care===
<div style="color:#00000a;">DR TB facilities must accommodate patient care, dignity and wellbeing. Medical and accommodation needs are clearly the minimum and most critical aspect that must be addressed by the facility. However the accommodation needs for long-term care must address patients’ needs in a more holistic way. </div>

===Balanced service provision===
<div style="color:#00000a;">Some of the identified problems related to long-term patient needs are isolation of economically active sufferers from their working environment, and interruption of schoolwork in children. The provision of education and development programmes for adults and children alike (library and multi-media facilities have the potential to reduce isolation, stigmatisation, and to contribute to a positive frame of mind) are therefore just some of the issues that can be addressed via facility design. A small business hub with information communications technology (ICT) connectivity may be provided to assist patients who may need to keep their businesses running while under treatment. Both indoor and outdoor recreational activities and other opportunities for physiological, psychological and spiritual needs during this extended stay should be provided in the facility. The provision of patient support accommodation and social counselling and support (visits from relatives and friends) is essential to promote a sense of wellbeing and purpose. Allied health services such as pharmacy, and rehabilitation therapy (occupational therapy, physiotherapy, and social work) play a critical role in supporting whole-patient care. Treatment side effects may include hearing loss, so that provision of audiology booth for regular testing is useful. Screened, covered and well-ventilated sputum booths should be provided in close proximity to clinical areas for production of sputum samples. These may be equipped with a hand-wash basin, a shelf and a plug point, to allow for nebulisation. Chest (and other) x-rays need to be taken, therefore provision of x-ray facilities with appropriate radiation protection should be provided.
Given resource constraints, it is not always possible to invest in the full complement of these facilities at DR TB centres in one capital investment. However, as each potentially adds to quality of care that can be delivered, which leads both directly and indirectly (say, through preventing absconding) to improved health outcomes, best practice recommends that these aspects be addressed as fully as practicable. It is useful to produce master-plan proposals, within a phasing framework so that a full complement of services can be provided over time, and so that short term development does not compromise medium and long term development potential.

Patients in some DR TB settings are permitted to prepare their own meals, but this is unusual practice and is usually optional and reserved for patients who are pending discharge. Policies in terms of meal presentation and delivery vary between institutions. Three basic modes of delivery include a pre-plated service delivered to the patient bed. The second mode is a tray served at a dining table and the third is a buffet-style service. As meal preparation services are frequently outsourced, the first two modes of delivery are most commonly found in South Africa. Dedicated dining facilities are not always available, so that meals must be served at patients’ bedsides or lounge areas (if provided). Bedridden and ill patients may be unable to use formal dining facilities. International studies in long-term care facilities have shown that there are increased appetite, nutrition and patient satisfaction in communal dining settings, and particularly with buffet-style eating. However these studies have primarily been undertaken for the elderly. Similar studies have not been undertaken in South Africa or for TB patients. To complicate matters, patients in communal dining settings are unable to use personal protective equipment, raising risk at these encounters. Nevertheless it is recommended that patient formal dining facilities be provided for and that they are treated as high risk areas in terms of infection control.

Facility policy may provide that patients in long-term care facilities are encouraged to participate in cleaning, laundry and gardening activities.
</div>

===Healing environments===
<div style="color:#00000a;">International research into evidence-based design has concluded that well designed built environments can play a critical role in improving healing outcomes. Infrastructure has an important role to play in this respect. Long-term DR TB care facilities should not only address the needs of patients and their families, but also the needs of healthcare workers.</div>

===Occupant comfort===
<div style="color:#00000a;">While ventilation is of significant importance to maintain effective infection control within the healthcare buildings, one of the most critical aspects of patient recovery is adherence and completion of their treatment regime.
Buildings should be designed so that comfort conditions in indoor environments can be achieved irrespective of climate conditions, bearing in mind that TB sufferers are typically very underweight and may have little tolerance for cold. The climate may require supplemental heating to achieve comfort conditions in winter without compromising the ventilation requirements. The operational constraints of the hospital (in terms of maintenance and operational costs as well as environmental impact) mean that fully air-conditioned or heated wards are usually not desirable either.The ISO standard 7730 provides a measure of thermal comfort based on the predicted mean vote (PMV) method. The ASHRAE 55 ''Thermal environmental conditions for human occupancy'' guide provides methodology for measuring comfort conditions, including provision for naturally ventilated buildings. It is proposed that these form the basis of the design assessment relating to thermal comfort.

The ventilation and comfort control design must weigh up these competing requirements to provide an optimal indoor environment (ventilation and thermal comfort) while bearing in mind the operational impacts on the hospital in the long term. As such, the following metrics should be used to demonstrate an optimal balance of ventilation, thermal comfort and operational costs:

*Proportion of hours where the targeted ACH rate is achieved (currently 160 l/s per person for naturally ventilated areas)

*Proportion of hours where either:
*PMV levels between -1.0 and 1.0 are achieved; or
*Acceptability limits of ASHRAE Standard 55, 2004 are achieved within 80% of acceptability limit 1
*Predicted operational costs (energy use and maintenance)</div>
The decision-making with respect to the mechanical or naural ventilation system or other systems relating to thermal comfort should take all these into account.

==Staff: patient ratios==
<div style="color:#00000a;">According to the ''Decentralised Management of Multi Drug Resistant TB – a Policy Framework for South Africa'', a provincial/ centralised MDR TB unit requires the following minimum staffing levels. This should be cross-referenced against the WHO Document “Workload Indicators of Staffing Need” (WHO, 2010) which has been formally adopted by the NDoH:
{| class="wikitable"
|Doctor
|1/40 beds
|-
|Professional nurse / Staff nurse or Nursing Assistant
|4/ 11 per 40 beds
|-
|Pharmacist
|1 per 100- 200 beds
|-
|Social worker
|1 for > 40 beds
|-
|Dietician
|1 for > 40 beds
|-
|Clinical Psychologist
|1 for > 40 beds
|-
|OT
|1 for > 40 beds
|-
|Audiologist
|1 for > 40 beds
|-
|Physiotherapist
|1 for > 40 beds
|-
|Data Capturer/ Admin Clerk
|1 for 100- 200 beds
|-
|Driver
|1 for > 40 beds
|}
Table 3: Sample Organisational Development Investigation the following staffing complement per 30 bed functional unit (''courtesy Brooklyn Chest Hospital'')
{| class="wikitable"
|'''OFFICE: ADMINISTRATION'''
|'''NUMBER OF POSTS'''
|'''COMMENTS'''
|-
|Administration clerk
|1
|
|-
|CLINICAL SERVICES
|
|
|-
|Medical officer
|1
|
|-
|MEDICAL AUXILLARY SERVICES
|
|
|-
|Physiotherapist
|
|Central services
|-
|Occupational therapist
|
|Central services
|-
|Social work
|
|Central services
|-
|Dietician
|
|Central services
|-
|Audio/speech therapist
|
|Central services
|-
|Clinical Psychologist
|
|Central services
|-
|Radiographer
|
|Central services
|-
|Pharmacist
|
|Central services
|-
|Counsellor
|
|Central services
|-
|NURSING SERVICES
|
|
|-
|ASD nursing area
|
|Central services
|-
|Operational manager nursing
|1
|
|-
|Professional nurse
|4
|
|-
|Staff nurse
|4
|
|-
|Auxiliary nurse
|8
|
|-
|Housekeeping supervisor
|1
|
|-
|Household aid
|6
|
|-
|NIGHT DUTY MANAGEMENT
|
|
|-
|Night duty manager
|1
|Central services
|-
|Professional nurse
|1
|
|-
|Staff nurse
|3
|
|-
|Auxiliary nurse
|2
|
|-
|Household aid
|1
|}

==Supporting the caregiver==
</div>
===Recruitment, retention and productivity in staff===

<div style="color:#00000a;">International research has shown that infrastructure has a part to play in staff recruitment, retention and productivity. South Africa has been experiencing an extended challenge in respect of attracting and retaining qualified healthcare professionals. This challenge is particularly marked in TB–specialist skills because of the additional risk. This risk is not merely perceived. Healthcare workers generally and TB-specialists specifically are exposed to higher risk of infection and higher infection rates than the general population.
Staff is thus a critical factor to take into consideration when DR TB planning facilities. In particular the provision of safe working environments:

*which address risk from an IPC perspective in a way which is explicit and reassuring;

*which provides for physical safety against violent/ disturbed patients; and
*which allow adequate safe storage for personal belongings.

Provision of staff housing, recreation facilities and other staff amenities may be an attractive benefit.
</div>
===Additional personnel considerations===
<div style="color:#00000a;">From an infrastructure point of view, it is critical that maintenance posts are established and filled with incumbents who are appropriately skilled to address the specialised needs of DR TB facilities, infection control and healing environments. As with healthcare workers, there are challenges in attracting and retaining skilled artisans, engineers, and health facility specialist maintenance staff, particularly in environments perceived to be high-risk.
While the most significant factor in staff recruitment and retention is salaries and benefits, especially in relation to many overseas destinations, many experts emphasize that pay is not the sole motive for leaving the South African public service. Other factors include poor work environments characterized by heavy workloads, lack of supervision, and limited organizational capacity. There are also environmental considerations; workplaces may be dangerous due to condition, functional or environmental design, or there may be a lack of supplies to protect workers from occupational exposure to diseases like tuberculosis.
</div>

==Site appraisal==
<div style="color:#00000a;">Where feasible the principle of redevelopment and reuse of existing buildings should be investigated before building new buildings. As a first stage in providing a comprehensive appraisal of the site, the consultant team should collect, collate and prepare a full assessment of accommodation and engineering services at the existing site including:</div>

===Building layouts===

*existing buildings with measured footprint and scaled spatial layout on site plan;
*current functional allocation (use) of existing buildings;
*level of utilisation of buildings;
*national monument status;
*building condition assessment (high level and quick professional estimate on scale one condemn to five as new);
*evaluate of the level of accessibility of proposed new structures and linkages to existing buildings; and
*evaluation of existing pedestrian and vehicular routes (i.e. staff, visitors, and service vehicular and pedestrian routes) to determine optimum layout of proposed new buildings.
<div style="color:#00000a;">A coloured site map should be prepared by the consultant team using the coding provided below to visualise the suitability of the existing building stock (see figure 8) and the condition of the existing building stock (see figure 9).[[File:Condition assessment coding.png|none|thumb|499x499px|Figure 7: Recommended suitability coding for site appraisal]][[File:Recommended Condition Assessment Coding For Site Appraisal.png|none|thumb|499x499px|Figure 8: Recommended Condition Assessment Coding For Site Appraisal]]

===Site Information===

*Major landscaping, trees and features;
*Site access points for staff, patients and service personnel and access constraints;
*Existing fencing and level of security provided;
*Service connection points, main service runs, water tanks (as they are currently being constructed), transformers, substations, generators, etc.; and
*Flood lines, water table levels, site storm water drainage and general potential for flooding.</div>

===Engineering and bulk services===

<div style="color:#00000a;">Engineering services

*Power: Analysis of existing power supply – types, current load, reliability, capacity, potential for expansion,

*Water supply: Analysis of existing water supply – source/s, storage, condition, current and projected demand,
*Sewage: Analysis of existing sewage reticulation and disposal system, connections, capacity, condition, current and projected load,
*ICT services: Telephones, internet connectivity, intranet connectivity. Analysis of existing supply – types, load, reliability, capacity, potential for expansion,
*Other services as identified by consultant team (gas, steam etc.)</div>
It is recommended that the photographic survey of existing infrastructure be compiled by the consultants.

===Climatic and sustainability considerations===
Prevailing climate conditions should be taken into consideration during the design process. The closest freely available (open source/ public domain) or alternate annual and diurnal temperature, rainfall, wind-speed and direction data should be collected, analysed and used in addressing building performance and patient comfort objectives (see Figure 10). Material specifications and details should address corrosive attributes associated with proximity to the sea.

Rational peak demand of electricity use and demand management systems should be considered in the design and specification. There should be a split between essential and non-essential electricity use, and emergency backup should be provided for essential services. Separate metering for water and electricity should be provided for the new unit. Refer to [https://www.iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Sustainability and the environment].

===Future development===
Future development for the site should be studied. The consultant team is to provide evidence that a very high level study has been undertaken to ascertain whether or not the proposed facility will likely compromise, limit or enable the proposed development through appropriate means (such as crude scale block positioning on site). The implications of the project on future development should be discussed in an open forum with stakeholders. Consideration should be given to the optimal positioning and size of central services to satisfy the future demand of the hospital site.

==Additional Project Studies, Approvals and Requirements==

===Environmental Impact Assessment (EIA)===
An Environmental impact assessment (EIA) may be required.

===Local authority submissions===
The following approvals must be provided, as stipulated by the local authority:

*A site development plan (SDP);
* A copy of a set of working drawings;
*A traffic engineer’s report; and
* A fire department.

===Phasing and decanting===
Where the project calls for a construction project to be conducted within an existing functional healthcare environment, phasing and decanting plans are required. The appropriate precautionary measures should be taken. Refer to [https://www.iussonline.co.za/norms-standards/procurement-and-operation IUSS:GNS Decommissioning]. The services currently provided for at the hospital must continue with as little disruption as is reasonably possible. Phased construction and/ or temporary decanting of functions may be required. Should decanting activities be required to accommodate the construction project, then this activity should be planned timeously with all stakeholders’ involvement under the leadership of the briefing authority (or if defined as extraordinary scope of services, principal agent, contractor or other clearly identified party).

===Commissioning and validation===
Refer to [https://www.iussonline.co.za/norms-standards/procurement-and-operation IUSS:GNS Commissioning].

===Post-occupancy evaluation===
At one year from practical completion date a post-occupancy evaluation is recommended. All participants in the planning, design, construction and commissioning of the new facility will be required to participate in a half day on-site assessment on whether the project objectives where met. Feedback should be provided to the briefing authority and custodial agent to inform future building projects.

===Operation and maintenance manual (O&M)===
The consultant team is required to prepare an operations and maintenance manual for the hospital management and the custodial agent for presentation at practical completion. The requirements regarding the content of this document will be determined by consensus at a focus meeting with stakeholders to be convened by the principal agent during the construction phase of the project. As a recommendation these manuals may contain the following information:

General information

*Description, make, model number of all equipment installed; and
*Contact details of suppliers and /or manufacturers etc.

Design information

*Design data sheets, containing all design and selection parameters, calculations, selection curves, etc.;
*Settings and values recorded during commissioning;
*Manufacturer's brochures and pamphlets;
*Maintenance data and schedules;
*The lapse of time between services and the description of the service required of each part, lubrication requirements, etc.;
*Schedule of spares; and
*A complete electrical equipment schedule.

These will include the description, make, model number, rating and other performance criteria, commissioned (default) settings, including all brochures, pamphlets and maintenance requirements. Names and contact details of supplier and manufacturer.

Detail description of the operation of the electrical, mechanical and control systems including the design information, manufacturer’s brochures and pamphlets, settings and values recorded during commissioning, maintenance data and schedules. Complete sets of:

*as built drawings";
*architectural work drawing;
*structural drawings;
*site works drawings;
*electrical reticulation drawings;
*mechanical installation drawings (i.e. all workshop and equipment layout drawings required for the manufacture and erection of the installations); and
*instrumentation/control drawings, such as schematic control diagrams and electronic/ electrical layout drawings.

='''Operational narrative and user room requirements'''=

==Daily Schedule==
Table 4: Sample: Current daily activities at long-term care facility
{| class="wikitable"
|TIME
|ACTIVITY
|VENUE
|DESIGN IMPLICATION
|-
|5:00
|Patients are woken up, urged to complete ablutions, and dress.

<br />
|Wards
|Each patient will have his own bedroom and adjoining bathroom.

Each bed will have an adjacent cupboard for clothes and possessions, and space for a bedside table.
<br />
|-
|
|Patients to produce sputum
|Sputum booth
|1.Monthly sputum samples taken from relevant patients
|-
|07:00
|Nursing on day shift attend a handover meeting with night staff. This includes discussing problems, and planning activities for the day.
|Nursing station
|The nursing station is a general area where much clinical information is shared between staff and between disciplines and is a separate area in the ward. Secure cupboards (and a safe), under desk shelving and notice board space are required.

The location of the nursing station should allow for a clear view of most of the ward (through transparent barriers/windows) and it should be as centrally placed as possible. It should accommodate up to 6 people, and be accessible to the offices of the other members of the team. Lock-up cupboards, computer points, telephone; nurse call control panels should be operated from here. In this ward the nursing station should provide a central place in terms of staff efficiencies.
|-
|
|
|Matron’s office
|While office should be separate from nursing station due to space requirements, easy communication and visible access should be available. Built-in office furniture with network points, plugs, telephone, filing space, lockable cupboards, enough space for at least three filing cabinets, appropriate storage and availability for ward stationery (some open and others locked), additional filing workspace, provision of pigeon holes for each for each patient file board, key cupboard.
|-
|7:30
|Daily injection given to patients
|Procedure room
|Nurses prepare injections according to medicine chart per individual patient.

The room requires a clinical hand-wash basin with clinical taps, lock-up cupboards, worktops, a patient couch, good lighting
|-
|08:30
|Breakfast and issuing of medication
|Dining hall
|This adjoins the kitchen and food delivery area. The nursing station should be nearby so that medication and general nursing tasks can be co-ordinated efficiently.

Food will be brought from a central kitchen located elsewhere in the hospital, but facilities for re-heating and to make hot beverages need to be available.

As patients mostly will proceed to the dining area from various other activity areas (sleeping, clinic, recreational, OT etc.) it will have to be in a central location, easily accessible from other patient areas.

Food must be delivered through a dedicated staff access point that allows for minimal patient contact.
<br />
|-
|09:30 – 12:30
|Therapeutic activities
|
|
|-
|
|Medical officer

The ward will have at least one medical officer.
|Consulting room
<br />
|These should have enough space for interviewing at least 3 people, as well as a desk, examining coach and x-ray box.
<br />
|-
|
|Occupational Therapy (OT)
|Games room and lounge
|During the day most patients will be allowed to attend the OT programme.
|-
|
|Psychologists & Social Workers

Interviews, psychotherapy and counselling with patients or their families (often together) occur daily, usually by appointment.
|Counselling rooms
<br />
|Each office will need built-in desks, computer and telephone points, and secure storage space.
|-
|12:30 – 13:30
|Lunch and using of medication
|Dining hall
|
|-
|13:30 – 14:00
|Rest period
<br />
|General rest areas
|Some patients may retire to their rooms for a brief period, but most will be in general areas (lounge, restricted outdoor areas).
|-
|14:00 – 16:30
|Continuation of many morning activities
|
|
|-
|
|Sport and Recreation
|Outdoor field
|These patients will have easier access to outdoor areas.
<br />
|-
|
|
|Indoor group area
|For use for group leisure.
|-
|
|
|Lounge
|A comfortable furnished area containing a TV, board games (such as Kerem). This area has to be fully visible from the nursing station. Public telephones should be situated nearby. It may be helpful if this was close to the dining area.
|-
|
|Visiting

Families, friends (and occasionally others) are allowed to visit during two afternoons per week and each evening between 19:00 to 20:00
|Visitors area
|Although visiting times are regulated, families here have easier access to the patients, and there does not have to be a strict separation between patients and visitors.
|-
|16:30 – 17:30
|Supper
<br />
|Dining area
|Activities as for other mealtimes.
|-
|17:30 – 19:00
|Leisure time
|Lounge
|Access to enclosed courtyards allows patients to smoke and relax in the restricted outdoors before retiring to sleep.
|-
|18:00
|Nursing handover to night staff
<br />
|Nursing station
|The same as in the morning
|-
|19:00 – 21:30
|Preparation for sleep

Dispensing of night medication
|Lounge and sleeping areas
|Usually a snack and hot drink is given to patients. Many watch TV, others socialise or smoke (the latter activity will take place in designated courtyard areas that adjoin onto the ward, but without direct access to the general campus area).
|-
|22:00 – 07:00
|Night activities
<br />
|Sleeping areas,

Nursing station
|
|}

==User room requirements==
Refer to [https://www.iussonline.co.za/norms-standards/healthcare-environment IUSS:GNS Generic room requirements] and [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Primary healthcare].

===TB outpatient services===
Discharged patients need to be seen for follow-up visits in their communities or at facility-based outpatients department (OPD) usually every two months or so. Treatment for newly diagnosed and uncomplicated MDR TB and TB patients is typically initiated by clinical staff at OPD, and in accordance with policy decentralised management of TB treated in the community. Complicated cases and XDR patients may be admitted into the inpatient accommodation units through the OPD unless a dedicated admissions facility is provided.

Paediatric patients may be seen for follow-up at paediatric wards or at the general OPD, depending on organisational structure. In small facilities the outpatient department can share clinical support services for inpatient care. Depending on patient loads and institutional preference, a dedicated OPD can be provided with similar facilities to clinical inpatient and support services.

Care should be taken to avoid enclosed congregate settings (such as waiting areas) where possible. Where these are required, they should be regarded as high risk for airborne contamination.

====Consulting room====
The consulting room is used by doctors and nursing staff for interviewing and examining patients, and to prescribe treatment for their condition. The doctor or certified nurse practitioner discusses the patients’ symptoms and records her case history. The patient sits on a chair during this stage and if a physical examination is necessary, lies on an examination couch. Once on the couch, the doctor or certified nurse practitioner examines the patient standing on the patients’ right hand side using medical supplies and instruments on an instrument trolley placed next to the head of the examination couch. The doctor or certified nurse practitioner may dispense medicine or instruct the patient to proceed to the treatment room for further medical treatment. Privacy is required during the consultation.

One consulting room should be provided per 30 patient beds or part thereof. The consulting rooms should be standard size. The consulting rooms requires a clinical hand-wash basin with a soap dispenser and paper towel holder, a desk and chair, two patient chairs, an examination couch with a curtain screen, a place to hang clothing, examination lights, access to shared x-ray viewing facility, wall mounted blood pressure monitors, telephone and computer and network connectivity. The room must have a desk with cupboard for the nurse/clinicians’ own personal belongings and a cupboard for standard forms. A separate cupboard must be in this room to provide for equipment and medicine necessary for procedures. Each room must be provided with a pinning board 900 x 900. An examination couch with an exam lamp is to be provided. Provide space next to the couch for a medicine and instrument trolley. Curtain tracks should be provided around the examination couch for visual privacy for patient being examined, if appropriate.

====Counselling room====
The counselling rooms must be the same size as the consulting rooms and correctly handed for use as consulting rooms should the need arise. The counselling rooms require a desk and chair, with telephone, shelves, IT and a network point, clinical hand-wash basin, soap dispenser and two easy chairs for counselling purposes.

====Diagnostic radiology services====
Diagnostic radiology services (chest x-rays) of all patients may be routinely required for diagnosis, during treatment and in follow-up. Baseline x-rays of all the staff and annually as part of the hospital’s infection prevention and control programme. Diagnostic radiology should be provided on-site or at a nearby referral facility. Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Diagnostic radiology]. Mobile x-ray services are a suitable alternative where fixed radiology equipment is not available and if not provided at a nearby referral facility.

====Sputum collection and induction====
Sputum collection is a process whereby a specimen of sputum, liberated from the lungs, is collected. In many adults this process is readily achieved, however, in younger children and adults who cannot liberate sputum spontaneously, sputum induction is performed. Sputum induction is a process whereby sputum is liberated from the lungs using sterile water or hypertonic saline to irritate the airway, which promotes coughing, to produce a sputum specimen (Francis J Curry National Tuberculosis Centre, 1999).

It is advised that sputum collection be conducted in an area which provides privacy, for patient dignity, but also conducted under observation of a clinician, should the patient go require support and in order to ensure sample integrity (that the sputum is from the individual). As sputum collection is a high risk procedure, good administrative and environmental control measures for the designated sputum collection area is essential for the safety of healthcare workers and patients.

The functional area for sputum collection should comprise a covered area, clinical hand-wash basin, soap dispenser and counter top and, if sputum induction is performed in the same space, a splash-proof power point for a nebulizer.

Sputum collection should be performed in a designated area. At naturally ventilated primary healthcare clinics and community healthcare centres, or any other single-storey naturally ventilated healthcare establishment, sputum collection should preferably be performed in a designated '''outside''' area. The “sputum booth” should be positioned within view of the nurse’s station, but should be at least four meters away from the nearest building. '''Sputum should not be collected in patient toilets or consulting/counselling rooms'''. Details of an outdoor sputum booth are available in ANNEXURE 2.

In a mechanically ventilated healthcare facility, rooms having characteristics of airborne infection isolation rooms (AIIR) can be used for sputum collection. These rooms should be ventilated with 80 L per second per person of outside air or the requirements of the National Building Regulations, whichever is greater (SANS 10400 Part O, Table 2, as amended) and are to be maintained at negative pressure relative to the adjacent space, with a pressure differential in the order of -5 Pa. These rooms should preferably be served by full fresh air systems, or in the case of recirculating systems, the exhaust air should be HEPA filtered (EN1822 H13).

Special, purpose-built sputum booths, also referred to as Local Exhaust Ventilation (LEV) devices can also be used for sputum collection. These devices may be portable, where they are beneficial in multi-storey healthcare facilities, where a single sputum booth can be used for the whole facility. Details of a mechanically ventilated sputum booth are available in ANNEXURE 1.

A patient is seated in a chamber where he/she produces a sputum specimen. Fresh air, preferably filtered, is supplied overhead, and exhausted from the chamber at low level. The exhaust air is passed through an H13 HEPA filter to remove the airborne contaminant, and is passed back to the room. To ensure the chamber is safe for the next patient, a time-lag between one patient and the next should be calculated and stipulated, based on the validated clean-up rate of the sputum booth (SANS 14644-3). Downflow booths are preferred as this provides the most efficient contaminant removal. For reliable operation, downflow velocities of 0.35-0.45 m/s should be maintained in the booth with the door closed.
[[File:An illustration of local exhaust ventilation device .png|none|thumb|346x346px|Figure 9: An illustration of local exhaust ventilation device (sputum booth)]]
To ensure that AIIRs and LEVs operate as designed, a good maintenance plan is essential. This involves maintenance of pre-filters and HEPA filters, general ventilation maintenance, and standard daily checks to ensure downward and inward airflow is maintained. These checks are simple, and may be performed with incense sticks or smoke /vapour generating ventilation tubes. Maintenance is critical in LEVs, as failure to maintain the device operating as designed could result in contaminated air being passed into occupied zones. Since ducted UV lights can fail catastrophically without any indication, it is not recommended that the HEPA filters considered for LEV systems be substituted with only in-duct UV lights.

Where sputum collection or induction is performed, signage informing patients about the associated procedure should be considered. This should include:

#Instructions inside the sputum collection booth about the sputum collection procedure.
#Time-lags between patients producing a sputum specimen in the same booth.
#Reminders to healthcare workers to wear respirators in the sputum collection area.

====Pharmacy====
Pharmacist and assistants pharmacists are required to prepare and dispense medication, and manage medicine stock for inpatient and outpatients services. Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Pharmacy]. The pharmacy may be responsible for community outreach programmes for community-based care and may be responsible for distributing medication to downstream referral facilities.

====Laboratory services====
Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Clinical and specialised diagnostic laboratory guidelines]

===Patient accommodation===
Table 5: Patient accommodation cohorts for short-term accommodation
{| class="wikitable"
|Service type
|Accommodation
|Occupancy
|Notes
|-
|Paediatric

(unisex)
|
|
|
|-
|TB and MDR TB (female)
|
|
|
|-
|TB and MDR TB (male)
|
|
|
|-
|XDR (male/unisex)
|
|
|
|-
|XDR (female/unisex)
|
|
|
|-
|XDR paediatrics (unisex)
|
|
|
|-
|Former correctional services/(unisex isolation)
|
|
|
|-
|Psychiatric TB patients/ (unisex isolation)
|
|
|
|}

===Clinical support services for inpatient care===
Nursing support is to be located centrally to serve several bed functional units (for sub-acute services) or dedicated per unit for acute services to ensure supervision and control of the department. Alternatively if functional units are physically separate, these nursing support facilities are to be duplicated. In addition to the inpatient facilities described here, TB patients will need access to facilities described in 2.1 above either as a dedicated facility or where appropriate, shared with outpatients.

====Duty station/ nurse’s station====
The duty station should be provided with a built-in worktop (desk height), a telephone, computer and network points, cupboards and a clinical hand-wash basin.

====Clean linen area====
A locked linen store with slatted racks to support the airing and safe storage of clean linen should be provided.

====Dirty utility room====
The dirty linen store near the sluice and a dirty utility service door with direct access to waste collection points for easy removal and disposal. Space for separate refuse bins for paper, medical waste and general waste.

====Sluice room====
A standard sluice room with bedpan, urinal racks, storage cupboards and a worktop should be provided.

====Surgery services (operating theatre)====
Surgical services are commonly required by TB patients so should be readily available in nearby referral facilities or for stand-alone TB-services minor procedures room may be provided on site. Support infrastructure such as CSSD is required in accordance with.

====Staff facilities====
A cluster of staff facilities should be provided for exclusive use by staff. These include a lounge/tea area/room; a kitchen area/room; staff locker area/room and staff ablutions. Staff facilities should be located remotely from patient areas to allow for:

*airborne infection control
*a “break-away” venue to rest following patient contact periods away from the demands of the work environment

Staff facilities should be readily accessible to the duty areas. The purpose of this kitchen is to prepare beverages for members of the staff at tea breaks and lunch breaks, and to provide a place for washing and storing crockery and stocks of tea, coffee, sugar, milk and cleaning materials under lock and key. The kitchen area/room should be equipped with a sink, lock-up cupboards, bar fridge, and an instant boiling water dispenser (“Hydroboil” or similar approved).

Staff lockers should be provided for each non-central service member of staff for storing personal belongings.

====Procedure room====
The procedure room can be provided for the taking of blood and other specimens (except sputum). Clinical hand-wash basin with elbow taps to be provided. Work tops at standing height. Lock-up cupboards and a patient couch with good lighting. The electrocardiogram and the emergency trolley can be stored in this room.

====Store rooms====
Store rooms for provisions and consumables, surgical stores, equipment (such as wheelchairs, crutches and health technology) should be provided. These stores must be ventilated and fitted with shelves selected for appropriate storage of goods. Where electrical equipment is stored, electrical socket points may be required to ensure battery charging.

====Medical store====
A lockable room for store for the safekeeping of ward stock and scheduled drugs, infusions etc. is required. This must room must be cool (as close to 18 °C with passive means as possible), dry and dark (that is its electrical lighting should be independently controlled). It should be provided with a cabinet, worktop and adjustable shelving.

====Matron’s office====
The office should be a standard office with the normal requirements (desk, telephone, computer and network points, cupboards and a clinical hand-wash basin).

====Mortuary====
If a nearby referral healthcare establishment is available, a bier room may suffice. Alternatively a small mortuary may be provided. Refer to <u> [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Mortuary Services]''.''</u>

===Patient Support===
Care should be taken to avoid enclosed congregate settings (such as waiting areas) where possible. Where these are required, they should be regarded as high risk for airborne contamination.

====Visitor’s area====
This area must be separate from the ward, should have a meeting room for several families, veranda and garden. Seating and tables must be built in. The visitor facility can be shared between male and female patients. Access control must be provided for visitors.

====Visitor’s ablution====
To be attached to visitor’s area. At least one unisex accessible toilet is to be provided.

====Dining facilities====
In acute settings, patients may be served meals in bed. A hall to accommodate patients is recommended in long-term care facilities. This room should provide tables and chairs for all patients, a small kitchenette, fridge, microwave, stove and an instant boiling water dispenser (“Hydroboil” or similar approved). These areas should have ample access to the outside. This room can be interlinked with games and TV rooms (if provided).

====Business centre====
This room should provide access to computers with Internet connectivity, space and chairs.

====Resource centre/ media room/ library====
This room should be like a small lounge providing space for books easy chairs and big table and chairs for occupational therapy activities.

====Games room====
This room should provide space for e.g. snooker, table tennis, and board games. This can be interlinked with other patient support areas (e.g. dining and TV room).

====TV room====
Separate from dining and games room, this room should have a TV, DVD and lounge suites. To be interlinked with Games and Dining Rooms.

====Kitchenette====
In addition to central kitchen services, an area may be provided in which patients can prepare their own meals and wash dishes. This area should be provided with a stove/oven, microwave, fridge, an instant boiling water dispenser (“Hydroboil” or similar approved), double sink, dishwasher. Lock-up cupboards and counter top working areas. Lock-up cupboards will provide store space for crockery and consumables.

====Patient laundry====
In addition to the central laundry services, provision may be made for a laundry for patient use only. This room should provide a washing machine and washing trough, and have direct access to a drying yard.

====Other recreation====
Patients are encouraged to spend much time outdoors during convalescence. Consideration should be made to providing pleasant garden and planting areas, possible vegetable gardens, and permanent weather-proof seats. An outdoor covered patio with braai facilities connected to dining area should be provided. An outdoor uncovered patio connected to the games/ TV room area may be provided. Storm-water management around the proposed building and affected grounds should be considered.

===Allied healthcare services===
National policy recognises the importance of have a holistic psycho-social approach to patient care. Therefor provision should be made for allied health services preferably by practitioners on site, visiting practitioners or, alternatively at a nearby referral facility. Refer to [https://www.iussonline.co.za/norms-standards/clinical-services IUSS:GNS Adult rehabilitation services for further guidance].

====Occupational therapy====
Occupational therapists (OTs) and assistant OTs deliver a service to TB patients. It may be challenging to motivate patients especially when they are sick and are treated with many drugs, which have severe side effects. OT aims to increase skills by training in several crafts, cooking classes etc.

====Audiology====
Audiology services are required as a common side-effect of TB treatment is hearing loss. A baseline hearing test ought to be performed upon patient admission and followed up with regular tests to determine the effects of the drugs on hearing. If hearing is affected, drugs regimens can be adapted. Sharing of audiology equipment with referral facilities may be problematic as conventionally audio booths are enclosed to control noise and may be inadequately adapted for airborne infection risk. It is highly recommended that dedicated mobile audiometers which do not require booths (see KUDUwave, or equivalent) are secured for TB facilities. These can be supported by telemedicine so that reduced on-site involvement of audiologist is possible. Where the use of mobile audiometers is not possible or appropriate, it is recommended that the audiology test booth used be ventilated and flushed with fresh air for 20 minutes between uses.

====Physiotherapy====
Physiotherapists and assistant physiotherapists deliver services to patients as required. This typically includes lung function tests, mobility exercises and assistance in sputum production where patients have difficulty.

====Clinical psychology====
Clinical psychologist sees patients on an individual basis, have climate groups and supervise the six lay counsellors in their work.

====Social services====
Social workers assist patients with social and economic issues which include the obtaining of grants, identity documents and family counselling.

===Support services===

====School====
Provision of school services may be negotiated with the relevant Provincial Department of Basic Education. Separate teaching and learning facilities may be provided.

====Kitchen====
Kitchen services may be outsourced or prepared on site. Refer to ''IUSS: GNS Catering Services''

====Laundry====
General laundry services can be provided on site, off site or can be shared (where co-located). Refer to [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Laundry and linen]. In addition to general laundry services some TB institutions encourage patients to wash their own clothing. Where this is the case, hand washing, washing machine, drying machines and/or drying yards should be provided.

===Facilities management===

====Waste management====
On-site disposal, storage and collection of waste need consideration. Refer to [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Waste disposal].

====Maintenance services - building====
Building maintenance services for both planned and unplanned maintenance (for example works foreman, electrician, painter, plumber, and carpenter) will be needed to provide service on site either on a full-time, part time or visiting basis depending on the size of the facility and institutional arrangement. Maintenance workshops and storage space may be required for this.

====Clinical engineering====

====Gardening services====
Gardening and grounds maintenance services may be provided on-site or outsourced. It is recommended that planting and landscaping is arranged near to building openings to discourage loitering nearby for infection prevention and control.

====Cleaning services====
Cleaning services may be outsourced. However storage of cleaning equipment, materials and staff facilities for cleaners is required to be provided on site.

===Administration===
Office accommodation is to be provided in accordance with the following reference: Department of Public Works, 2005. Space planning norms and standards for office accommodation used by organs of state. (Government notice 1665). Cape Town South Africa: Government Gazette.

===Other===

====Co-located institutions/ activities====
Medical researchers, NGOs and other organisations may provide services to and be co-located with the facility.

====Overnight stay====
Family member overnight accommodation is not routinely provided but may be desirable, particularly in rural settings.

====Commercial support (tuck shop, ATM)====
Tuck shop facilities and banking services may be provided - if viable - on site for staff and patients. This is highly recommended as otherwise infectious patients leave the site in order to attend to these requirements.

====Staff accommodation====
Staff accommodation for nursing and or/clinical staff may be required by provincial policy, and may be recommended in most cases, especially in rural settings. Separation on site of staff quarters and patient facilities on site should allow for staff safety and privacy, whilst remaining within comfortable walking distance of the patient facilities. Refer to [https://www.iussonline.co.za/norms-standards/support-services IUSS:GNS Health facility residential]

='''Case studies'''=

==List of case studies==

* Areas comparison of long-term XDR TB care facilities at:
**Bongani Hospital, Mpumalanga
**Tshepong Hospital, North West
**Modimolle Hospital, Limpopo
*Modimolle TB Hospital
**site layout
**patient rooms
**natural ventilation design
*Catherine Booth TB Hospital, KwaZulu-Natal
**Roof ventilation and windows concept drawings
**Two-bed patient rooms plan

[[File:Case study A and B.jpg|none|thumb|535x535px|Case study A - Bongani Hospital, Case study B - Tshepong Hospital]]
[[File:Case study C and BCH proposal.jpg|none|thumb|536x536px|Case study C - MDR TB Unit, Modimolle and BCH proposal - Brooklyn chest Hospital]]
[[File:Modimolle TB hospital iite layout .png|none|thumb|537x537px|Modimolle TB Hospital (site layout)]]
[[File:Modimolle TB hospital patient rooms.png|none|thumb|537x537px|Modimolle TB Hospital (patient rooms)]]
[[File:Natural ventilation design principles.png|none|thumb|535x535px|Modimolle TB Hospital (Natural ventilation design principles)]]
[[File:Catherine Booth construction, windows and ventilation.png|none|thumb|536x536px|Catherine Booth TB Hospital, KwaZulu-NatalRoof (ventilation and windows concept drawings)]]
[[File:Two-bed patient rooms plan.png|none|thumb|537x537px|Catherine Booth TB Hospital, KwaZulu-Natal (Two-bed patient rooms plan)]]

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Department of Health and Human Services (DHHS) and National Institute for Occupational Safety and Health (NIOSH), 2009. Environmental control for tuberculosis: Basic upper-room ultraviolet germicidal irradiation guidelines for healthcare settings''.'' Atlanta, GA: DHHS.

Department of Public Works, 2005. Space planning norms and standards for office accommodation used by organs of state. (Government notice 1665). Cape Town South Africa: Government Gazette.

Dugger, C.W., 2008. In South Africa, TB patients behind barbed wire. The New York Times'','' [online] 24 March. Available at: <nowiki>http://www.nytimes.com/2008/03/24/world/africa/24iht-saf.4.11377837.html?pagewanted=all&_r=0</nowiki> [Accessed 26 March 2014].

First, M.W., Nardell, E.A., Chaisson, W. and Riley, R., 1999. Guidelines for the application of upper-room ultraviolet germicidal irradiation for the prevention of airborne contagion- part I: Basic principles. ASHRAE Transactions 105(1).

First, M.W., Nardell, E.A., Chaisson, W. and Riley, R., 1999b. Guidelines for the application of upper-room ultraviolet germicidal irradiation for the prevention of airborne contagion- part II: Design and operation guidance. ASHRAE Transactions 105(1).

Gandhi, N.R., Shah, N.S., Andrews, J.R., Vella, V., Moll, A.P., Scott, M., Weissman, D., Marra, C., Lalloo, U.G., and Friedland, G.H. and Tugela Ferry Care and Research Collaboration, 2010. HIV coinfection in multidrug and extensively drug-resistant tuberculosis results in high early mortality. American Journal of Respiratory and Critical Care Medicine, 181(1),pp.80-86.

Hamilton, K. and Yau, J., 2004. The global tug-of-war for health care workers. Washington USA: Migration Policy Institute. Available at: <nowiki>http://www.migrationinformation.org/feature/display.cfm?ID=271</nowiki> [Accessed 4 February 2014].

Hinds, W.C., 1999. Aerosol technology: Properties, behaviour and measurement of airborne particles''.''2nd ed. New York: John Wiley & Sons.

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International Radiation Protection Association (IRPA), 1985. Guidelines on Limits of Exposure to Ultraviolet Radiation of Wavelengths between 180 nm and 400 nm (Incoherent Optical Radiation). Health Physics, 39, pp. 331–340.

Joshi, R., Reingold, A.L., Menzies, D., and Pai, M., 2006. Tuberculosis among health-care workers in low- and middle-income countries: A systematic review. PLoS Medicine, 3(12).

Ko Gwangpyo, First Melvin W and Burge Harriette A The Characterization of Upper-Room Ultraviolet Germicidal Irradiation in Inactivating Airborne Microorganisms [Journal] // Environmental Health Perspectives - Harvard School of Public Health. - Boston : EBSCO, January 2002. - 1 : Vol. 110. - pp. 95-101. - Harvard School of Public Health.

Ko, G., First, M.W. and Burge, H.A., 2002. The characterization of upper-room ultraviolet germicidal irradiation in inactivating airborne microorganisms. Environmental Health Perspectives'','' 110(1), pp.95- 101.

Lawn, S.D., Bekker, L.G., Middelkoop, K., Myer, L. and Wood, R., 2006. Impact of HIV infection on the epidemiology of tuberculosis in a peri-urban community in South Africa: the need for age-specific interventions. Clinical Infectious Diseases, 42(7), pp.1040-1047.

London, L., 2009. Confinement for extensively drug-resistant tuberculosis: balancing protection of health systems, individual rights and the public’s health. International Journal of Tuberculosis and Lung Disease, 13(10), pp.1200-9.

Menzies, D., Joshi, R., Pai, M., 2007. Risk of tuberculosis infection and disease associated with work in health care settings. The International Journal of Tuberculosis and Lung Disease. 11(6), pp.593-605.

Molhave, L., 1987. The sick buildings-A subpopulation among the problem buildings. In: Seifert, B.; Esdorn, H.; Fischer, M.; Rueden, H.; Wegner, J., eds. Indoor Air ’87, 4th international conference on indoor air quality and climate. West Berlin Germany, August 1987. Berlin Germany: Institute for water, soil and hygiene.

Molhave, L., Bach, B. and Pedersen, O.F., 1986. Human reactions to low concentrations of volatile organic compounds. Environment International, 12(1-4), pp.167–175.

Morey, P.R., Hodgson, M.J., Sorenson, W.G., Kullman, G.J., Rhodes, W.W. and Visvesvara, G.S., 1984. Environmental studies in moldy office buildings: Biological agents, sources and preventive measures. In: Annual American conference of governmental industrial hygiene, Vol. 10, 1984, pp.21-35.

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Nardell, E.A., 1995. Interrupting transmission from patients with unsuspected tuberculosis: a unique role for upper room ultraviolet air disinfection. American journal of Infection Control, 23(2),pp.156 64.

National Department of Health (NDoH), 2007. The draft national infection prevention and control policy for TB, MDRTB and XDRTB. South Africa: NDoH.

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Price Waterhouse Coopers LLP in association with the University of Sheffield and Queen Margaret University College Edinburgh, 2004. The role of hospital design in the recruitment, retention and performance of NHS nurses in England. [pdf] Belfast UK: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/the-role-of-hospital-design-appendices.pdf</nowiki> [Accessed 13 February 2014].

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Riley, R.L. and Nardell, E.A., 1989. Clearing the air: The theory and application of ultraviolet air disinfection. The American Review of Respiratory Disease'','' 139(5), pp.1286– 1294.

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Riley, R.L., Knight, M. and Middlebrook, G., 1976. Ultraviolet susceptibility of BCG and virulent tubercle bacilli. The American Review of Respiratory Disease, 113(4), pp.413–418.

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Xu Peng [et al.] Efficacy of ultraviolet germicidal irradiation of upper-room air in inactivatingairborne bacterial spores and mycobacteria in full-scale studies [Journal] // Athmospheric Environment 37. - 2003. - pp. 405-419.

Xu, P., Peccia, J., Fabian, P., Martyny, J.W., Fennelly, K.P., Hernandez, M. and Miller, S.L., 2003. Efficacy of ultraviolet germicidal irradiation of upper-room air in inactivating airborne bacterial spores and mycobacteria in full-scale studies. Atmospheric Environment, 37 (2003), pp.405–419.

='''Abbreviations'''=
{| class="wikitable"
|ACGIH
|American Conference of Governmental Hygienists
|-
|ACH
|Air changes per hour
|-
|AIA
|American Institute of Architects
|-
|AIIR
|Airborne infection isolation room
|-
|ASHRAE
|American Society of Heating, Refrigerating and Air-Conditioning Engineers
|-
|CDC
|Centers for Disease Control and Prevention (US agency)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|CSSD
|central sterile supply department
|-
|DR
|drug-resistant
|-
|DR TB
|drug-resistant TB
|-
|EIA
|environmental impact assessment
|-
|IAQ
|indoor air quality
|-
|ICT
|information communications technology
|-
|IPC
|infection prevention and control
|-
|IRPA
|International Radiation Protection Agency
|-
|LEV
|local exhaust ventilation
|-
|MDR TB
|multi-drug-resistant TB
|-
|NDoH
|National Department of Health
|-
|NGO
|non-governmental organisation
|-
|NHLS
|National Health Laboratory Service (SA agency)
|-
|NHI
|National Health Insurance
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|OHS
|occupational health and safety
|-
|OPD
|outpatient department
|-
|OT
|occupational therapy / occupational therapist
|-
|PAC
|Portable air cleaner
|-
|PHC
|primary healthcare
|-
|PMV
|predicted mean vote
|-
|PPE
|personal protective equipment
|-
|QASA
|Quadra-para Association of South Africa
|-
|REL
|recommended exposure limit
|-
|RH
|relative humidity
|-
|RSE
|relative spectral effectiveness
|-
|SAHNORMS
|South African hospital norms
|-
|SDP
|site development plan
|-
|TB
|tuberculosis
|-
|TLV
|threshold limit values
|-
|UVA
|ultraviolet “A” (wavelength 400 nm–315 nm)
|-
|UVB
|ultraviolet “B” (wavelength 315 nm–280 nm)
|-
|UVC
|ultraviolet “C” (wavelength 280 nm–100 nm)
|-
|UVGI
|ultraviolet germicidal irradiation
|-
|WHO
|World Health Organisation
|-
|XDR TB
|extreme (or extensively) drug-resistant TB
|}

='''Annexure 1. Indoor sputum booth'''=

==Application==
This document contains a set of drawings and specifications presenting prototype concept of a Sputum Booth developed at the CSIR. These are intended for the clinical applications. Further information can be obtained from the Architectural Engineering Group of the Building Scient and Technology Unit of the CSIR'''''.'''''

==Background==
This document presents technical drawings and specifications of the concept a sputum induction and collection booth designed for TB infection control in clinical settings. The prototype was developed by the Architectural Engineering Group, Building Science & Technology Programme, Division of Built Environment, CSIR. The development process of this facility was described in a separate report: ''“Development of a prototype of the Sputum Booth; CDC project”'', November 2013.

The related work was carried out in terms of the international research project funded by the Centre for Disease Control (CDC).
[[File:Sputum booth, rear view.jpg|none|thumb|Figure 10: Sputum booth, rear view]]

==Suggestions improvements on concept booth==
Upon the completion of the prototype unit, a few areas were identified for further improvements. These relate to the following:

*The mass of the unit is still too high for safe and resiliant transport. Solutions for weight reduction should be soughtExternal fold away handels could be included in the design for easier handling of the unit.
*The overall length of the booth could be reduced by about 150 mm. This would still provide enough space to accommodate a person in a wheelchair.
*The costs and mass of future units could be reduced by replacing the aluminium sandwich panelling with polymer sheeting
*The fan-filter unit could be constructed such that is an integral structural component of the booth, reducing size and weight of the overall unit.
*Incorporating an additional flexible one-way membrane behind the screen of the pre filter would limit the reversed airflow back into the booth when the booth is non-operational or during transportation.

==Arduino wiring code for door interlock timer==
/*Begin*/

/*

Sputum booth door lock control Sample code 08/11/2013

Written by: Tobias van Reenen (CSIR)

This Arduino Uno sketch controls a 12V magnetic door lock for a mechanically ventilated sputum booth

The door in this sketch remains normally locked and is released on the press of the external and internal door release buttons

The internal door release button will always unlock the door while the external button will only release the door after it has remained locked

for the predetermined length of time. This is in order to allow the booth ventilation system to adequately flush the booth between occupants.

The following wiring connections are made:

Arduino________Interface

GND ------------------ gnd

5.0v------------------ Vcc

Magnet power---------- +12V & -12V

8 -------------------- Release Button (Internal)

9 -------------------- Unlock Button (External)

10 ------------------- Unlock LED (Green)

11 ------------------- Locked LED (Red)

12 ------------------- Door Magnet Relay

<nowiki>*</nowiki>/

//Initiate variables

int doorLOCK = 12;    //5v relay pin, switching 12V Magnet

int lockedLED = 11;    //redLED

int unlockLED = 10;    //greenLED

int unlockButton = 9;    //External Button requesting an door unlock. Cannot override timer --requires 10k pull-up resistor & 5V Vcc

int releaseButton = 8; //Internal button requesting a door release. Overrides timer --requires 10k pull-up resistor & 5V Vcc

float unlockDELAY = 3000; //3 seconds

float lockDELAY = 30000;    //30 seconds

float unlockTimeStamp;

float lockTimeStamp;

int pressed = 0;

int unpressed = 1;

int UNLOCK = 1;

int LOCK = 0; //using normally closed relay config

int ON = 1;

int OFF = 0;

void setup() {

pinMode(doorLOCK,OUTPUT);

pinMode(lockedLED,OUTPUT);

pinMode(unlockLED,OUTPUT);

pinMode(unlockButton,INPUT);

pinMode(releaseButton,INPUT);

Serial.begin(9600);

Serial.println("restart");

digitalWrite(unlockLED,OFF);

digitalWrite(lockedLED,ON);

}

void loop() {

Serial.print("unlock: ");

Serial.print(digitalRead(unlockButton));

Serial.print(" release: ");

Serial.print(digitalRead(releaseButton));

Serial.print(" unlockLED: ");

Serial.println(digitalRead(unlockLED));

if (digitalRead(releaseButton) == pressed){ //check for release button press

while (digitalRead(releaseButton) == pressed){    //holds code until button released

unlockDOOR();    // unlock door function

}

}

if (digitalRead(unlockButton) == pressed){ //check for unlock button press

   if (digitalRead(unlockLED) == ON){ //only unlocks door if unlock LED is lit

while (digitalRead(unlockButton) == pressed){//holds code until button released

   unlockDOOR();

}

} //unlock door function

   }

if (millis()> (unlockTimeStamp+unlockDELAY)){    //counts down unlock delay and then locks door again

   Serial.print("CountDown: "); Serial.println((lockDELAY+unlockTimeStamp+unlockDELAY-millis())/1000);

   if ((digitalRead(unlockButton) == unpressed)&&(digitalRead(releaseButton) == unpressed)){

if (digitalRead(doorLOCK)!=LOCK){ //checks for unlock button hold before locking door

   lockDOOR(); //lock door function

}

   }

}

if (millis()> (lockTimeStamp+lockDELAY)){

   digitalWrite(unlockLED, ON);

   }

}

void unlockDOOR(){

Serial.println("unlocking...");

unlockTimeStamp = millis();    // initiate unlock counter

digitalWrite(lockedLED,OFF);

digitalWrite(unlockLED,OFF);

digitalWrite(doorLOCK,UNLOCK);

}

void lockDOOR(){

Serial.print("locking... ");

lockTimeStamp = millis();

digitalWrite(doorLOCK,LOCK);

digitalWrite(lockedLED,ON);

digitalWrite(unlockLED,OFF);

Serial.print("unlockLED: ");

Serial.println(digitalRead(unlockLED));

}

/*end*/

==Drawings==
[[File:Sputum booth, left view.jpg|none|thumb|490x490px|Figure 11: Sputum booth, left view]]
[[File:Sputum booth, front view.png|none|thumb|484x484px|Figure 12: Sputum booth, front view]]
[[File:Sputum booth, Isometric view.png|none|thumb|498x498px|Figure 13: Sputum booth, Isometric view]]
[[File:Sputum booth, door control logic.png|none|thumb|547x547px|Figure 14: Sputum booth, door control logic]]
[[File:Sputum booth, door controller wiring.png|none|thumb|Figure 15: Sputum booth, door controller wiring]]
[[File:Sputum booth, door controller PCB (NTS).png|none|thumb|Figure 16: Sputum booth, door controller PCB (NTS)]]
='''Annexure 2.    Pre-fabricated outdoor sputum booth'''=
[[File:Sputum Booth Isometric view.png|none|thumb|Figure 17: Sputum booth Isometric view]]
[[File:Sputum Booth front view.png|none|thumb|Figure 18: Sputum booth front view]]
[[File:Sputum booth, side view..png|none|thumb|Figure 19: Sputum booth, side view.]]

='''Annexure 3. Brickwork outdoor sputum booth'''=
[[File:Brickwork sputum booth-layout and detail.png|none|thumb|502x502px|Figure 20: Brickwork sputum booth-layout and detail]]

<br />
[[Category:Clinical Services]]

Materials and finishes

2020-10-27T13:05:58Z

VSadiki:

=Internal Ceiling Finishes in Healthcare Facilities=

=Context=

==Overview – finishes in the healthcare environment==
<br />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 (historically) where even more attention should be paid to creating a caring atmosphere.

It is this paradigm shift that is required when considering and selecting finishes. The role of finishes in a healthcare facility has become as important an aspect of design as room sizes and relationships.
“UNTIL THE GERM THEORY WAS DEVELOPED, MORE MEN WERE DYING FROM SMALL WOUNDS AND DISEASES THAN FROM MAJOR TRAUMAS ON THE FRONTLINES. BUT AS SOON AS GERM THEORY WAS DEVELOPED A WHOLE NEW PARADIGM, A BETTER WAY OF UNDERSTANDING WHAT WAS HAPPENING
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.
[[File:Facility finishes.png|thumb|none]]

==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.

'''How to use this document:'''

#Review the Selection Criteria - Part B
#Select a Room / Department name in Part D, and note Performance Category
#Refer to Table 1 for the Properties that make up that Performance category
#Refer to Part C to assess ceiling types that could satisfy those performance requirements.

'''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 <u>www.iussonline.co.za</u>

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.

==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:

SANS 204 Energy-Efficiency in buildings general

SANS 622 Gypsum cove cornice

SANS 637 Wood-wood panels (cement-bonded)

SANS 640 Flexible PU-foams

SANS 803 Fibre cement boards

SANS 1039 Wooden ceiling and panelling boards

SANS 1381 Materials for thermal insulation boards

SANS 1508 Expanded polystyrene thermal insulation boards

SANS 1783 Softwood brandering and battens

SANS 6013 Dimensional and mass stability of particle boards with varying humidy

SANS 6016 Transverse tensile strength of particle boards

SANS10177 Fire-testing of materials

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

=Selection Criteria=

==Scope==
A ceiling in any facility forms the third dimension in any given room area, along with the walls and the floor, and it sometimes separates the roof space from the occupied area below. The manner 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.
[[File:Ceiling.png|thumb|none|338x338px]]
Ceiling: “upper interior surface of a room or similar compartment, including all materials comprising such surface”

Roof assembly: “building cover and its supporting structure, including any ceiling attached to such structure, including any additional components such as insulation”
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.
[[File:Actual Soffit of structure overhead.png|thumb|none]]

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.
[[File:Membrane fixed directly to the structure overhead.png|thumb|none|344x344px]]

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.
[[File:Membrane suspended from the structure overhea.png|thumb|none|329x329px]]

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

==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

===Embodied energy of materials===
{| class="wikitable"
|+
!Material
!Embodied Energy in MJ / kg (million joules per kilogram)
|-
|Extruded anodised aluminium(virgin)
|227
|-
|Extruded anodised aluminium (recycled)
|42.9
|-
|Fibre-cement board
|9.5
|-
|Fibreglass insulation
|30.3
|-
|Gypsum plaster
|4.5
|-
|Plasterboard
|6.1
|-
|Concrete (in situ)
|1.0 - 1.6
|-
|Concrete (precast)
|2.0
|-
|Cement
|7 - 8
|-
|Particle board
|8.0
|-
|Steel (virgin)
|32
|-
|PVC
|70
|-
|Paint (solvent-based)
|98.1
|}
''Source: Alcorn and Wood, 1998.''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.

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

==Life cycle costing and sustainability==
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 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 importance of life cycle costs.
[[File:Capital outlay costs vs life span costs.png|thumb|none]]

Sustainability should be considered in all four stages of product life:

*Manufacture
*Use
*Maintenance
*Disposal

[[File:Product life sustainability.png|thumb|none|402x402px]]

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.
[[File:Life cycle costing and sustainability diag.png|thumb|none|365x365px]]

===Toxicity and effect on indoor environment===
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)
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.

'''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.
[[File:Toxicity and effect on indoor environment diag.jpg|thumb|none]]

==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)

[[File:Facility design.png|thumb|none]]

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.

==Selection criteria==

===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.”
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)
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.

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.
“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 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 also carried out microbiological studies comparing patient rooms with and without carpet. The study found higher microbial counts and more E.coli and other organisms on carpet samples than bare floors.

While this issue may not affect the selection of a ceiling finish, there are principles to be borne in mind when establishing what finish is best in high-risk environments.
[[File:Selection criteria diag.png|thumb|none|360x360px]]

Below is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Although ceilings are out of reach and therefore less affected by regular touching, airborne bacteria can be carried on circulating mechanical ventilation, and aerosol contaminants which are distributed when water is splashed, (Ayliffe et al., 2000) can carry pathogens to ceiling level.

Ceiling materials and finishes that resist the spread of infection will have qualities that can be summarised as follows:

*Smooth
*Impervious
*Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, ceilings will have the following properties:

*Textured
*Perforated
*Jointed

[[File:Selection criteria diag 2.jpg|thumb|none]]

Certain materials have been shown to inhibit bacterial growth – such as vinyl, PuR and natural materials such as cork. This will also contribute to the prevention of infection. Ceilings with these properties will have the following quality:

*Bacteriostatic

'''A note about anti-bacterial treatments and additives to ceiling products:'''

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

Synthetic fibres such as polypropylene textile and vinyl for example, in themselves do no provide a nutrient source which microbes need to survive, but some finishes can trap soil, dust and moisture which do provide that source.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risks and benefits to healthcare users.

==Cleaning and maintenance==
Connected with infection prevention is the issue of cleaning. Ceilings tend to have ’reactive’ cleaning regimes, rather than regular cleaning programmes. This is partially because the ceiling gives an impression of cleanliness, but this can be misleading.

Whether the materials/finish of a ceiling can be cleaned thoroughly will define the extent to which infectious agents can be prevented from multiplying on a surface. Some materials can tolerate a reasonable amount of moisture, facilitating regular washing, while others would be adversely affected by it and can only be dusted or wiped.
[[File:Cleaning and maintenance diag.jpg|thumb|none|341x341px]]

For cleaning to be effective, the surface must be able to withstand regular and fairly vigorous cleaning, with proper access to all surfaces. Where there are small recesses or difficult to reach corners, dirt is easily trapped providing dark, undisturbed conditions – the perfect breeding area for bacteria.

Information regarding cleaning materials should also be considered, as solvents and cleaning agents can quickly cause deterioration of the finish if it is not robust enough to withstand the cleaning required.

A further aspect to consider is the disruption that will be required to carry out the cleaning regime and possible maintenance. This is pertinent to areas such as operating theatres that may remain in use 24 hours a day.

Where there is a high requirement for regular cleaning of a ceiling in view of its location in a sensitive area, together with a need for minimal disruption for maintenance, the ceiling properties could be summarised as:

*Washable
*Low maintenance

[[File:Cleaning and maintenance diag 2.jpg|thumb|none]]

An additional consideration in the selection of ceiling finishes in health facilities in terms of maintenance is the provision of access to services in the ceiling void. Health facilities will generally require a high concentration of various services, most of which run in the ceiling void.

This will include electrical power and lighting, data, nurse call systems, medical gas and vacuum lines, air-conditioning and extract ducts, as well as hot water and waste pipes to name a few. Although service ducts and shafts can alleviate this congestion in the ceiling, distribution on the horizontal plane will nonetheless be required.

By selecting ceiling types that cater for easy access and giving thought to the best positions for these access panels - even marking these panels where necessary - this will facilitate easier maintenance of in-ceiling services during the life span of the building. This in turn will reduce ’downtime’, and disruption of the health facility.
[[File:Access panel.jpg|thumb|none]]

While the location of access panels is determined by the layout of services, certain rooms or areas will be more suitable for these panels.

*No combustible materials are permitted in ceilings or roof structures for buildings classified as hospitals.
*Medical facilities and healthcare categories are classified separately and have different requirements.
*Strict parameters are given for the depth of ceiling voids and this is related to the need for sprinklers when the voids exceed a given depth.
*Compartmentalisation of the ceiling void is required in area and distance, with fire stops.
*A dedicated section is written regarding operating theatres and intensive, high and critical care units, stipulating 120 min fire resistance for division separations.
*A full list of materials deemed to be non-combustible is provided.

This has been listed as the property:

*Access panels

===Safety===
Unlike floors which can prevent - or contribute to - falls by patients and staff, ceilings are largely out of reach and need not be assessed for safety as is relevant to floors. The safety aspect of fire performance does however need to be highlighted. The SANS 10400 lists specific requirements for hospitals and medical facilities with regard to ceilings. This is aimed at protecting the patients who are most likely frail, may not be able to walk, and would require assistance and more time to escape in the event of fire.

The definitions in the SANS 10400: Part A read:

*E2 Hospital

Occupancy where people are cared for or treated because of physical or mental disabilities, and where they are generally bedridden.

*E3 Other institutional (residential)

Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

*E4 Healthcare

Occupancy which is a common place of long term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

These requirements are set out in Part T of SANS 10400, and include:

All ceilings in hospitals would need to be non-combustible material. In other health facilities, such as community health centres or clinics, there are exceptions to the non-combustible requirement, subject to compliance with certain conditions. Since each project varies, the advice of a competent fire engineer should be obtained.

==Indoor air quality==
There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality. The first is he effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces, The second is the effect of the material on the floor material - namely the emission of volatile organic compounds.
[[File:Indoor air quality diag.jpg|thumb|none]]

===Humidity===
Certain rooms and areas of health facilities are by nature of the function they house - wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture-resistant finishes. If the ceiling panels or surfaces are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a ceiling finish, this property will be listed as:

*High humidity

===Emissions from materials===
As discussed under Environmental Aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off by – commonly referred to as off-gassing:

*The product itself, along with its structure
*The adhesives used to fix the product or its layers
*The paints or sealants used to finish
*The cleaning solutions required for regular maintenance

[[File:Emissions from materias diag 1.jpg|thumb|none]]

People who work in noisy environments for long shifts day in and day out, also have similar stress-induced experiences. They report everything from exhaustion to burnout, depression and irritability”
The smell of the interior of a new car - enjoyed by many is an example of plasticizers that have evaporated - emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality. The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels’ outlines.

IEQ14 section measured the formaldehyde minimisation which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used.

It should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.
Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space
Patients with respiratory weaknesses such as asthma are most likely to be affected by VOC emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility. Materials such as paints and polyvinyl-chlorides can emit VOCs which can have a negative effect on indoor air quality.

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. VOCs can also cause irritation and odour annoyance, and could lead to behavioural, neurotoxic, hepatoxic and genotoxic effects (Meininghaus et al., 2000; Hoskins, 2003; Hodgson et al., 2000.)
[[File:Emissions from materias diag 2.jpg|thumb|none]]

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of enamel paint on plaster, for example, may result in higher VOC emissions than say, a pre-finished lay-in ceiling board, but the infection control benefits of the seamless finish will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) Ceilings often present an opportunity to reduce the heat load on rooms from the roof space through insulation. This could form part of the ceiling material itself or be laid over the ceiling.

==Acoustics==
Noise in health facilities is mainly generated by:

*Impact sounds e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.
*Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LA<sub>eq</sub>) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization’s recommended LA<sub>eq</sub> value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November, 2005 showing that chronic noise increased the risk of heart-attack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.
[[File:Acoustics diag 1.jpg|thumb|none]]

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. 2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Sound-absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:
High acoustic
[[File:Acoustics diag 2.jpg|thumb|none]]

==Aesthetics==
Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results of a study by Becker and Douglass (2008), show that the physical appearance of the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Reflectivity of the ceiling material can boost natural light in a room or alternately produce glare - both of which have a direct impact on the comfort levels in the room. By ensuring skylights are oriented correctly, and shaded appropriately, natural light could be introduced through the ceiling.
[[File:Aesthetics diag.jpg|thumb|none]]

The ceiling surface finish should complement the function of the room, and monotony for the sake of economics should be avoided, bearing in mind that most patients will be focused on the ceiling for the duration of their stay.

Printed ceiling tiles, or polycarbonate panels with vinyl film images, behind which lighting can be introduced, could be used in key areas. This can transform a dull ward ceiling into a fascinating window to the outside world. CABE (2004) highlights the need for patients to have a ’connection with nature’, and these ceiling ‘windows’ are the ideal opportunity to supplement views to the exterior.

Natural light is a key factor in creating an environment for patient recovery. The occupants of the ward should be considered – paediatric wards are opportunities for playful scenes that will help little patients feel at ease.

In public areas where more emphasis might be placed on an attractive and welcoming interior than other factors, then this factor would be listed as:

   • High aesthetics

=Technical Information - Ceiling Types=

==Paint on seamless plaster==
'''General description and properties'''

Paint is easily applied by roller to a plastered ceiling soffit. The soffit could be constructed from plasterboard sheets, which are then skimmed or from concrete. Note that the structure onto which the plasterboard is fixed would need to be non-combustible if the facility is a hospital. Following a primer and undercoat, usually three coats of paint are applied. Two-coat plaster or skimming is highly recommended prior to painting, as defects will be highlighted with the high-gloss type paints.

Paint types that can be applied to the ceiling soffit will vary between oil-based and water-based types. Enamel paint dries to a hard, glossy, finish. It is usually oil-based. Velvet sheen paints are water-based, but produce a less glossy finish. PVA-paints are also water-based, but produce a matt finish. Paint is fairly inexpensive when compared to other ceiling finishes - excluding the structure.
[[File:Paint on seamless plaster diag.jpg|thumb|none]]

'''Infection prevention'''

The smooth seamless finish produced by painted concrete or plasterboard ceilings, make this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Paints with nanotechnology enhancements are also being developed. These paints inhibit the growth of algae and fungus.

'''Cleaning and maintenance'''

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant. Paint is a low maintenance finish which may require re-application every few years, unless latent defects arise.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Paint on a concrete soffit is considered a non-combustible finish as the thickness of the paint is usually less than

0.5 mm – refer to manufacturers’ specifications, and consult with the SANS Part T (4.13).

'''Indoor air quality: Humidity'''

Generally, paints are not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Enamel paints are most resistant to absorbing moisture, when compared to PVA-type paints.

'''Indoor air quality: Emissions and insulation'''

Paints are notorious for high VOC emissions, although manufacturers are now working on products with reduced or zero VOCs. Refer to product specific literature.

'''Acoustics'''

The hard surface of painted soffits reflects sounds and where acoustics are important, there are certainly better options available.

'''Aesthetics'''

While paint can be used effectively to introduce colour for features or emphasis, generally on ceilings in areas where infection prevention is important, the ceilings should be kept single colours - white or light colours – this ceiling would be used in areas where aesthetics is not the highest priority.

==Cementitious board – nail-up ceilings==
'''General description and properties'''

Plain and textured ceiling boards are available for nail-up applications where joints are not a problem. These boards are manufactured from a combination of cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses, and can be nailed at regular intervals to the overhead structure.

The joints between the ceiling boards can be finished using joiners or cover-strips. The ceiling boards can also be fixed between exposed beams.

Although no paint finish is required, paint can be applied. (Refer to comments on paint on plaster above.)
[[File:Cementitious board – nail-up ceilings diag.png|thumb|none]]

'''Infection prevention'''

The textured boards and the joining strips will create areas where microbes can grow. This ceiling finish is therefore not suitable for areas where infection prevention is critical.

'''Cleaning and maintenance'''

Nail-up cementitious boards are unaffected by moisture and resistant to corrosion. When painted they are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is possible if boards do get damaged, but this would be disruptive to the functioning of the room.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Nail-up cementitious boards are non-combustible.

'''Indoor air quality: Humidity'''

These painted boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the building from roof spaces where applicable. Fibres are safe and recyclable, and manufacturers claim low embodied energy used for assembly and construction. Refer to product specific literature. Emissions from paints should be considered.

'''Aesthetics'''

This type of ceiling board is aesthetically acceptable, and with paint, can be used to create an interesting functional ceiling.

'''Acoustics'''

The hard surface reflects sound and will not aid in sound absorption in the room it covers.

==Vinyl-clad ceiling tiles in suspended grid==
'''General description and properties'''

Vinyl-clad ceiling tiles are manufactured from cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses and are clad on the exposed surface with vinyl. They are suitable for 1 200 x 600mm or 600 x 600mm exposed ceiling grids. The grids are suspended from the structure above. The ceiling tiles can also be supplied with 25 mm insulation backing. No further painting or finishing is required.

'''Infection prevention'''

The vinyl finish is impervious, and vinyl inhibits the growth of bacteria. The boards are unaffected by moisture, and can be washed regularly. This makes them suitable for infection prevention. There are however joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

As mentioned, the vinyl-clad tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is very easy if boards do get damaged, with very little disruption to the room function.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Fire safety'''

Vinyl-clad boards are non-combustible; however, fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the room. Fibres are safe and recyclable, (no asbestos fibres) and manufacturers claim low embodied energy used for assembly and construction. However, the vinyl has low VOC emissions, when compared to some paints. Refer to product specific literature.

'''Aesthetics'''

This type of ceiling board gives a hygienic impression and is aesthetically acceptable. Tiles can also be printed with designs where budgets allow.

'''Acoustics'''

The surface is relatively hard, and does not assist with acoustic control or absorb sounds.
[[File:Vinyl-clad ceiling tiles in suspended grid.jpg|thumb|none]]

==Acoustic ceiling tiles in suspended grid==
'''General description and properties'''

These mineral fibre acoustic ceiling tiles – nominally 20 mm thick - have a pre-painted textured and perforated finish. The boards can be supplied with various edge finishes suitable for an exposed grid, or recessed grid with regular or chamfered edges. They are suitable for 1200 x 600mm or 600 x 600mm ceiling grids. The grids are suspended from the structure above. No further painting or finishing is required.

'''Infection prevention'''

The fissured surface may harbour dust and bacteria, making this type of ceiling board unsuitable for areas where infection prevention is critical – such as theatres. Some manufacturers do produce an ‘anti-microbial’ tile. Refer to the section on Selection Criteria- Infection Prevention for more discussion on this aspect. The boards cannot be washed as they will absorb moisture. Dirty or stained panels can be replaced easily. There are also joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

Since the boards are adversely affected by moisture, they can only be brush-cleaned and must be kept dry. Dirt often gathers where air-conditioning ducts blow across these tiles, and these then are difficult to clean. They are lightweight and fairly low maintenance. Replacement is very easy if boards do get damaged, with very little disruption to the room function, although batch colours and textures may vary.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Indoor air quality: Humidity'''

These boards are unsuited to areas of high humidity as they absorb moisture and will swell and droop over time when exposed to moist conditions.

'''Indoor air quality: Emissions and insulation'''

These boards provide some thermal insulation which will reduces the heat load of the building. The tiles do have low VOC emissions which will vary according to the manufacturer. Refer to product specific literature.

'''Aesthetics'''

The patterns of the fissures on this type of ceiling tile can create an interesting ceiling which is aesthetically acceptable.

'''Acoustics'''

The perforated surface is excellent for sound absorption and this product is well-suited to areas where noise reduction is prioritised.
[[File:Acoustic ceiling tiles in suspended grid.png|thumb|none]]

==Pressed metal ceiling tiles in suspended grid==
'''General description and properties'''

Pressed metal tiles are manufactured from galvanised steel, and are then epoxy-coated for a durable finish. The ceiling tiles are made to a variety of sizes. Stainless steel tiles are also available. Perforations are made in the surface – in different patterns and diameter to reduce the weight and improve acoustic performance. They are laid in a suspended ceiling grid, or can be hinged to the grid to open downwards. No further painting or finishing is required.

'''Infection prevention'''

The perforated surface may harbour dust and bacteria, and the joints mean the ceiling is not seamless. This type of ceiling is not suitable for areas where infection prevention is critical. The tiles are however washable.

'''Access to services'''

The hinged access tiles are purpose-made for access to services in the ceiling void as they are hinged to swing down leaving the void clear of grid transoms. The lay-in type of panel is also removable in a suspended grid ceiling, allowing for maximum flexibility for access to services in the ceiling void.

'''Cleaning and maintenance'''

The epoxy-coated tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stainresistant. They are robust and unlikely to be damaged easily, making them very low maintenance and durable. Replacement is easy if tiles do need replacing, with very little disruption to the room function.

'''Fire safety'''

Metal is listed as non-combustible in the SANS Part T as tested under 10177-5, however fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The metal tiles are generally made from recycled material and can also be recycled. Refer to product specific literature. The tile itself does not provide any insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically-pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics'''

The perforated surface contributes to sound absorption and compensates somewhat for the hard, reflective metal surface.
[[File:Pressed metal ceiling tiles in suspended grid.jpg|thumb|none]]

==Rigid extruded polystyrene panels (XPS)==
'''General description and properties'''

Polystyrene ceiling panels combine the aesthetic of a ceiling panel with the insulation properties of closed-cell insulation board. These panels are manufactured from high-density rigid extruded polystyrene. These can be supplied smooth for a flush appearance, bevelled to pronounce the 600 mm joint, or grooved at 100 mm intervals to resemble tongue and groove timber planks. Although neatly finished, painting with PVA is recommended. The boards can be fitted over-purlin, nailed-up to brandering, or between exposed trusses, and should be ordered in long lengths to avoid butt-joints on ends. The panels are available in thicknesses of 25, 30 or 40 mm.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the polystyrene itself is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. In certified tests, (by SANAS accredited laboratory) the rigid polystyrene showed no microbial growth and was declared suitable for use in the food industry. Since the surface is jointed, however, its use will be limited.

'''Access to services'''

Access panels need to be planned in the ceiling prior to installation. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They can however be mechanically damaged, and should preferably be fitted at high levels. Replacement of damaged panels would create a fair amount of disruption.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ’healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 – noncombustible materials only.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The insulation properties of the rigid polystyrene will reduce the heat load and act as a bulk insulator. The Rvalues increase with the thickness from 0.833 (for 25 mm thick board) to 2.667 for 80 mm thickness – double layer). Rigid polystyrene panels have no obvious odour, but under high heat conditions (near heat-generating light fitting , for example), some aromatic hydrocarbons are released. The manufacture of rigid polystyrene panels requires the use of HCFC-gasses, however, the measure of these gasses is at levels less than 150 ppm even where large quantities are stored. The VOC emissions of adhesives used to install the product should also be considered.

'''Aesthetics'''

The tongue and groove pattern creates interest in the surface of the ceiling, and can evoke a homely residential feel to the room/area. This can be used to good effect in healthcare facilities.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.
[[File:Rigid extruded polystyrene panels (XPS).jpg|thumb|none]]

==Expanded polystyrene panels (EPS)==
'''General description and properties'''

These laminated expanded polystyrene panels are made up of low-density fire-retardant board finished with a fire retardant PVC-foil, the surface of which can be embossed or smooth. The layers are bonded under high temperatures. The panels can be supplied full size in 4.8 x1.2 m boards for over-purlin fixing, or cut to suit a suspended ceiling grid (1 200 x 600mm). It can also be installed under purlin or between rafters. PVC H-joiners are used at junctions. Because the panels are very light, wire-hung suspended grids are not recommended, as these could result in drafts lifting the ceiling. Rigid steel battens are required. No further painting or finishing is required. The panels are generally available in 40 mm thickness.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the PVC-foil surface finish is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. Since the surface is jointed, however, its use will be limited to areas where ‘seamless’ ceiling surfaces are not required.

'''Access to services'''

Access panels are easily accommodated where the suspended grid system is utilised. Where nail-up systems are installed, access panels need to be planned in the ceiling prior to installation.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They do not require repainting or maintenance apart from occasional cleaning. Replacement of damaged panels in the suspended grid is not disruptive.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ‘healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 - noncombustible materials only. Fire-rating of the suspended grid should also be considered.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The excellent insulation properties of the polystyrene will reduce the heat load and act as a bulk insulator. The manufacture of expanded polystyrene panel does not require the use of CFCs and no adhesives are used to install the product.

'''Aesthetics'''

The wood-grain or random textured embossing creates interest in the surface of the ceiling. The board has a slightly shiny finish.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.

==Timber and timber composites==
'''General description and properties'''

Timber products have been used in ceilings for many generations. The most common locally available timber is maranti and pine - in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of fitting ceilings - from standard tongue and groove planks, to slatted battens. The timber is usually varnished or treated with a preservative. Engineered timber products are also available with melamine or veneer finishes.

'''Infection prevention'''

Timber is a source of nutrient to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based antibacterial varnish containing silver has superior microbial and chemical resistance, and will extend the life span of the timber. Medium-density fibreboards (MDFs) with melamine/veneer finishes could be installed in suspended grids.

'''Access to services'''

Access panels in a timber ceiling would need to be planned before the installation, and a purpose-made hinged or removable door created. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required. Where suspended grids are installed, this provides easy access to services.

'''Cleaning and maintenance'''

The timber slats or planks are washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered MDF ceiling panels do not require repainting and should not be put in contact with water, but cleaned by dry brushing/vacuuming. These panels can easily be replaced however, where installed in a suspended grid.

'''Fire safety'''

In terms of SANS 10400, timber is combustible and not permitted for use in ceilings for the Occupancy E2 (hospitals). It is however permitted under certain conditions for E3 and E4 occupancies.

'''Indoor air quality: Humidity'''

Well-varnished timber will be protected from the effects of moisture, but generally, timber should not be used in rooms where humid, moist conditions persist. MDF ceiling panels are not suitable for humid or wet areas.

'''Indoor air quality: Emissions and insulation'''

Timber is a natural product that does not emit VOCs. However, engineered timber products such as mediumdensity fibre-board contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognized as being the highest formaldehyde emitting pressed wood product. (source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product specific literature. The timber planks or engineered panels do not provide much insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics''' <br />The perforated surface of the slatted ceiling or MDF tiles aid in reducing the re-transmission of sound. MDF acoustic tiles are specifically manufactured for their superior performance in absorbing sound.
[[File:Timber and timber composites.jpg|thumb|none]]

=Performance=

==Performance categories==
The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility
[[File:Performance category.png|thumb|none|535x535px]]

*Skimmed or plastered and painted – seamless ceiling

Examples of ceiling materials or finishes for Class 2 (typical room – general ward):

*Vinyl-clad or pressed metal tiles in grid, etc.

Examples of ceiling materials or finishes for Class 3 (typical area – dirty utility):

*Skimmed or plastered and painted – jointed, vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Examples of ceiling materials or finishes for Class 4 (typical area – office or waiting room):

*Acoustic ceiling tiles in grid; timber and composite panels, etc.

Examples of ceiling materials or finishes for Class 5 (typical area – plant room):

*Expanded or extruded polystyrene; skimmed or plastered and painted – jointed; vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Refer to Table 2 – Matrix of recommended performance categories to establish what performance category the ceiling of the room in question will require – this could be a number of options in some cases.

==Performance categories recommended per room==
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="4" |'''1 2 3 4'''
|'''5'''
|-
| rowspan="22" |'''Acute In-patient Wards (Adults)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Day Lounge (patients)'''
|
|
|
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurse Station '''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Administration Department'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Offices/Interview Rooms'''
|
|*
|*
|*
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Boardroom'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Print room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Casualty and Trauma'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Hazmat Shower'''
|*
|
|
|
|
|-
|'''Minor Theatre/Suture Room'''
|*
|
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2 3    4    5'''
|-
| rowspan="12" |
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs'''
|
|
|*
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Scrub area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Central Sterilising and Supply Department (CSSD)'''
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Packing'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Sterile Storage'''
|
|*
|
|
|
|-
|'''Sterilisation (autoclaves)'''
|
|*
|
|
|
|-
|'''Trolley Wash'''
|
|*
|
|
|
|-
|'''Washing and Disinfecting Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Community Health Centre'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dental Surgery'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Isolation/Separate Nursing Ward'''
|*
|
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|
|
|-
|'''Offloading or Holding Area for Pharmacy'''
|
|
|
|
|*
|-
|'''PABX/Server Rooms'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-Assisted Ablution'''
|
|
|*
|
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs and Change Rooms'''
|
|
|*
|
|
|-
|'''Reception/Nurses’ Station '''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3 4    5'''
|-
| rowspan="14" |

|'''Records Room'''
|
|
|*
|
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|*
|
|
|
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Ward'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''X-Ray Room'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Day Clinic (Department)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient Waiting '''
|
|
|
|*
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Scrub Area'''
|*
|
|
|
|
|-
|'''Setting Area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurses’ Station '''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''High Care or Cardiac Care Unit (HC/CCU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|}

{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
|
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="15" |'''Intensive Care Unit (ICU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Kitchen – (Main Hospital)'''
|'''Bulk Dry Goods Store'''
|
|*
|
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Cold Room/Freezer'''
| colspan="4" |specialised
|
|-
|'''Cooking Area '''
|
|*
|
|
|
|-
|'''Cutlery/Crockery Store'''
|
|*
|
|
|
|-
|'''Dishwashing and Potwashing Area'''
|
|*
|
|
|
|-
|'''Food Preparation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|
|*
|
|
|-
|'''Plating/Serving Area'''
|
|*
|
|
|
|-
|'''Receiving Area'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|*
|*
|
|-
|'''Trolley Wash Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="17" |'''Laboratory'''

'''(Pathology/Cytology/Haemato logy/Chemistry) '''

'''(Biosafety Level 2)'''

''' '''

''' '''
|'''Blood and Blood Products Store'''
|
|*
|
|
|
|-
|'''Cell and Tissue Laboratory'''
|
|*
|
|
|
|-
|'''Cytopathology Sample Storage'''
|
|*
|
|
|
|-
|'''Clinical Material Store'''
|
|*
|
|
|
|-
|'''Disposal Area (dangerous materials)'''
|
|
|
|
|*
|-
|'''Drug and Vaccines Store'''
|
|*
|
|
|
|-
|'''Flammable Goods Store (external)'''
|
|
|
|
|*
|-
|'''Gas Cylinder and Pressure Vessel Store'''
|
|
|
|
|*
|-
|'''Hazardous Substances Store'''
|
|
|
|
|*
|-
|'''Histopathology Laboratory'''
|
|*
|
|
|
|-
|'''Microbiology Laboratory'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POCT consulting room'''
|
|
|*
|
|
|-
|'''Reagents/Chemical Stores'''
|
|
|
|
|*
|-
|'''Records Rooms'''
|
|
|*
|
|
|-
|'''Sample Collection Laboratory'''
|
|*
|
|
|
|-
|'''Specimen Reception and Sorting Rooms'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="4" |
|'''Stores (protective clothing/equipment)'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room (including lockers)'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Laundry – (Main Hospital)'''
|'''Assembly, Packing and Dispatch'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|*
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pressing '''
|
|
|*
|
|
|-
|'''Sorting'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Washing Room'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="21" |'''Maternity/Delivery Department'''
|'''Baby Bathing Area'''
|
|
|*
|
|
|-
|'''Circulation '''
|
|
|
|*
|
|-
|'''Delivery Suite'''
|*
|
|
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''First Stage Room'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Nurse Station'''
|
|
|
|*
|
|-
|'''Nursery'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Viewing Area'''
|
|
|
|*
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="12" |'''Mental Health Facility'''
|'''Body Room'''
|
|*
|
|
|
|-
|'''Children's Play Area'''
|
|
|
|*
|
|-
|'''Clean Utility'''
|
|
|*
|
|
|-
|'''Cleaners’ Room/Station'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Counselling Room'''
|
|
|
|*
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Dirty Utility (Sluice)'''
|
|
|*
|
|
|-
|'''ECT Procedure Room'''
|
|*
|
|
|
|-
|'''En Suite Bath/Shower Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Group Therapy Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="24" |
|'''Gymnasium (OT and physio)'''
|
|*
|
|
|
|-
|'''IT Room'''
|
|
|*
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Medicine Store'''
|
|*
|
|
|
|-
|'''Multi-Purpose Hall'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient-Assisted Bathroom/Shower'''
|
|
|*
|
|
|-
|'''Patient Dining Room'''
|
|
|
|*
|
|-
|'''Patient Laundry'''
|
|*
|
|
|
|-
|'''Patient Lounge'''
|
|
|
|*
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Quiet Room'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Seclusion Room'''
|*
|
|
|
|
|-
|'''Security Control Room'''
|
|
|*
|
|
|-
|'''Security Search Room'''
|
|
|*
|
|
|-
|'''Staff Change Room and WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Waste Disposal Room'''
|
|
|
|
|*
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''Mortuary'''
|'''Blue Room'''
|
|*
|
|
|
|-
|'''Circulation Space'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Instruments Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Medical Observation Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pathologist Change Room'''
|
|
|*
|
|
|-
|'''Post-Mortem Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Viewing Room'''
|
|
|
|*
|
|-
|'''Visitors’ Waiting Room'''
|
|
|
|*
|
|-
|
|
|
|
|
|
|
|-
| rowspan="13" |'''Neonatal Intensive Care Unit'''

'''(NICU)'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Incubator Ward Area'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Mothers’ Rest Area'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="2" |
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Operating Theatre (Department)'''
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|*
|
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Nurses’ Station'''
|
|
|*
|
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Post-Operative Recovery Area'''
|
|*
|
|
|
|-
|'''Pre-Operative Holding Area'''
|
|*
|
|
|
|-
|'''Scrub-up Area/Room'''
|
|*
|
|
|
|-
|'''Setting Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="22" |'''Outpatients Department '''
|'''Reception/Nurses’ Station'''
|
|
|
|*
|
|-
|'''Admissions Room'''
|
|*
|*
|*
|
|-
|'''Baby Changing Area '''
|
|
|
|*
|
|-
|'''Children’s Play/Waiting Area'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POPS Room'''
|
|*
|
|
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|'''Wheelchair Storage Area'''
|
|
|*
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="11" |'''Paediatric Ward'''
|'''Child-Assist Ablution'''
|
|
|*
|
|
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility (isolation)'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="11" |
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk/Ward Kitchen'''
|
|*
|
|
|
|-
|'''Nurses’ Station '''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Parent Ablutions'''
|
|
|*
|
|
|-
|'''Play Area (patients)'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Pharmacy/Dispensary'''
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Bulk Stores'''
|
|
|
|
|*
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Counselling Cubicle'''
|
|
|
|*
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Liquid Filling Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Offloading Bay'''
|
|
|
|
|*
|-
|'''Patient Waiting Room'''
|
|
|*
|
|
|-
|'''Schedule Drugs Strong Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Tablet Packing Room'''
|
|*
|
|
|
|-
|'''Vacolitre Stores'''
|
|
|
|
|*
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Physiotherapy Department'''
|'''Audiology Testing'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Gymnasium'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Occupational Therapy Room'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Speech Therapy'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Primary Health Clinic'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary and Pharmacy'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation/Rehydration Area'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="12" |
|'''Office'''
|
|*
|*
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|
|
|
|*
|-
|'''Waiting Area (public)'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="25" |'''Radiology (Diagnostic)'''
|'''Bucky Room (general X-ray Room)'''
|
|*
|
|
|
|-
|'''Change Cubicles'''
|
|*
|
|
|
|-
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''CT/MRI Scan Room'''
|*
|
|
|
|
|-
|'''Dirty Utility/Sluice'''
|
|
|*
|
|
|-
|'''Fluoroscopy Room'''
|
|*
|
|
|
|-
|'''Fluoroscopy Control Room'''
|
|*
|
|
|
|-
|'''Inpatient Waiting Area'''
|
|*
|
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Mammogram Room'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Public Waiting Area'''
|
|*
|*
|
|
|-
|'''Porters and Wheelchair/Trolley Parking'''
|
|*
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Server Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Stores (Equipment/General)'''
|
|
|
|
|*
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Telemedicine Room'''
|
|
|
|*
|
|-
|'''Viewing Room/CR Room/Reporting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Residences (e.g., Nurses)'''
|'''Ablutions'''
|
|
|*
|
|
|-
|'''Bedrooms'''
|*
|*
|*
|*
|
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Lounge'''
|
|
|
|*
|
|-
|'''Offices'''
|
|
|
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|}

=Definitions=

==Terminology==
''Aggregation    Collected together from different sources and considered a whole.''

''Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.''

''Bacteriostatic    A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.''

''Bariatric Describing the condition of obesity.''

''Bonded Chemically attached or fused in layers.''

''Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.''

''Homogenous Consisting of things of similar type throughout.''

''Heterogeneous Consisting of various layers or types throughout.''

''Hygroscopic Readily absorbing moisture from the atmosphere.''

''Hydrophobic Water-repellent.''

''Impervious Not allowing passage through (usually of water/moisture).''

''Interstices Small holes or perforations. ''

''Jointed Junctions which may be open or covered, but not completely sealed and smooth.''

''Jointless Without joints or having joints, which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.''

''Olfactory Relating to the smell or the sense of smell.''

''Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.''

''Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.''

''Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed,'' '''resilient''' ''flooring'' ''refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.''

''Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.''

''Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail. ''

''Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.''

''Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.''

''Tufted A group of threads drawn through a fabric and tied securely beneath the surface.''

''Vitrified To change a material into glass, under high heat and other conditions.''

''Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.''

''Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.'' ''' '''

==Abbreviations==
{| class="wikitable"
|''CFC''
|''Chlorofluorocarbon''
|-
|''CHD''
|''Centre for Health Design''
|-
|''ENT''
|''Ear, nose and throat''
|-
|''HAI ''
|''Healthcare-associated infections ''
|-
|''HCFC''
|''Hydrochlorofluorocarbon''
|-
|''HDF''
|''High-density fibreboard''
|-
|''IEQ''
|''Indoor Environmental Quality''
|-
|''IUSS ''
|''Infrastructure Unit Systems Support''
|-
|''MDF''
|''Medium-density fibreboard''
|-
|''MRSA   ''
|''Methicillin-resistant staphylococcus aureus, (which is a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria''
|-
|''NDoH ''
|''National Department of Health''
|-
|''OoM ''
|''Order of Magnitude''
|-
|''PMIS ''
|''Project Management Information System''
|-
|''PMSU ''
|''Project Management Support Unit''
|-
|''PuR''
|''Polyurethane-resistant''
|-
|''PVC''
|''Polyvinylchloride''
|-
|''RC ''
|''Recommendation Committee''
|-
|''VOC   ''
|''Volatile organic compound''
|}

=References=

==Bibliography==
Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

AASA, the School Suprintendents Association, 2009. ''Improving indoor air quality: Materials selection.'' [online] Alexandria, Egypt: AASA. Available at: <nowiki>http://www.aasa.org/search.aspx?query=Materials+Selection+</nowiki>[Accessed 9 April 2014].

Cement & Concrete Institute (CCI), 2009. ''Sand-cement screeds and concrete toppings for floors.'' [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. ''Floor coverings in healthcare buildings.'' (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. ''Finishes''. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. ''Core elements: Health Building Note 00-03: Clinical and clinical support spaces''. UK: DH.

Department of Health (DoH), 1980. ''Regulations governing private hospitals and unattached operating theatres.'' (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. ''Health''

''Technical Memorandum 61: Building component series flooring.'' [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. ''Performance requirements for building elements used in healthcare facilities.'' (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. ''R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes.'' Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. ''Sound practices: Noise control in the healthcare environment.'' (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. ''Healthcare environmental terms and outcome measures: An evidence-based design glossary.'' Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. ''Applied and Environmental Microbiology'', 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, ''18th CIB World Building Congress: Facilities management and maintenance''. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. ''Achieving EBD goals through flooring selection & design.'' [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 56: Building component series: Partitions.'' UK: TSO.

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 60: Ceilings.'' 2<sup>nd</sup> ed. UK: TSO.

NHS, National Services Scotland, 2006. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. ''Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning.'' (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. ''The role of hospital design in the recruitment, retention and performance of NHS nurses in England.'' (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. ''Health Building Note 04-01: Adult in-patient accommodation''. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. ''The Science of the Total Environment,'' 227(1999), pp.197-213

==Websites: Further reading ==
<nowiki>https://www.transparency.perkinswill.com</nowiki>

<nowiki>http://www.gatech.edu</nowiki>

<nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki>

<nowiki>http://www.green-buildings.com</nowiki>

<nowiki>http://www.healthcaredesignmagazine.com</nowiki>

<nowiki>http://www.isoboard.com</nowiki>

<nowiki>http://www.isolite.co.za</nowiki>

<nowiki>http://www.everite.co.za</nowiki>

<nowiki>http://www.armstrong.com</nowiki>

<nowiki>http://www.owa.co.za</nowiki>

=Photographic and illustration credits=
Cover photo: M. Swinney
{| class="wikitable"
|Fig.1
|M. Swinney
|-
|Fig.2 to 5
|Diagram by C. Hiralal
|-
|Fig.6
|R.Cubbin based on Lifecycle Floor Cost Table – by Nora®, USA
|-
|Fig.7
|G. Abbott- CSIR
|-
|Fig.8
|R.Cubbin
|-
|Fig.9
|M. Swinney
|-
|Fig.10
|R. van Rensburg
|-
|Fig.11
|M. Swinney
|-
|Fig.12
|R. van Rensburg
|-
|Fig.13 to20
|M. Swinney
|-
|Fig.21
|R. van Rensburg
|-
|Fig.22
|M. Swinney
|-
|Fig.23
|R. Cubbin
|-
|Fig.24
|M. Swinney
|-
|Fig.25
|R. Cubbin
|-
|Fig.26 to28
|M. Swinney
|}
<br />{{Expand}}
{{DEFAULTSORT:Materials and finishes - Internal ceiling finishes}}
[[Category:Crosscutting Issues]]

Materials and finishes

2020-10-27T12:56:28Z

VSadiki:

Materials and finishes

2020-10-23T09:44:23Z

VSadiki:

=Internal Ceiling Finishes in Healthcare Facilities=

=Context=

==Overview – finishes in the healthcare environment==
<br />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 (historically) where even more attention should be paid to creating a caring atmosphere.

It is this paradigm shift that is required when considering and selecting finishes. The role of finishes in a healthcare facility has become as important an aspect of design as room sizes and relationships.
“UNTIL THE GERM THEORY WAS DEVELOPED, MORE MEN WERE DYING FROM SMALL WOUNDS AND DISEASES THAN FROM MAJOR TRAUMAS ON THE FRONTLINES. BUT AS SOON AS GERM THEORY WAS DEVELOPED A WHOLE NEW PARADIGM, A BETTER WAY OF UNDERSTANDING WHAT WAS HAPPENING
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.
[[File:Facility finishes.png|thumb|none]]

==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.

'''How to use this document:'''

#Review the Selection Criteria - Part B
#Select a Room / Department name in Part D, and note Performance Category
#Refer to Table 1 for the Properties that make up that Performance category
#Refer to Part C to assess ceiling types that could satisfy those performance requirements.

'''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 <u>www.iussonline.co.za</u>

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.

==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:

SANS 204 Energy-Efficiency in buildings general

SANS 622 Gypsum cove cornice

SANS 637 Wood-wood panels (cement-bonded)

SANS 640 Flexible PU-foams

SANS 803 Fibre cement boards

SANS 1039 Wooden ceiling and panelling boards

SANS 1381 Materials for thermal insulation boards

SANS 1508 Expanded polystyrene thermal insulation boards

SANS 1783 Softwood brandering and battens

SANS 6013 Dimensional and mass stability of particle boards with varying humidy

SANS 6016 Transverse tensile strength of particle boards

SANS10177 Fire-testing of materials

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

=Selection Criteria=

==Scope==
A ceiling in any facility forms the third dimension in any given room area, along with the walls and the floor, and it sometimes separates the roof space from the occupied area below. The manner 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.
[[File:Ceiling.png|thumb|none]]
Ceiling: “upper interior surface of a room or similar compartment, including all materials comprising such surface”

Roof assembly: “building cover and its supporting structure, including any ceiling attached to such structure, including any additional components such as insulation”
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.
[[File:Actual Soffit of structure overhead.png|thumb|none]]

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.
[[File:Membrane fixed directly to the structure overhead.png|thumb|none]]

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.
[[File:Membrane suspended from the structure overhea.png|thumb|none]]

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

==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

===Embodied energy of materials===
{| class="wikitable"
|+
!Material
!Embodied Energy in MJ / kg (million joules per kilogram)
|-
|Extruded anodised aluminium(virgin)
|227
|-
|Extruded anodised aluminium (recycled)
|42.9
|-
|Fibre-cement board
|9.5
|-
|Fibreglass insulation
|30.3
|-
|Gypsum plaster
|4.5
|-
|Plasterboard
|6.1
|-
|Concrete (in situ)
|1.0 - 1.6
|-
|Concrete (precast)
|2.0
|-
|Cement
|7 - 8
|-
|Particle board
|8.0
|-
|Steel (virgin)
|32
|-
|PVC
|70
|-
|Paint (solvent-based)
|98.1
|}
''Source: Alcorn and Wood, 1998.''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.

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

==Life cycle costing and sustainability==
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 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 importance of life cycle costs.
[[File:Capital outlay costs vs life span costs.png|thumb|none]]

Sustainability should be considered in all four stages of product life:

*Manufacture
*Use
*Maintenance
*Disposal

[[File:Product life sustainability.png|thumb|none]]

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.
[[File:Life cycle costing and sustainability diag.png|thumb|none]]

===Toxicity and effect on indoor environment===
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)
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.

'''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.
[[File:Toxicity and effect on indoor environment diag.jpg|thumb|none]]

==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)

[[File:Facility design.png|thumb|none]]

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.

==Selection criteria==

===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.”
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)
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.

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.
“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 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 also carried out microbiological studies comparing patient rooms with and without carpet. The study found higher microbial counts and more E.coli and other organisms on carpet samples than bare floors.

While this issue may not affect the selection of a ceiling finish, there are principles to be borne in mind when establishing what finish is best in high-risk environments.
[[File:Selection criteria diag.png|thumb|none]]

Below is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Although ceilings are out of reach and therefore less affected by regular touching, airborne bacteria can be carried on circulating mechanical ventilation, and aerosol contaminants which are distributed when water is splashed, (Ayliffe et al., 2000) can carry pathogens to ceiling level.

Ceiling materials and finishes that resist the spread of infection will have qualities that can be summarised as follows:

*Smooth
*Impervious
*Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, ceilings will have the following properties:

*Textured
*Perforated
*Jointed

[[File:Selection criteria diag 2.jpg|thumb|none]]

Certain materials have been shown to inhibit bacterial growth – such as vinyl, PuR and natural materials such as cork. This will also contribute to the prevention of infection. Ceilings with these properties will have the following quality:

*Bacteriostatic

'''A note about anti-bacterial treatments and additives to ceiling products:'''

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

Synthetic fibres such as polypropylene textile and vinyl for example, in themselves do no provide a nutrient source which microbes need to survive, but some finishes can trap soil, dust and moisture which do provide that source.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risks and benefits to healthcare users.

==Cleaning and maintenance==
Connected with infection prevention is the issue of cleaning. Ceilings tend to have ’reactive’ cleaning regimes, rather than regular cleaning programmes. This is partially because the ceiling gives an impression of cleanliness, but this can be misleading.

Whether the materials/finish of a ceiling can be cleaned thoroughly will define the extent to which infectious agents can be prevented from multiplying on a surface. Some materials can tolerate a reasonable amount of moisture, facilitating regular washing, while others would be adversely affected by it and can only be dusted or wiped.
[[File:Cleaning and maintenance diag.jpg|thumb|none]]

For cleaning to be effective, the surface must be able to withstand regular and fairly vigorous cleaning, with proper access to all surfaces. Where there are small recesses or difficult to reach corners, dirt is easily trapped providing dark, undisturbed conditions – the perfect breeding area for bacteria.

Information regarding cleaning materials should also be considered, as solvents and cleaning agents can quickly cause deterioration of the finish if it is not robust enough to withstand the cleaning required.

A further aspect to consider is the disruption that will be required to carry out the cleaning regime and possible maintenance. This is pertinent to areas such as operating theatres that may remain in use 24 hours a day.

Where there is a high requirement for regular cleaning of a ceiling in view of its location in a sensitive area, together with a need for minimal disruption for maintenance, the ceiling properties could be summarised as:

*Washable
*Low maintenance

[[File:Cleaning and maintenance diag 2.jpg|thumb|none]]

An additional consideration in the selection of ceiling finishes in health facilities in terms of maintenance is the provision of access to services in the ceiling void. Health facilities will generally require a high concentration of various services, most of which run in the ceiling void.

This will include electrical power and lighting, data, nurse call systems, medical gas and vacuum lines, air-conditioning and extract ducts, as well as hot water and waste pipes to name a few. Although service ducts and shafts can alleviate this congestion in the ceiling, distribution on the horizontal plane will nonetheless be required.

By selecting ceiling types that cater for easy access and giving thought to the best positions for these access panels - even marking these panels where necessary - this will facilitate easier maintenance of in-ceiling services during the life span of the building. This in turn will reduce ’downtime’, and disruption of the health facility.
[[File:Access panel.jpg|thumb|none]]

While the location of access panels is determined by the layout of services, certain rooms or areas will be more suitable for these panels.

*No combustible materials are permitted in ceilings or roof structures for buildings classified as hospitals.
*Medical facilities and healthcare categories are classified separately and have different requirements.
*Strict parameters are given for the depth of ceiling voids and this is related to the need for sprinklers when the voids exceed a given depth.
*Compartmentalisation of the ceiling void is required in area and distance, with fire stops.
*A dedicated section is written regarding operating theatres and intensive, high and critical care units, stipulating 120 min fire resistance for division separations.
*A full list of materials deemed to be non-combustible is provided.

This has been listed as the property:

*Access panels

===Safety===
Unlike floors which can prevent - or contribute to - falls by patients and staff, ceilings are largely out of reach and need not be assessed for safety as is relevant to floors. The safety aspect of fire performance does however need to be highlighted. The SANS 10400 lists specific requirements for hospitals and medical facilities with regard to ceilings. This is aimed at protecting the patients who are most likely frail, may not be able to walk, and would require assistance and more time to escape in the event of fire.

The definitions in the SANS 10400: Part A read:

*E2 Hospital

Occupancy where people are cared for or treated because of physical or mental disabilities, and where they are generally bedridden.

*E3 Other institutional (residential)

Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

*E4 Healthcare

Occupancy which is a common place of long term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

These requirements are set out in Part T of SANS 10400, and include:

All ceilings in hospitals would need to be non-combustible material. In other health facilities, such as community health centres or clinics, there are exceptions to the non-combustible requirement, subject to compliance with certain conditions. Since each project varies, the advice of a competent fire engineer should be obtained.

==Indoor air quality==
There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality. The first is he effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces, The second is the effect of the material on the floor material - namely the emission of volatile organic compounds.
[[File:Indoor air quality diag.jpg|thumb|none]]

===Humidity===
Certain rooms and areas of health facilities are by nature of the function they house - wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture-resistant finishes. If the ceiling panels or surfaces are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a ceiling finish, this property will be listed as:

*High humidity

===Emissions from materials===
As discussed under Environmental Aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off by – commonly referred to as off-gassing:

*The product itself, along with its structure
*The adhesives used to fix the product or its layers
*The paints or sealants used to finish
*The cleaning solutions required for regular maintenance

[[File:Emissions from materias diag 1.jpg|thumb|none]]

People who work in noisy environments for long shifts day in and day out, also have similar stress-induced experiences. They report everything from exhaustion to burnout, depression and irritability”
The smell of the interior of a new car - enjoyed by many is an example of plasticizers that have evaporated - emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality. The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels’ outlines.

IEQ14 section measured the formaldehyde minimisation which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used.

It should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.
Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space
Patients with respiratory weaknesses such as asthma are most likely to be affected by VOC emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility. Materials such as paints and polyvinyl-chlorides can emit VOCs which can have a negative effect on indoor air quality.

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. VOCs can also cause irritation and odour annoyance, and could lead to behavioural, neurotoxic, hepatoxic and genotoxic effects (Meininghaus et al., 2000; Hoskins, 2003; Hodgson et al., 2000.)
[[File:Emissions from materias diag 2.jpg|thumb|none]]

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of enamel paint on plaster, for example, may result in higher VOC emissions than say, a pre-finished lay-in ceiling board, but the infection control benefits of the seamless finish will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) Ceilings often present an opportunity to reduce the heat load on rooms from the roof space through insulation. This could form part of the ceiling material itself or be laid over the ceiling.

==Acoustics==
Noise in health facilities is mainly generated by:

*Impact sounds e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.
*Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LA<sub>eq</sub>) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization’s recommended LA<sub>eq</sub> value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November, 2005 showing that chronic noise increased the risk of heart-attack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.
[[File:Acoustics diag 1.jpg|thumb|none]]

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. 2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Sound-absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:
High acoustic
[[File:Acoustics diag 2.jpg|thumb|none]]

==Aesthetics==
Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results of a study by Becker and Douglass (2008), show that the physical appearance of the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Reflectivity of the ceiling material can boost natural light in a room or alternately produce glare - both of which have a direct impact on the comfort levels in the room. By ensuring skylights are oriented correctly, and shaded appropriately, natural light could be introduced through the ceiling.
[[File:Aesthetics diag.jpg|thumb|none]]

The ceiling surface finish should complement the function of the room, and monotony for the sake of economics should be avoided, bearing in mind that most patients will be focused on the ceiling for the duration of their stay.

Printed ceiling tiles, or polycarbonate panels with vinyl film images, behind which lighting can be introduced, could be used in key areas. This can transform a dull ward ceiling into a fascinating window to the outside world. CABE (2004) highlights the need for patients to have a ’connection with nature’, and these ceiling ‘windows’ are the ideal opportunity to supplement views to the exterior.

Natural light is a key factor in creating an environment for patient recovery. The occupants of the ward should be considered – paediatric wards are opportunities for playful scenes that will help little patients feel at ease.

In public areas where more emphasis might be placed on an attractive and welcoming interior than other factors, then this factor would be listed as:

   • High aesthetics

=Technical Information - Ceiling Types=

==Paint on seamless plaster==
'''General description and properties'''

Paint is easily applied by roller to a plastered ceiling soffit. The soffit could be constructed from plasterboard sheets, which are then skimmed or from concrete. Note that the structure onto which the plasterboard is fixed would need to be non-combustible if the facility is a hospital. Following a primer and undercoat, usually three coats of paint are applied. Two-coat plaster or skimming is highly recommended prior to painting, as defects will be highlighted with the high-gloss type paints.

Paint types that can be applied to the ceiling soffit will vary between oil-based and water-based types. Enamel paint dries to a hard, glossy, finish. It is usually oil-based. Velvet sheen paints are water-based, but produce a less glossy finish. PVA-paints are also water-based, but produce a matt finish. Paint is fairly inexpensive when compared to other ceiling finishes - excluding the structure.
[[File:Paint on seamless plaster diag.jpg|thumb|none]]

'''Infection prevention'''

The smooth seamless finish produced by painted concrete or plasterboard ceilings, make this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Paints with nanotechnology enhancements are also being developed. These paints inhibit the growth of algae and fungus.

'''Cleaning and maintenance'''

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant. Paint is a low maintenance finish which may require re-application every few years, unless latent defects arise.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Paint on a concrete soffit is considered a non-combustible finish as the thickness of the paint is usually less than

0.5 mm – refer to manufacturers’ specifications, and consult with the SANS Part T (4.13).

'''Indoor air quality: Humidity'''

Generally, paints are not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Enamel paints are most resistant to absorbing moisture, when compared to PVA-type paints.

'''Indoor air quality: Emissions and insulation'''

Paints are notorious for high VOC emissions, although manufacturers are now working on products with reduced or zero VOCs. Refer to product specific literature.

'''Acoustics'''

The hard surface of painted soffits reflects sounds and where acoustics are important, there are certainly better options available.

'''Aesthetics'''

While paint can be used effectively to introduce colour for features or emphasis, generally on ceilings in areas where infection prevention is important, the ceilings should be kept single colours - white or light colours – this ceiling would be used in areas where aesthetics is not the highest priority.

==Cementitious board – nail-up ceilings==
'''General description and properties'''

Plain and textured ceiling boards are available for nail-up applications where joints are not a problem. These boards are manufactured from a combination of cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses, and can be nailed at regular intervals to the overhead structure.

The joints between the ceiling boards can be finished using joiners or cover-strips. The ceiling boards can also be fixed between exposed beams.

Although no paint finish is required, paint can be applied. (Refer to comments on paint on plaster above.)
[[File:Cementitious board – nail-up ceilings diag.png|thumb|none]]

'''Infection prevention'''

The textured boards and the joining strips will create areas where microbes can grow. This ceiling finish is therefore not suitable for areas where infection prevention is critical.

'''Cleaning and maintenance'''

Nail-up cementitious boards are unaffected by moisture and resistant to corrosion. When painted they are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is possible if boards do get damaged, but this would be disruptive to the functioning of the room.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Nail-up cementitious boards are non-combustible.

'''Indoor air quality: Humidity'''

These painted boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the building from roof spaces where applicable. Fibres are safe and recyclable, and manufacturers claim low embodied energy used for assembly and construction. Refer to product specific literature. Emissions from paints should be considered.

'''Aesthetics'''

This type of ceiling board is aesthetically acceptable, and with paint, can be used to create an interesting functional ceiling.

'''Acoustics'''

The hard surface reflects sound and will not aid in sound absorption in the room it covers.

==Vinyl-clad ceiling tiles in suspended grid==
'''General description and properties'''

Vinyl-clad ceiling tiles are manufactured from cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses and are clad on the exposed surface with vinyl. They are suitable for 1 200 x 600mm or 600 x 600mm exposed ceiling grids. The grids are suspended from the structure above. The ceiling tiles can also be supplied with 25 mm insulation backing. No further painting or finishing is required.

'''Infection prevention'''

The vinyl finish is impervious, and vinyl inhibits the growth of bacteria. The boards are unaffected by moisture, and can be washed regularly. This makes them suitable for infection prevention. There are however joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

As mentioned, the vinyl-clad tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is very easy if boards do get damaged, with very little disruption to the room function.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Fire safety'''

Vinyl-clad boards are non-combustible; however, fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the room. Fibres are safe and recyclable, (no asbestos fibres) and manufacturers claim low embodied energy used for assembly and construction. However, the vinyl has low VOC emissions, when compared to some paints. Refer to product specific literature.

'''Aesthetics'''

This type of ceiling board gives a hygienic impression and is aesthetically acceptable. Tiles can also be printed with designs where budgets allow.

'''Acoustics'''

The surface is relatively hard, and does not assist with acoustic control or absorb sounds.
[[File:Vinyl-clad ceiling tiles in suspended grid.jpg|thumb|none]]

==Acoustic ceiling tiles in suspended grid==
'''General description and properties'''

These mineral fibre acoustic ceiling tiles – nominally 20 mm thick - have a pre-painted textured and perforated finish. The boards can be supplied with various edge finishes suitable for an exposed grid, or recessed grid with regular or chamfered edges. They are suitable for 1200 x 600mm or 600 x 600mm ceiling grids. The grids are suspended from the structure above. No further painting or finishing is required.

'''Infection prevention'''

The fissured surface may harbour dust and bacteria, making this type of ceiling board unsuitable for areas where infection prevention is critical – such as theatres. Some manufacturers do produce an ‘anti-microbial’ tile. Refer to the section on Selection Criteria- Infection Prevention for more discussion on this aspect. The boards cannot be washed as they will absorb moisture. Dirty or stained panels can be replaced easily. There are also joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

Since the boards are adversely affected by moisture, they can only be brush-cleaned and must be kept dry. Dirt often gathers where air-conditioning ducts blow across these tiles, and these then are difficult to clean. They are lightweight and fairly low maintenance. Replacement is very easy if boards do get damaged, with very little disruption to the room function, although batch colours and textures may vary.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Indoor air quality: Humidity'''

These boards are unsuited to areas of high humidity as they absorb moisture and will swell and droop over time when exposed to moist conditions.

'''Indoor air quality: Emissions and insulation'''

These boards provide some thermal insulation which will reduces the heat load of the building. The tiles do have low VOC emissions which will vary according to the manufacturer. Refer to product specific literature.

'''Aesthetics'''

The patterns of the fissures on this type of ceiling tile can create an interesting ceiling which is aesthetically acceptable.

'''Acoustics'''

The perforated surface is excellent for sound absorption and this product is well-suited to areas where noise reduction is prioritised.
[[File:Acoustic ceiling tiles in suspended grid.png|thumb|none]]

==Pressed metal ceiling tiles in suspended grid==
'''General description and properties'''

Pressed metal tiles are manufactured from galvanised steel, and are then epoxy-coated for a durable finish. The ceiling tiles are made to a variety of sizes. Stainless steel tiles are also available. Perforations are made in the surface – in different patterns and diameter to reduce the weight and improve acoustic performance. They are laid in a suspended ceiling grid, or can be hinged to the grid to open downwards. No further painting or finishing is required.

'''Infection prevention'''

The perforated surface may harbour dust and bacteria, and the joints mean the ceiling is not seamless. This type of ceiling is not suitable for areas where infection prevention is critical. The tiles are however washable.

'''Access to services'''

The hinged access tiles are purpose-made for access to services in the ceiling void as they are hinged to swing down leaving the void clear of grid transoms. The lay-in type of panel is also removable in a suspended grid ceiling, allowing for maximum flexibility for access to services in the ceiling void.

'''Cleaning and maintenance'''

The epoxy-coated tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stainresistant. They are robust and unlikely to be damaged easily, making them very low maintenance and durable. Replacement is easy if tiles do need replacing, with very little disruption to the room function.

'''Fire safety'''

Metal is listed as non-combustible in the SANS Part T as tested under 10177-5, however fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The metal tiles are generally made from recycled material and can also be recycled. Refer to product specific literature. The tile itself does not provide any insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically-pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics'''

The perforated surface contributes to sound absorption and compensates somewhat for the hard, reflective metal surface.
[[File:Pressed metal ceiling tiles in suspended grid.jpg|thumb|none]]

==Rigid extruded polystyrene panels (XPS)==
'''General description and properties'''

Polystyrene ceiling panels combine the aesthetic of a ceiling panel with the insulation properties of closed-cell insulation board. These panels are manufactured from high-density rigid extruded polystyrene. These can be supplied smooth for a flush appearance, bevelled to pronounce the 600 mm joint, or grooved at 100 mm intervals to resemble tongue and groove timber planks. Although neatly finished, painting with PVA is recommended. The boards can be fitted over-purlin, nailed-up to brandering, or between exposed trusses, and should be ordered in long lengths to avoid butt-joints on ends. The panels are available in thicknesses of 25, 30 or 40 mm.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the polystyrene itself is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. In certified tests, (by SANAS accredited laboratory) the rigid polystyrene showed no microbial growth and was declared suitable for use in the food industry. Since the surface is jointed, however, its use will be limited.

'''Access to services'''

Access panels need to be planned in the ceiling prior to installation. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They can however be mechanically damaged, and should preferably be fitted at high levels. Replacement of damaged panels would create a fair amount of disruption.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ’healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 – noncombustible materials only.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The insulation properties of the rigid polystyrene will reduce the heat load and act as a bulk insulator. The Rvalues increase with the thickness from 0.833 (for 25 mm thick board) to 2.667 for 80 mm thickness – double layer). Rigid polystyrene panels have no obvious odour, but under high heat conditions (near heat-generating light fitting , for example), some aromatic hydrocarbons are released. The manufacture of rigid polystyrene panels requires the use of HCFC-gasses, however, the measure of these gasses is at levels less than 150 ppm even where large quantities are stored. The VOC emissions of adhesives used to install the product should also be considered.

'''Aesthetics'''

The tongue and groove pattern creates interest in the surface of the ceiling, and can evoke a homely residential feel to the room/area. This can be used to good effect in healthcare facilities.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.
[[File:Rigid extruded polystyrene panels (XPS).jpg|thumb|none]]

==Expanded polystyrene panels (EPS)==
'''General description and properties'''

These laminated expanded polystyrene panels are made up of low-density fire-retardant board finished with a fire retardant PVC-foil, the surface of which can be embossed or smooth. The layers are bonded under high temperatures. The panels can be supplied full size in 4.8 x1.2 m boards for over-purlin fixing, or cut to suit a suspended ceiling grid (1 200 x 600mm). It can also be installed under purlin or between rafters. PVC H-joiners are used at junctions. Because the panels are very light, wire-hung suspended grids are not recommended, as these could result in drafts lifting the ceiling. Rigid steel battens are required. No further painting or finishing is required. The panels are generally available in 40 mm thickness.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the PVC-foil surface finish is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. Since the surface is jointed, however, its use will be limited to areas where ‘seamless’ ceiling surfaces are not required.

'''Access to services'''

Access panels are easily accommodated where the suspended grid system is utilised. Where nail-up systems are installed, access panels need to be planned in the ceiling prior to installation.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They do not require repainting or maintenance apart from occasional cleaning. Replacement of damaged panels in the suspended grid is not disruptive.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ‘healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 - noncombustible materials only. Fire-rating of the suspended grid should also be considered.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The excellent insulation properties of the polystyrene will reduce the heat load and act as a bulk insulator. The manufacture of expanded polystyrene panel does not require the use of CFCs and no adhesives are used to install the product.

'''Aesthetics'''

The wood-grain or random textured embossing creates interest in the surface of the ceiling. The board has a slightly shiny finish.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.

==Timber and timber composites==
'''General description and properties'''

Timber products have been used in ceilings for many generations. The most common locally available timber is maranti and pine - in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of fitting ceilings - from standard tongue and groove planks, to slatted battens. The timber is usually varnished or treated with a preservative. Engineered timber products are also available with melamine or veneer finishes.

'''Infection prevention'''

Timber is a source of nutrient to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based antibacterial varnish containing silver has superior microbial and chemical resistance, and will extend the life span of the timber. Medium-density fibreboards (MDFs) with melamine/veneer finishes could be installed in suspended grids.

'''Access to services'''

Access panels in a timber ceiling would need to be planned before the installation, and a purpose-made hinged or removable door created. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required. Where suspended grids are installed, this provides easy access to services.

'''Cleaning and maintenance'''

The timber slats or planks are washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered MDF ceiling panels do not require repainting and should not be put in contact with water, but cleaned by dry brushing/vacuuming. These panels can easily be replaced however, where installed in a suspended grid.

'''Fire safety'''

In terms of SANS 10400, timber is combustible and not permitted for use in ceilings for the Occupancy E2 (hospitals). It is however permitted under certain conditions for E3 and E4 occupancies.

'''Indoor air quality: Humidity'''

Well-varnished timber will be protected from the effects of moisture, but generally, timber should not be used in rooms where humid, moist conditions persist. MDF ceiling panels are not suitable for humid or wet areas.

'''Indoor air quality: Emissions and insulation'''

Timber is a natural product that does not emit VOCs. However, engineered timber products such as mediumdensity fibre-board contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognized as being the highest formaldehyde emitting pressed wood product. (source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product specific literature. The timber planks or engineered panels do not provide much insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics''' <br />The perforated surface of the slatted ceiling or MDF tiles aid in reducing the re-transmission of sound. MDF acoustic tiles are specifically manufactured for their superior performance in absorbing sound.
[[File:Timber and timber composites.jpg|thumb|none]]

=Performance=

==Performance categories==
The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility
[[File:Performance category.png|thumb|none]]

*Skimmed or plastered and painted – seamless ceiling

Examples of ceiling materials or finishes for Class 2 (typical room – general ward):

*Vinyl-clad or pressed metal tiles in grid, etc.

Examples of ceiling materials or finishes for Class 3 (typical area – dirty utility):

*Skimmed or plastered and painted – jointed, vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Examples of ceiling materials or finishes for Class 4 (typical area – office or waiting room):

*Acoustic ceiling tiles in grid; timber and composite panels, etc.

Examples of ceiling materials or finishes for Class 5 (typical area – plant room):

*Expanded or extruded polystyrene; skimmed or plastered and painted – jointed; vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Refer to Table 2 – Matrix of recommended performance categories to establish what performance category the ceiling of the room in question will require – this could be a number of options in some cases.

==Performance categories recommended per room==
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" |'''1 2 3 4'''
|'''5'''
|-
| rowspan="22" |'''Acute In-patient Wards (Adults)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Day Lounge (patients)'''
|
|
|
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurse Station '''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Administration Department'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Offices/Interview Rooms'''
|
|*
|*
|*
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Boardroom'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Print room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Casualty and Trauma'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Hazmat Shower'''
|*
|
|
|
|
|-
|'''Minor Theatre/Suture Room'''
|*
|
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="12" |
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs'''
|
|
|*
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Scrub area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Central Sterilising and Supply Department (CSSD)'''
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Packing'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Sterile Storage'''
|
|*
|
|
|
|-
|'''Sterilisation (autoclaves)'''
|
|*
|
|
|
|-
|'''Trolley Wash'''
|
|*
|
|
|
|-
|'''Washing and Disinfecting Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Community Health Centre'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dental Surgery'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Isolation/Separate Nursing Ward'''
|*
|
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|
|
|-
|'''Offloading or Holding Area for Pharmacy'''
|
|
|
|
|*
|-
|'''PABX/Server Rooms'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-Assisted Ablution'''
|
|
|*
|
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs and Change Rooms'''
|
|
|*
|
|
|-
|'''Reception/Nurses’ Station '''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="14" |

|'''Records Room'''
|
|
|*
|
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|*
|
|
|
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Ward'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''X-Ray Room'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Day Clinic (Department)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient Waiting '''
|
|
|
|*
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Scrub Area'''
|*
|
|
|
|
|-
|'''Setting Area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurses’ Station '''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''High Care or Cardiac Care Unit (HC/CCU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|}

{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
|
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="15" |'''Intensive Care Unit (ICU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Kitchen – (Main Hospital)'''
|'''Bulk Dry Goods Store'''
|
|*
|
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Cold Room/Freezer'''
| colspan="4" |specialised
|
|-
|'''Cooking Area '''
|
|*
|
|
|
|-
|'''Cutlery/Crockery Store'''
|
|*
|
|
|
|-
|'''Dishwashing and Potwashing Area'''
|
|*
|
|
|
|-
|'''Food Preparation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|
|*
|
|
|-
|'''Plating/Serving Area'''
|
|*
|
|
|
|-
|'''Receiving Area'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|*
|*
|
|-
|'''Trolley Wash Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="17" |'''Laboratory'''

'''(Pathology/Cytology/Haemato logy/Chemistry) '''

'''(Biosafety Level 2)'''

''' '''

''' '''
|'''Blood and Blood Products Store'''
|
|*
|
|
|
|-
|'''Cell and Tissue Laboratory'''
|
|*
|
|
|
|-
|'''Cytopathology Sample Storage'''
|
|*
|
|
|
|-
|'''Clinical Material Store'''
|
|*
|
|
|
|-
|'''Disposal Area (dangerous materials)'''
|
|
|
|
|*
|-
|'''Drug and Vaccines Store'''
|
|*
|
|
|
|-
|'''Flammable Goods Store (external)'''
|
|
|
|
|*
|-
|'''Gas Cylinder and Pressure Vessel Store'''
|
|
|
|
|*
|-
|'''Hazardous Substances Store'''
|
|
|
|
|*
|-
|'''Histopathology Laboratory'''
|
|*
|
|
|
|-
|'''Microbiology Laboratory'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POCT consulting room'''
|
|
|*
|
|
|-
|'''Reagents/Chemical Stores'''
|
|
|
|
|*
|-
|'''Records Rooms'''
|
|
|*
|
|
|-
|'''Sample Collection Laboratory'''
|
|*
|
|
|
|-
|'''Specimen Reception and Sorting Rooms'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="4" |
|'''Stores (protective clothing/equipment)'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room (including lockers)'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Laundry – (Main Hospital)'''
|'''Assembly, Packing and Dispatch'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|*
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pressing '''
|
|
|*
|
|
|-
|'''Sorting'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Washing Room'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="21" |'''Maternity/Delivery Department'''
|'''Baby Bathing Area'''
|
|
|*
|
|
|-
|'''Circulation '''
|
|
|
|*
|
|-
|'''Delivery Suite'''
|*
|
|
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''First Stage Room'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Nurse Station'''
|
|
|
|*
|
|-
|'''Nursery'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Viewing Area'''
|
|
|
|*
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="12" |'''Mental Health Facility'''
|'''Body Room'''
|
|*
|
|
|
|-
|'''Children's Play Area'''
|
|
|
|*
|
|-
|'''Clean Utility'''
|
|
|*
|
|
|-
|'''Cleaners’ Room/Station'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Counselling Room'''
|
|
|
|*
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Dirty Utility (Sluice)'''
|
|
|*
|
|
|-
|'''ECT Procedure Room'''
|
|*
|
|
|
|-
|'''En Suite Bath/Shower Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Group Therapy Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="24" |
|'''Gymnasium (OT and physio)'''
|
|*
|
|
|
|-
|'''IT Room'''
|
|
|*
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Medicine Store'''
|
|*
|
|
|
|-
|'''Multi-Purpose Hall'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient-Assisted Bathroom/Shower'''
|
|
|*
|
|
|-
|'''Patient Dining Room'''
|
|
|
|*
|
|-
|'''Patient Laundry'''
|
|*
|
|
|
|-
|'''Patient Lounge'''
|
|
|
|*
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Quiet Room'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Seclusion Room'''
|*
|
|
|
|
|-
|'''Security Control Room'''
|
|
|*
|
|
|-
|'''Security Search Room'''
|
|
|*
|
|
|-
|'''Staff Change Room and WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Waste Disposal Room'''
|
|
|
|
|*
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''Mortuary'''
|'''Blue Room'''
|
|*
|
|
|
|-
|'''Circulation Space'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Instruments Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Medical Observation Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pathologist Change Room'''
|
|
|*
|
|
|-
|'''Post-Mortem Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Viewing Room'''
|
|
|
|*
|
|-
|'''Visitors’ Waiting Room'''
|
|
|
|*
|
|-
|
|
|
|
|
|
|
|-
| rowspan="13" |'''Neonatal Intensive Care Unit'''

'''(NICU)'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Incubator Ward Area'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Mothers’ Rest Area'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="2" |
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Operating Theatre (Department)'''
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|*
|
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Nurses’ Station'''
|
|
|*
|
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Post-Operative Recovery Area'''
|
|*
|
|
|
|-
|'''Pre-Operative Holding Area'''
|
|*
|
|
|
|-
|'''Scrub-up Area/Room'''
|
|*
|
|
|
|-
|'''Setting Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="22" |'''Outpatients Department '''
|'''Reception/Nurses’ Station'''
|
|
|
|*
|
|-
|'''Admissions Room'''
|
|*
|*
|*
|
|-
|'''Baby Changing Area '''
|
|
|
|*
|
|-
|'''Children’s Play/Waiting Area'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POPS Room'''
|
|*
|
|
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|'''Wheelchair Storage Area'''
|
|
|*
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="11" |'''Paediatric Ward'''
|'''Child-Assist Ablution'''
|
|
|*
|
|
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility (isolation)'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="11" |
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk/Ward Kitchen'''
|
|*
|
|
|
|-
|'''Nurses’ Station '''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Parent Ablutions'''
|
|
|*
|
|
|-
|'''Play Area (patients)'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Pharmacy/Dispensary'''
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Bulk Stores'''
|
|
|
|
|*
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Counselling Cubicle'''
|
|
|
|*
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Liquid Filling Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Offloading Bay'''
|
|
|
|
|*
|-
|'''Patient Waiting Room'''
|
|
|*
|
|
|-
|'''Schedule Drugs Strong Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Tablet Packing Room'''
|
|*
|
|
|
|-
|'''Vacolitre Stores'''
|
|
|
|
|*
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Physiotherapy Department'''
|'''Audiology Testing'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Gymnasium'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Occupational Therapy Room'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Speech Therapy'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Primary Health Clinic'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary and Pharmacy'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation/Rehydration Area'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="12" |
|'''Office'''
|
|*
|*
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|
|
|
|*
|-
|'''Waiting Area (public)'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="25" |'''Radiology (Diagnostic)'''
|'''Bucky Room (general X-ray Room)'''
|
|*
|
|
|
|-
|'''Change Cubicles'''
|
|*
|
|
|
|-
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''CT/MRI Scan Room'''
|*
|
|
|
|
|-
|'''Dirty Utility/Sluice'''
|
|
|*
|
|
|-
|'''Fluoroscopy Room'''
|
|*
|
|
|
|-
|'''Fluoroscopy Control Room'''
|
|*
|
|
|
|-
|'''Inpatient Waiting Area'''
|
|*
|
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Mammogram Room'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Public Waiting Area'''
|
|*
|*
|
|
|-
|'''Porters and Wheelchair/Trolley Parking'''
|
|*
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Server Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Stores (Equipment/General)'''
|
|
|
|
|*
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Telemedicine Room'''
|
|
|
|*
|
|-
|'''Viewing Room/CR Room/Reporting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Residences (e.g., Nurses)'''
|'''Ablutions'''
|
|
|*
|
|
|-
|'''Bedrooms'''
|*
|*
|*
|*
|
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Lounge'''
|
|
|
|*
|
|-
|'''Offices'''
|
|
|
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|}

=Definitions=

==Terminology==
''Aggregation    Collected together from different sources and considered a whole.''

''Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.''

''Bacteriostatic    A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.''

''Bariatric Describing the condition of obesity.''

''Bonded Chemically attached or fused in layers.''

''Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.''

''Homogenous Consisting of things of similar type throughout.''

''Heterogeneous Consisting of various layers or types throughout.''

''Hygroscopic Readily absorbing moisture from the atmosphere.''

''Hydrophobic Water-repellent.''

''Impervious Not allowing passage through (usually of water/moisture).''

''Interstices Small holes or perforations. ''

''Jointed Junctions which may be open or covered, but not completely sealed and smooth.''

''Jointless Without joints or having joints, which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.''

''Olfactory Relating to the smell or the sense of smell.''

''Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.''

''Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.''

''Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed,'' '''resilient''' ''flooring'' ''refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.''

''Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.''

''Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail. ''

''Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.''

''Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.''

''Tufted A group of threads drawn through a fabric and tied securely beneath the surface.''

''Vitrified To change a material into glass, under high heat and other conditions.''

''Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.''

''Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.'' ''' '''

==Abbreviations==
{| class="wikitable"
|''CFC''
|''Chlorofluorocarbon''
|-
|''CHD''
|''Centre for Health Design''
|-
|''ENT''
|''Ear, nose and throat''
|-
|''HAI ''
|''Healthcare-associated infections ''
|-
|''HCFC''
|''Hydrochlorofluorocarbon''
|-
|''HDF''
|''High-density fibreboard''
|-
|''IEQ''
|''Indoor Environmental Quality''
|-
|''IUSS ''
|''Infrastructure Unit Systems Support''
|-
|''MDF''
|''Medium-density fibreboard''
|-
|''MRSA   ''
|''Methicillin-resistant staphylococcus aureus, (which is a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria''
|-
|''NDoH ''
|''National Department of Health''
|-
|''OoM ''
|''Order of Magnitude''
|-
|''PMIS ''
|''Project Management Information System''
|-
|''PMSU ''
|''Project Management Support Unit''
|-
|''PuR''
|''Polyurethane-resistant''
|-
|''PVC''
|''Polyvinylchloride''
|-
|''RC ''
|''Recommendation Committee''
|-
|''VOC   ''
|''Volatile organic compound''
|}

=References=

==Bibliography==
Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

AASA, the School Suprintendents Association, 2009. ''Improving indoor air quality: Materials selection.'' [online] Alexandria, Egypt: AASA. Available at: <nowiki>http://www.aasa.org/search.aspx?query=Materials+Selection+</nowiki>[Accessed 9 April 2014].

Cement & Concrete Institute (CCI), 2009. ''Sand-cement screeds and concrete toppings for floors.'' [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. ''Floor coverings in healthcare buildings.'' (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. ''Finishes''. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. ''Core elements: Health Building Note 00-03: Clinical and clinical support spaces''. UK: DH.

Department of Health (DoH), 1980. ''Regulations governing private hospitals and unattached operating theatres.'' (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. ''Health''

''Technical Memorandum 61: Building component series flooring.'' [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. ''Performance requirements for building elements used in healthcare facilities.'' (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. ''R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes.'' Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. ''Sound practices: Noise control in the healthcare environment.'' (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. ''Healthcare environmental terms and outcome measures: An evidence-based design glossary.'' Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. ''Applied and Environmental Microbiology'', 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, ''18th CIB World Building Congress: Facilities management and maintenance''. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. ''Achieving EBD goals through flooring selection & design.'' [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 56: Building component series: Partitions.'' UK: TSO.

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 60: Ceilings.'' 2<sup>nd</sup> ed. UK: TSO.

NHS, National Services Scotland, 2006. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. ''Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning.'' (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. ''The role of hospital design in the recruitment, retention and performance of NHS nurses in England.'' (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. ''Health Building Note 04-01: Adult in-patient accommodation''. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. ''The Science of the Total Environment,'' 227(1999), pp.197-213

==Websites: Further reading ==
<nowiki>https://www.transparency.perkinswill.com</nowiki>

<nowiki>http://www.gatech.edu</nowiki>

<nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki>

<nowiki>http://www.green-buildings.com</nowiki>

<nowiki>http://www.healthcaredesignmagazine.com</nowiki>

<nowiki>http://www.isoboard.com</nowiki>

<nowiki>http://www.isolite.co.za</nowiki>

<nowiki>http://www.everite.co.za</nowiki>

<nowiki>http://www.armstrong.com</nowiki>

<nowiki>http://www.owa.co.za</nowiki>

=Photographic and illustration credits=
Cover photo: M. Swinney
{| class="wikitable"
|Fig.1
|M. Swinney
|-
|Fig.2 to 5
|Diagram by C. Hiralal
|-
|Fig.6
|R.Cubbin based on Lifecycle Floor Cost Table – by Nora®, USA
|-
|Fig.7
|G. Abbott- CSIR
|-
|Fig.8
|R.Cubbin
|-
|Fig.9
|M. Swinney
|-
|Fig.10
|R. van Rensburg
|-
|Fig.11
|M. Swinney
|-
|Fig.12
|R. van Rensburg
|-
|Fig.13 to20
|M. Swinney
|-
|Fig.21
|R. van Rensburg
|-
|Fig.22
|M. Swinney
|-
|Fig.23
|R. Cubbin
|-
|Fig.24
|M. Swinney
|-
|Fig.25
|R. Cubbin
|-
|Fig.26 to28
|M. Swinney
|}
<br />{{Expand}}
{{DEFAULTSORT:Materials and finishes - Internal ceiling finishes}}
[[Category:Crosscutting Issues]]

Materials and finishes

2020-10-23T08:37:13Z

VSadiki:

=Internal Ceiling Finishes in Healthcare Facilities=

=Context=

==Overview – finishes in the healthcare environment==
<br />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 (historically) where even more attention should be paid to creating a caring atmosphere.

It is this paradigm shift that is required when considering and selecting finishes. The role of finishes in a healthcare facility has become as important an aspect of design as room sizes and relationships.
“UNTIL THE GERM THEORY WAS DEVELOPED, MORE MEN WERE DYING FROM SMALL WOUNDS AND DISEASES THAN FROM MAJOR TRAUMAS ON THE FRONTLINES. BUT AS SOON AS GERM THEORY WAS DEVELOPED A WHOLE NEW PARADIGM, A BETTER WAY OF UNDERSTANDING WHAT WAS HAPPENING
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.
[[File:Facility finishes.png|thumb|none]]

==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.

'''How to use this document:'''

#Review the Selection Criteria - Part B
#Select a Room / Department name in Part D, and note Performance Category
#Refer to Table 1 for the Properties that make up that Performance category
#Refer to Part C to assess ceiling types that could satisfy those performance requirements.

'''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 <u>www.iussonline.co.za</u>

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.

==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:

SANS 204 Energy-Efficiency in buildings general

SANS 622 Gypsum cove cornice

SANS 637 Wood-wood panels (cement-bonded)

SANS 640 Flexible PU-foams

SANS 803 Fibre cement boards

SANS 1039 Wooden ceiling and panelling boards

SANS 1381 Materials for thermal insulation boards

SANS 1508 Expanded polystyrene thermal insulation boards

SANS 1783 Softwood brandering and battens

SANS 6013 Dimensional and mass stability of particle boards with varying humidy

SANS 6016 Transverse tensile strength of particle boards

SANS10177 Fire-testing of materials

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

=Selection Criteria=

==Scope==
A ceiling in any facility forms the third dimension in any given room area, along with the walls and the floor, and it sometimes separates the roof space from the occupied area below. The manner 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.
[[File:Ceiling.png|thumb|none]]
Ceiling: “upper interior surface of a room or similar compartment, including all materials comprising such surface”

Roof assembly: “building cover and its supporting structure, including any ceiling attached to such structure, including any additional components such as insulation”
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.
[[File:Actual Soffit of structure overhead.png|thumb|none]]

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.
[[File:Membrane fixed directly to the structure overhead.png|thumb|none]]

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.
[[File:Membrane suspended from the structure overhea.png|thumb|none]]

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

==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

===Embodied energy of materials===
{| class="wikitable"
|+
!Material
!Embodied Energy in MJ / kg (million joules per kilogram)
|-
|Extruded anodised aluminium(virgin)
|227
|-
|Extruded anodised aluminium (recycled)
|42.9
|-
|Fibre-cement board
|9.5
|-
|Fibreglass insulation
|30.3
|-
|Gypsum plaster
|4.5
|-
|Plasterboard
|6.1
|-
|Concrete (in situ)
|1.0 - 1.6
|-
|Concrete (precast)
|2.0
|-
|Cement
|7 - 8
|-
|Particle board
|8.0
|-
|Steel (virgin)
|32
|-
|PVC
|70
|-
|Paint (solvent-based)
|98.1
|}
''Source: Alcorn and Wood, 1998.''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.

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

==Life cycle costing and sustainability==
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 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 importance of life cycle costs.
[[File:Capital outlay costs vs life span costs.png|thumb|none]]

Sustainability should be considered in all four stages of product life:

*Manufacture
*Use
*Maintenance
*Disposal

[[File:Product life sustainability.png|thumb|none]]

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.
[[File:Life cycle costing and sustainability diag.png|thumb|none]]

===Toxicity and effect on indoor environment===
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)
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.

'''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.
[[File:Toxicity and effect on indoor environment diag.jpg|thumb|none]]

==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)

[[File:Facility design.png|thumb|none]]

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.

==Selection criteria==

===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.”
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)
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.

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.
“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 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 also carried out microbiological studies comparing patient rooms with and without carpet. The study found higher microbial counts and more E.coli and other organisms on carpet samples than bare floors.

While this issue may not affect the selection of a ceiling finish, there are principles to be borne in mind when establishing what finish is best in high-risk environments.
[[File:Selection criteria diag.png|thumb|none]]

Below is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Although ceilings are out of reach and therefore less affected by regular touching, airborne bacteria can be carried on circulating mechanical ventilation, and aerosol contaminants which are distributed when water is splashed, (Ayliffe et al., 2000) can carry pathogens to ceiling level.

Ceiling materials and finishes that resist the spread of infection will have qualities that can be summarised as follows:

*Smooth
*Impervious
*Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, ceilings will have the following properties:

*Textured
*Perforated
*Jointed

[[File:Selection criteria diag 2.jpg|thumb|none]]

Certain materials have been shown to inhibit bacterial growth – such as vinyl, PuR and natural materials such as cork. This will also contribute to the prevention of infection. Ceilings with these properties will have the following quality:

*Bacteriostatic

'''A note about anti-bacterial treatments and additives to ceiling products:'''

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

Synthetic fibres such as polypropylene textile and vinyl for example, in themselves do no provide a nutrient source which microbes need to survive, but some finishes can trap soil, dust and moisture which do provide that source.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risks and benefits to healthcare users.

==Cleaning and maintenance==
Connected with infection prevention is the issue of cleaning. Ceilings tend to have ’reactive’ cleaning regimes, rather than regular cleaning programmes. This is partially because the ceiling gives an impression of cleanliness, but this can be misleading.

Whether the materials/finish of a ceiling can be cleaned thoroughly will define the extent to which infectious agents can be prevented from multiplying on a surface. Some materials can tolerate a reasonable amount of moisture, facilitating regular washing, while others would be adversely affected by it and can only be dusted or wiped.
[[File:Cleaning and maintenance diag.jpg|thumb|none]]

For cleaning to be effective, the surface must be able to withstand regular and fairly vigorous cleaning, with proper access to all surfaces. Where there are small recesses or difficult to reach corners, dirt is easily trapped providing dark, undisturbed conditions – the perfect breeding area for bacteria.

Information regarding cleaning materials should also be considered, as solvents and cleaning agents can quickly cause deterioration of the finish if it is not robust enough to withstand the cleaning required.

A further aspect to consider is the disruption that will be required to carry out the cleaning regime and possible maintenance. This is pertinent to areas such as operating theatres that may remain in use 24 hours a day.

Where there is a high requirement for regular cleaning of a ceiling in view of its location in a sensitive area, together with a need for minimal disruption for maintenance, the ceiling properties could be summarised as:

*Washable
*Low maintenance

[[File:Cleaning and maintenance diag 2.jpg|thumb|none]]

An additional consideration in the selection of ceiling finishes in health facilities in terms of maintenance is the provision of access to services in the ceiling void. Health facilities will generally require a high concentration of various services, most of which run in the ceiling void.

This will include electrical power and lighting, data, nurse call systems, medical gas and vacuum lines, air-conditioning and extract ducts, as well as hot water and waste pipes to name a few. Although service ducts and shafts can alleviate this congestion in the ceiling, distribution on the horizontal plane will nonetheless be required.

By selecting ceiling types that cater for easy access and giving thought to the best positions for these access panels - even marking these panels where necessary - this will facilitate easier maintenance of in-ceiling services during the life span of the building. This in turn will reduce ’downtime’, and disruption of the health facility.
[[File:Access panel.jpg|thumb|none]]

While the location of access panels is determined by the layout of services, certain rooms or areas will be more suitable for these panels.

*No combustible materials are permitted in ceilings or roof structures for buildings classified as hospitals.
*Medical facilities and healthcare categories are classified separately and have different requirements.
*Strict parameters are given for the depth of ceiling voids and this is related to the need for sprinklers when the voids exceed a given depth.
*Compartmentalisation of the ceiling void is required in area and distance, with fire stops.
*A dedicated section is written regarding operating theatres and intensive, high and critical care units, stipulating 120 min fire resistance for division separations.
*A full list of materials deemed to be non-combustible is provided.

This has been listed as the property:

*Access panels

===Safety===
Unlike floors which can prevent - or contribute to - falls by patients and staff, ceilings are largely out of reach and need not be assessed for safety as is relevant to floors. The safety aspect of fire performance does however need to be highlighted. The SANS 10400 lists specific requirements for hospitals and medical facilities with regard to ceilings. This is aimed at protecting the patients who are most likely frail, may not be able to walk, and would require assistance and more time to escape in the event of fire.

The definitions in the SANS 10400: Part A read:

*E2 Hospital

Occupancy where people are cared for or treated because of physical or mental disabilities, and where they are generally bedridden.

*E3 Other institutional (residential)

Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

*E4 Healthcare

Occupancy which is a common place of long term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

These requirements are set out in Part T of SANS 10400, and include:

All ceilings in hospitals would need to be non-combustible material. In other health facilities, such as community health centres or clinics, there are exceptions to the non-combustible requirement, subject to compliance with certain conditions. Since each project varies, the advice of a competent fire engineer should be obtained.

==Indoor air quality==
There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality. The first is he effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces, The second is the effect of the material on the floor material - namely the emission of volatile organic compounds.
[[File:Indoor air quality diag.jpg|thumb|none]]

===Humidity===
Certain rooms and areas of health facilities are by nature of the function they house - wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture-resistant finishes. If the ceiling panels or surfaces are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a ceiling finish, this property will be listed as:

*High humidity

===Emissions from materials===
As discussed under Environmental Aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off by – commonly referred to as off-gassing:

*The product itself, along with its structure
*The adhesives used to fix the product or its layers
*The paints or sealants used to finish
*The cleaning solutions required for regular maintenance

[[File:Emissions from materias diag 1.jpg|thumb|none]]

People who work in noisy environments for long shifts day in and day out, also have similar stress-induced experiences. They report everything from exhaustion to burnout, depression and irritability”
The smell of the interior of a new car - enjoyed by many is an example of plasticizers that have evaporated - emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality. The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels’ outlines.

IEQ14 section measured the formaldehyde minimisation which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used.

It should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.
Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space
Patients with respiratory weaknesses such as asthma are most likely to be affected by VOC emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility. Materials such as paints and polyvinyl-chlorides can emit VOCs which can have a negative effect on indoor air quality.

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. VOCs can also cause irritation and odour annoyance, and could lead to behavioural, neurotoxic, hepatoxic and genotoxic effects (Meininghaus et al., 2000; Hoskins, 2003; Hodgson et al., 2000.)
[[File:Emissions from materias diag 2.jpg|thumb|none]]

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of enamel paint on plaster, for example, may result in higher VOC emissions than say, a pre-finished lay-in ceiling board, but the infection control benefits of the seamless finish will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) Ceilings often present an opportunity to reduce the heat load on rooms from the roof space through insulation. This could form part of the ceiling material itself or be laid over the ceiling.

==Acoustics==
Noise in health facilities is mainly generated by:

*Impact sounds e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.
*Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LA<sub>eq</sub>) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization’s recommended LA<sub>eq</sub> value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November, 2005 showing that chronic noise increased the risk of heart-attack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.
[[File:Acoustics diag 1.jpg|thumb|none]]

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. 2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Sound-absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:
High acoustic
[[File:Acoustics diag 2.jpg|thumb|none]]

==Aesthetics==
Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results of a study by Becker and Douglass (2008), show that the physical appearance of the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Reflectivity of the ceiling material can boost natural light in a room or alternately produce glare - both of which have a direct impact on the comfort levels in the room. By ensuring skylights are oriented correctly, and shaded appropriately, natural light could be introduced through the ceiling.
[[File:Aesthetics diag.jpg|thumb|none]]

The ceiling surface finish should complement the function of the room, and monotony for the sake of economics should be avoided, bearing in mind that most patients will be focused on the ceiling for the duration of their stay.

Printed ceiling tiles, or polycarbonate panels with vinyl film images, behind which lighting can be introduced, could be used in key areas. This can transform a dull ward ceiling into a fascinating window to the outside world. CABE (2004) highlights the need for patients to have a ’connection with nature’, and these ceiling ‘windows’ are the ideal opportunity to supplement views to the exterior.

Natural light is a key factor in creating an environment for patient recovery. The occupants of the ward should be considered – paediatric wards are opportunities for playful scenes that will help little patients feel at ease.

In public areas where more emphasis might be placed on an attractive and welcoming interior than other factors, then this factor would be listed as:

   • High aesthetics

=Technical Information - Ceiling Types=

==Paint on seamless plaster==
'''General description and properties'''

Paint is easily applied by roller to a plastered ceiling soffit. The soffit could be constructed from plasterboard sheets, which are then skimmed or from concrete. Note that the structure onto which the plasterboard is fixed would need to be non-combustible if the facility is a hospital. Following a primer and undercoat, usually three coats of paint are applied. Two-coat plaster or skimming is highly recommended prior to painting, as defects will be highlighted with the high-gloss type paints.

Paint types that can be applied to the ceiling soffit will vary between oil-based and water-based types. Enamel paint dries to a hard, glossy, finish. It is usually oil-based. Velvet sheen paints are water-based, but produce a less glossy finish. PVA-paints are also water-based, but produce a matt finish. Paint is fairly inexpensive when compared to other ceiling finishes - excluding the structure.
[[File:Paint on seamless plaster diag.jpg|thumb|none]]

'''Infection prevention'''

The smooth seamless finish produced by painted concrete or plasterboard ceilings, make this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Paints with nanotechnology enhancements are also being developed. These paints inhibit the growth of algae and fungus.

'''Cleaning and maintenance'''

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant. Paint is a low maintenance finish which may require re-application every few years, unless latent defects arise.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Paint on a concrete soffit is considered a non-combustible finish as the thickness of the paint is usually less than

0.5 mm – refer to manufacturers’ specifications, and consult with the SANS Part T (4.13).

'''Indoor air quality: Humidity'''

Generally, paints are not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Enamel paints are most resistant to absorbing moisture, when compared to PVA-type paints.

'''Indoor air quality: Emissions and insulation'''

Paints are notorious for high VOC emissions, although manufacturers are now working on products with reduced or zero VOCs. Refer to product specific literature.

'''Acoustics'''

The hard surface of painted soffits reflects sounds and where acoustics are important, there are certainly better options available.

'''Aesthetics'''

While paint can be used effectively to introduce colour for features or emphasis, generally on ceilings in areas where infection prevention is important, the ceilings should be kept single colours - white or light colours – this ceiling would be used in areas where aesthetics is not the highest priority.

==Cementitious board – nail-up ceilings==
'''General description and properties'''

Plain and textured ceiling boards are available for nail-up applications where joints are not a problem. These boards are manufactured from a combination of cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses, and can be nailed at regular intervals to the overhead structure.

The joints between the ceiling boards can be finished using joiners or cover-strips. The ceiling boards can also be fixed between exposed beams.

Although no paint finish is required, paint can be applied. (Refer to comments on paint on plaster above.)
[[File:Cementitious board – nail-up ceilings diag.png|thumb|none]]

'''Infection prevention'''

The textured boards and the joining strips will create areas where microbes can grow. This ceiling finish is therefore not suitable for areas where infection prevention is critical.

'''Cleaning and maintenance'''

Nail-up cementitious boards are unaffected by moisture and resistant to corrosion. When painted they are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is possible if boards do get damaged, but this would be disruptive to the functioning of the room.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Nail-up cementitious boards are non-combustible.

'''Indoor air quality: Humidity'''

These painted boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the building from roof spaces where applicable. Fibres are safe and recyclable, and manufacturers claim low embodied energy used for assembly and construction. Refer to product specific literature. Emissions from paints should be considered.

'''Aesthetics'''

This type of ceiling board is aesthetically acceptable, and with paint, can be used to create an interesting functional ceiling.

'''Acoustics'''

The hard surface reflects sound and will not aid in sound absorption in the room it covers.

==Vinyl-clad ceiling tiles in suspended grid==
'''General description and properties'''

Vinyl-clad ceiling tiles are manufactured from cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses and are clad on the exposed surface with vinyl. They are suitable for 1 200 x 600mm or 600 x 600mm exposed ceiling grids. The grids are suspended from the structure above. The ceiling tiles can also be supplied with 25 mm insulation backing. No further painting or finishing is required.

'''Infection prevention'''

The vinyl finish is impervious, and vinyl inhibits the growth of bacteria. The boards are unaffected by moisture, and can be washed regularly. This makes them suitable for infection prevention. There are however joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

As mentioned, the vinyl-clad tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is very easy if boards do get damaged, with very little disruption to the room function.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Fire safety'''

Vinyl-clad boards are non-combustible; however, fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the room. Fibres are safe and recyclable, (no asbestos fibres) and manufacturers claim low embodied energy used for assembly and construction. However, the vinyl has low VOC emissions, when compared to some paints. Refer to product specific literature.

'''Aesthetics'''

This type of ceiling board gives a hygienic impression and is aesthetically acceptable. Tiles can also be printed with designs where budgets allow.

'''Acoustics'''

The surface is relatively hard, and does not assist with acoustic control or absorb sounds.
[[File:Vinyl-clad ceiling tiles in suspended grid.jpg|thumb|none]]

==Acoustic ceiling tiles in suspended grid==
'''General description and properties'''

These mineral fibre acoustic ceiling tiles – nominally 20 mm thick - have a pre-painted textured and perforated finish. The boards can be supplied with various edge finishes suitable for an exposed grid, or recessed grid with regular or chamfered edges. They are suitable for 1200 x 600mm or 600 x 600mm ceiling grids. The grids are suspended from the structure above. No further painting or finishing is required.

'''Infection prevention'''

The fissured surface may harbour dust and bacteria, making this type of ceiling board unsuitable for areas where infection prevention is critical – such as theatres. Some manufacturers do produce an ‘anti-microbial’ tile. Refer to the section on Selection Criteria- Infection Prevention for more discussion on this aspect. The boards cannot be washed as they will absorb moisture. Dirty or stained panels can be replaced easily. There are also joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

Since the boards are adversely affected by moisture, they can only be brush-cleaned and must be kept dry. Dirt often gathers where air-conditioning ducts blow across these tiles, and these then are difficult to clean. They are lightweight and fairly low maintenance. Replacement is very easy if boards do get damaged, with very little disruption to the room function, although batch colours and textures may vary.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Indoor air quality: Humidity'''

These boards are unsuited to areas of high humidity as they absorb moisture and will swell and droop over time when exposed to moist conditions.

'''Indoor air quality: Emissions and insulation'''

These boards provide some thermal insulation which will reduces the heat load of the building. The tiles do have low VOC emissions which will vary according to the manufacturer. Refer to product specific literature.

'''Aesthetics'''

The patterns of the fissures on this type of ceiling tile can create an interesting ceiling which is aesthetically acceptable.

'''Acoustics'''

The perforated surface is excellent for sound absorption and this product is well-suited to areas where noise reduction is prioritised.
[[File:Acoustic ceiling tiles in suspended grid.png|thumb|none]]

==Pressed metal ceiling tiles in suspended grid==
'''General description and properties'''

Pressed metal tiles are manufactured from galvanised steel, and are then epoxy-coated for a durable finish. The ceiling tiles are made to a variety of sizes. Stainless steel tiles are also available. Perforations are made in the surface – in different patterns and diameter to reduce the weight and improve acoustic performance. They are laid in a suspended ceiling grid, or can be hinged to the grid to open downwards. No further painting or finishing is required.

'''Infection prevention'''

The perforated surface may harbour dust and bacteria, and the joints mean the ceiling is not seamless. This type of ceiling is not suitable for areas where infection prevention is critical. The tiles are however washable.

'''Access to services'''

The hinged access tiles are purpose-made for access to services in the ceiling void as they are hinged to swing down leaving the void clear of grid transoms. The lay-in type of panel is also removable in a suspended grid ceiling, allowing for maximum flexibility for access to services in the ceiling void.

'''Cleaning and maintenance'''

The epoxy-coated tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stainresistant. They are robust and unlikely to be damaged easily, making them very low maintenance and durable. Replacement is easy if tiles do need replacing, with very little disruption to the room function.

'''Fire safety'''

Metal is listed as non-combustible in the SANS Part T as tested under 10177-5, however fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The metal tiles are generally made from recycled material and can also be recycled. Refer to product specific literature. The tile itself does not provide any insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically-pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics'''

The perforated surface contributes to sound absorption and compensates somewhat for the hard, reflective metal surface.
[[File:Pressed metal ceiling tiles in suspended grid.jpg|thumb|none]]

==Rigid extruded polystyrene panels (XPS)==
'''General description and properties'''

Polystyrene ceiling panels combine the aesthetic of a ceiling panel with the insulation properties of closed-cell insulation board. These panels are manufactured from high-density rigid extruded polystyrene. These can be supplied smooth for a flush appearance, bevelled to pronounce the 600 mm joint, or grooved at 100 mm intervals to resemble tongue and groove timber planks. Although neatly finished, painting with PVA is recommended. The boards can be fitted over-purlin, nailed-up to brandering, or between exposed trusses, and should be ordered in long lengths to avoid butt-joints on ends. The panels are available in thicknesses of 25, 30 or 40 mm.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the polystyrene itself is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. In certified tests, (by SANAS accredited laboratory) the rigid polystyrene showed no microbial growth and was declared suitable for use in the food industry. Since the surface is jointed, however, its use will be limited.

'''Access to services'''

Access panels need to be planned in the ceiling prior to installation. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They can however be mechanically damaged, and should preferably be fitted at high levels. Replacement of damaged panels would create a fair amount of disruption.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ’healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 – noncombustible materials only.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The insulation properties of the rigid polystyrene will reduce the heat load and act as a bulk insulator. The Rvalues increase with the thickness from 0.833 (for 25 mm thick board) to 2.667 for 80 mm thickness – double layer). Rigid polystyrene panels have no obvious odour, but under high heat conditions (near heat-generating light fitting , for example), some aromatic hydrocarbons are released. The manufacture of rigid polystyrene panels requires the use of HCFC-gasses, however, the measure of these gasses is at levels less than 150 ppm even where large quantities are stored. The VOC emissions of adhesives used to install the product should also be considered.

'''Aesthetics'''

The tongue and groove pattern creates interest in the surface of the ceiling, and can evoke a homely residential feel to the room/area. This can be used to good effect in healthcare facilities.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.
[[File:Rigid extruded polystyrene panels (XPS).jpg|thumb|none]]

==Expanded polystyrene panels (EPS)==
'''General description and properties'''

These laminated expanded polystyrene panels are made up of low-density fire-retardant board finished with a fire retardant PVC-foil, the surface of which can be embossed or smooth. The layers are bonded under high temperatures. The panels can be supplied full size in 4.8 x1.2 m boards for over-purlin fixing, or cut to suit a suspended ceiling grid (1 200 x 600mm). It can also be installed under purlin or between rafters. PVC H-joiners are used at junctions. Because the panels are very light, wire-hung suspended grids are not recommended, as these could result in drafts lifting the ceiling. Rigid steel battens are required. No further painting or finishing is required. The panels are generally available in 40 mm thickness.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the PVC-foil surface finish is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. Since the surface is jointed, however, its use will be limited to areas where ‘seamless’ ceiling surfaces are not required.

'''Access to services'''

Access panels are easily accommodated where the suspended grid system is utilised. Where nail-up systems are installed, access panels need to be planned in the ceiling prior to installation.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They do not require repainting or maintenance apart from occasional cleaning. Replacement of damaged panels in the suspended grid is not disruptive.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ‘healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 - noncombustible materials only. Fire-rating of the suspended grid should also be considered.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The excellent insulation properties of the polystyrene will reduce the heat load and act as a bulk insulator. The manufacture of expanded polystyrene panel does not require the use of CFCs and no adhesives are used to install the product.

'''Aesthetics'''

The wood-grain or random textured embossing creates interest in the surface of the ceiling. The board has a slightly shiny finish.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.

==Timber and timber composites==
'''General description and properties'''

Timber products have been used in ceilings for many generations. The most common locally available timber is maranti and pine - in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of fitting ceilings - from standard tongue and groove planks, to slatted battens. The timber is usually varnished or treated with a preservative. Engineered timber products are also available with melamine or veneer finishes.

'''Infection prevention'''

Timber is a source of nutrient to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based antibacterial varnish containing silver has superior microbial and chemical resistance, and will extend the life span of the timber. Medium-density fibreboards (MDFs) with melamine/veneer finishes could be installed in suspended grids.

'''Access to services'''

Access panels in a timber ceiling would need to be planned before the installation, and a purpose-made hinged or removable door created. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required. Where suspended grids are installed, this provides easy access to services.

'''Cleaning and maintenance'''

The timber slats or planks are washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered MDF ceiling panels do not require repainting and should not be put in contact with water, but cleaned by dry brushing/vacuuming. These panels can easily be replaced however, where installed in a suspended grid.

'''Fire safety'''

In terms of SANS 10400, timber is combustible and not permitted for use in ceilings for the Occupancy E2 (hospitals). It is however permitted under certain conditions for E3 and E4 occupancies.

'''Indoor air quality: Humidity'''

Well-varnished timber will be protected from the effects of moisture, but generally, timber should not be used in rooms where humid, moist conditions persist. MDF ceiling panels are not suitable for humid or wet areas.

'''Indoor air quality: Emissions and insulation'''

Timber is a natural product that does not emit VOCs. However, engineered timber products such as mediumdensity fibre-board contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognized as being the highest formaldehyde emitting pressed wood product. (source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product specific literature. The timber planks or engineered panels do not provide much insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics''' <br />The perforated surface of the slatted ceiling or MDF tiles aid in reducing the re-transmission of sound. MDF acoustic tiles are specifically manufactured for their superior performance in absorbing sound.
[[File:Timber and timber composites.jpg|thumb|none]]

=Performance=

==Performance categories==
The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility
[[File:Performance category.png|thumb|none]]

*Skimmed or plastered and painted – seamless ceiling

Examples of ceiling materials or finishes for Class 2 (typical room – general ward):

*Vinyl-clad or pressed metal tiles in grid, etc.

Examples of ceiling materials or finishes for Class 3 (typical area – dirty utility):

*Skimmed or plastered and painted – jointed, vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Examples of ceiling materials or finishes for Class 4 (typical area – office or waiting room):

*Acoustic ceiling tiles in grid; timber and composite panels, etc.

Examples of ceiling materials or finishes for Class 5 (typical area – plant room):

*Expanded or extruded polystyrene; skimmed or plastered and painted – jointed; vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Refer to Table 2 – Matrix of recommended performance categories to establish what performance category the ceiling of the room in question will require – this could be a number of options in some cases.

==Performance categories recommended per room==
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" |'''1 2 3 4'''
|'''5'''
|-
| rowspan="22" |'''Acute In-patient Wards (Adults)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Day Lounge (patients)'''
|
|
|
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurse Station '''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Administration Department'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Offices/Interview Rooms'''
|
|*
|*
|*
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Boardroom'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Print room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Casualty and Trauma'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Hazmat Shower'''
|*
|
|
|
|
|-
|'''Minor Theatre/Suture Room'''
|*
|
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="12" |
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs'''
|
|
|*
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Scrub area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Central Sterilising and Supply Department (CSSD)'''
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Packing'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Sterile Storage'''
|
|*
|
|
|
|-
|'''Sterilisation (autoclaves)'''
|
|*
|
|
|
|-
|'''Trolley Wash'''
|
|*
|
|
|
|-
|'''Washing and Disinfecting Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Community Health Centre'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dental Surgery'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Isolation/Separate Nursing Ward'''
|*
|
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|
|
|-
|'''Offloading or Holding Area for Pharmacy'''
|
|
|
|
|*
|-
|'''PABX/Server Rooms'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-Assisted Ablution'''
|
|
|*
|
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs and Change Rooms'''
|
|
|*
|
|
|-
|'''Reception/Nurses’ Station '''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="14" |

|'''Records Room'''
|
|
|*
|
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|*
|
|
|
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Ward'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''X-Ray Room'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Day Clinic (Department)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient Waiting '''
|
|
|
|*
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Scrub Area'''
|*
|
|
|
|
|-
|'''Setting Area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurses’ Station '''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''High Care or Cardiac Care Unit (HC/CCU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|}

{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
|
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="15" |'''Intensive Care Unit (ICU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Kitchen – (Main Hospital)'''
|'''Bulk Dry Goods Store'''
|
|*
|
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Cold Room/Freezer'''
| colspan="4" |specialised
|
|-
|'''Cooking Area '''
|
|*
|
|
|
|-
|'''Cutlery/Crockery Store'''
|
|*
|
|
|
|-
|'''Dishwashing and Potwashing Area'''
|
|*
|
|
|
|-
|'''Food Preparation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|
|*
|
|
|-
|'''Plating/Serving Area'''
|
|*
|
|
|
|-
|'''Receiving Area'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|*
|*
|
|-
|'''Trolley Wash Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="17" |'''Laboratory'''

'''(Pathology/Cytology/Haemato logy/Chemistry) '''

'''(Biosafety Level 2)'''

''' '''

''' '''
|'''Blood and Blood Products Store'''
|
|*
|
|
|
|-
|'''Cell and Tissue Laboratory'''
|
|*
|
|
|
|-
|'''Cytopathology Sample Storage'''
|
|*
|
|
|
|-
|'''Clinical Material Store'''
|
|*
|
|
|
|-
|'''Disposal Area (dangerous materials)'''
|
|
|
|
|*
|-
|'''Drug and Vaccines Store'''
|
|*
|
|
|
|-
|'''Flammable Goods Store (external)'''
|
|
|
|
|*
|-
|'''Gas Cylinder and Pressure Vessel Store'''
|
|
|
|
|*
|-
|'''Hazardous Substances Store'''
|
|
|
|
|*
|-
|'''Histopathology Laboratory'''
|
|*
|
|
|
|-
|'''Microbiology Laboratory'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POCT consulting room'''
|
|
|*
|
|
|-
|'''Reagents/Chemical Stores'''
|
|
|
|
|*
|-
|'''Records Rooms'''
|
|
|*
|
|
|-
|'''Sample Collection Laboratory'''
|
|*
|
|
|
|-
|'''Specimen Reception and Sorting Rooms'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="4" |
|'''Stores (protective clothing/equipment)'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room (including lockers)'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Laundry – (Main Hospital)'''
|'''Assembly, Packing and Dispatch'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|*
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pressing '''
|
|
|*
|
|
|-
|'''Sorting'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Washing Room'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="21" |'''Maternity/Delivery Department'''
|'''Baby Bathing Area'''
|
|
|*
|
|
|-
|'''Circulation '''
|
|
|
|*
|
|-
|'''Delivery Suite'''
|*
|
|
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''First Stage Room'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Nurse Station'''
|
|
|
|*
|
|-
|'''Nursery'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Viewing Area'''
|
|
|
|*
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="12" |'''Mental Health Facility'''
|'''Body Room'''
|
|*
|
|
|
|-
|'''Children's Play Area'''
|
|
|
|*
|
|-
|'''Clean Utility'''
|
|
|*
|
|
|-
|'''Cleaners’ Room/Station'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Counselling Room'''
|
|
|
|*
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Dirty Utility (Sluice)'''
|
|
|*
|
|
|-
|'''ECT Procedure Room'''
|
|*
|
|
|
|-
|'''En Suite Bath/Shower Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Group Therapy Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="24" |
|'''Gymnasium (OT and physio)'''
|
|*
|
|
|
|-
|'''IT Room'''
|
|
|*
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Medicine Store'''
|
|*
|
|
|
|-
|'''Multi-Purpose Hall'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient-Assisted Bathroom/Shower'''
|
|
|*
|
|
|-
|'''Patient Dining Room'''
|
|
|
|*
|
|-
|'''Patient Laundry'''
|
|*
|
|
|
|-
|'''Patient Lounge'''
|
|
|
|*
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Quiet Room'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Seclusion Room'''
|*
|
|
|
|
|-
|'''Security Control Room'''
|
|
|*
|
|
|-
|'''Security Search Room'''
|
|
|*
|
|
|-
|'''Staff Change Room and WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Waste Disposal Room'''
|
|
|
|
|*
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''Mortuary'''
|'''Blue Room'''
|
|*
|
|
|
|-
|'''Circulation Space'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Instruments Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Medical Observation Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pathologist Change Room'''
|
|
|*
|
|
|-
|'''Post-Mortem Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Viewing Room'''
|
|
|
|*
|
|-
|'''Visitors’ Waiting Room'''
|
|
|
|*
|
|-
|
|
|
|
|
|
|
|-
| rowspan="13" |'''Neonatal Intensive Care Unit'''

'''(NICU)'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Incubator Ward Area'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Mothers’ Rest Area'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="2" |
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Operating Theatre (Department)'''
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|*
|
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Nurses’ Station'''
|
|
|*
|
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Post-Operative Recovery Area'''
|
|*
|
|
|
|-
|'''Pre-Operative Holding Area'''
|
|*
|
|
|
|-
|'''Scrub-up Area/Room'''
|
|*
|
|
|
|-
|'''Setting Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="22" |'''Outpatients Department '''
|'''Reception/Nurses’ Station'''
|
|
|
|*
|
|-
|'''Admissions Room'''
|
|*
|*
|*
|
|-
|'''Baby Changing Area '''
|
|
|
|*
|
|-
|'''Children’s Play/Waiting Area'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POPS Room'''
|
|*
|
|
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|'''Wheelchair Storage Area'''
|
|
|*
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="11" |'''Paediatric Ward'''
|'''Child-Assist Ablution'''
|
|
|*
|
|
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility (isolation)'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="11" |
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk/Ward Kitchen'''
|
|*
|
|
|
|-
|'''Nurses’ Station '''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Parent Ablutions'''
|
|
|*
|
|
|-
|'''Play Area (patients)'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Pharmacy/Dispensary'''
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Bulk Stores'''
|
|
|
|
|*
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Counselling Cubicle'''
|
|
|
|*
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Liquid Filling Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Offloading Bay'''
|
|
|
|
|*
|-
|'''Patient Waiting Room'''
|
|
|*
|
|
|-
|'''Schedule Drugs Strong Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Tablet Packing Room'''
|
|*
|
|
|
|-
|'''Vacolitre Stores'''
|
|
|
|
|*
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Physiotherapy Department'''
|'''Audiology Testing'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Gymnasium'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Occupational Therapy Room'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Speech Therapy'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Primary Health Clinic'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary and Pharmacy'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation/Rehydration Area'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="12" |
|'''Office'''
|
|*
|*
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|
|
|
|*
|-
|'''Waiting Area (public)'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="25" |'''Radiology (Diagnostic)'''
|'''Bucky Room (general X-ray Room)'''
|
|*
|
|
|
|-
|'''Change Cubicles'''
|
|*
|
|
|
|-
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''CT/MRI Scan Room'''
|*
|
|
|
|
|-
|'''Dirty Utility/Sluice'''
|
|
|*
|
|
|-
|'''Fluoroscopy Room'''
|
|*
|
|
|
|-
|'''Fluoroscopy Control Room'''
|
|*
|
|
|
|-
|'''Inpatient Waiting Area'''
|
|*
|
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Mammogram Room'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Public Waiting Area'''
|
|*
|*
|
|
|-
|'''Porters and Wheelchair/Trolley Parking'''
|
|*
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Server Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Stores (Equipment/General)'''
|
|
|
|
|*
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Telemedicine Room'''
|
|
|
|*
|
|-
|'''Viewing Room/CR Room/Reporting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Residences (e.g., Nurses)'''
|'''Ablutions'''
|
|
|*
|
|
|-
|'''Bedrooms'''
|*
|*
|*
|*
|
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Lounge'''
|
|
|
|*
|
|-
|'''Offices'''
|
|
|
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|}

=Definitions=

==Terminology==
''Aggregation    Collected together from different sources and considered a whole.''

''Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.''

''Bacteriostatic    A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.''

''Bariatric Describing the condition of obesity.''

''Bonded Chemically attached or fused in layers.''

''Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.''

''Homogenous Consisting of things of similar type throughout.''

''Heterogeneous Consisting of various layers or types throughout.''

''Hygroscopic Readily absorbing moisture from the atmosphere.''

''Hydrophobic Water-repellent.''

''Impervious Not allowing passage through (usually of water/moisture).''

''Interstices Small holes or perforations. ''

''Jointed Junctions which may be open or covered, but not completely sealed and smooth.''

''Jointless Without joints or having joints, which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.''

''Olfactory Relating to the smell or the sense of smell.''

''Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.''

''Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.''

''Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed,'' '''resilient''' ''flooring'' ''refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.''

''Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.''

''Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail. ''

''Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.''

''Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.''

''Tufted A group of threads drawn through a fabric and tied securely beneath the surface.''

''Vitrified To change a material into glass, under high heat and other conditions.''

''Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.''

''Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.'' ''' '''

==Abbreviations==
{| class="wikitable"
|''CFC''
|''Chlorofluorocarbon''
|-
|''CHD''
|''Centre for Health Design''
|-
|''ENT''
|''Ear, nose and throat''
|-
|''HAI ''
|''Healthcare-associated infections ''
|-
|''HCFC''
|''Hydrochlorofluorocarbon''
|-
|''HDF''
|''High-density fibreboard''
|-
|''IEQ''
|''Indoor Environmental Quality''
|-
|''IUSS ''
|''Infrastructure Unit Systems Support''
|-
|''MDF''
|''Medium-density fibreboard''
|-
|''MRSA   ''
|''Methicillin-resistant staphylococcus aureus, (which is a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria''
|-
|''NDoH ''
|''National Department of Health''
|-
|''OoM ''
|''Order of Magnitude''
|-
|''PMIS ''
|''Project Management Information System''
|-
|''PMSU ''
|''Project Management Support Unit''
|-
|''PuR''
|''Polyurethane-resistant''
|-
|''PVC''
|''Polyvinylchloride''
|-
|''RC ''
|''Recommendation Committee''
|-
|''VOC   ''
|''Volatile organic compound''
|}

=References=

==Bibliography==
Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

AASA, the School Suprintendents Association, 2009. ''Improving indoor air quality: Materials selection.'' [online] Alexandria, Egypt: AASA. Available at: <nowiki>http://www.aasa.org/search.aspx?query=Materials+Selection+</nowiki>[Accessed 9 April 2014].

Cement & Concrete Institute (CCI), 2009. ''Sand-cement screeds and concrete toppings for floors.'' [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. ''Floor coverings in healthcare buildings.'' (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. ''Finishes''. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. ''Core elements: Health Building Note 00-03: Clinical and clinical support spaces''. UK: DH.

Department of Health (DoH), 1980. ''Regulations governing private hospitals and unattached operating theatres.'' (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. ''Health''

''Technical Memorandum 61: Building component series flooring.'' [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. ''Performance requirements for building elements used in healthcare facilities.'' (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. ''R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes.'' Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. ''Sound practices: Noise control in the healthcare environment.'' (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. ''Healthcare environmental terms and outcome measures: An evidence-based design glossary.'' Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. ''Applied and Environmental Microbiology'', 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, ''18th CIB World Building Congress: Facilities management and maintenance''. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. ''Achieving EBD goals through flooring selection & design.'' [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 56: Building component series: Partitions.'' UK: TSO.

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 60: Ceilings.'' 2<sup>nd</sup> ed. UK: TSO.

NHS, National Services Scotland, 2006. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. ''Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning.'' (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. ''The role of hospital design in the recruitment, retention and performance of NHS nurses in England.'' (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. ''Health Building Note 04-01: Adult in-patient accommodation''. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. ''The Science of the Total Environment,'' 227(1999), pp.197-213

==Websites: Further reading ==
<nowiki>https://www.transparency.perkinswill.com</nowiki>

<nowiki>http://www.gatech.edu</nowiki>

<nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki>

<nowiki>http://www.green-buildings.com</nowiki>

<nowiki>http://www.healthcaredesignmagazine.com</nowiki>

<nowiki>http://www.isoboard.com</nowiki>

<nowiki>http://www.isolite.co.za</nowiki>

<nowiki>http://www.everite.co.za</nowiki>

<nowiki>http://www.armstrong.com</nowiki>

<nowiki>http://www.owa.co.za</nowiki>

=Photographic and illustration credits=
Cover photo: M. Swinney
{| class="wikitable"
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|Fig.6
|R.Cubbin based on Lifecycle Floor Cost Table – by Nora®, USA
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|Fig.7
|G. Abbott- CSIR
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|Fig.8
|R.Cubbin
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|Fig.9
|M. Swinney
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|Fig.10
|R. van Rensburg
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|Fig.11
|M. Swinney
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|Fig.12
|R. van Rensburg
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|Fig.13 to20
|M. Swinney
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|Fig.21
|R. van Rensburg
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|Fig.22
|M. Swinney
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|Fig.23
|R. Cubbin
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|Fig.24
|M. Swinney
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|Fig.25
|R. Cubbin
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|Fig.26 to28
|M. Swinney
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{{DEFAULTSORT:Materials and finishes - Internal ceiling finishes}}
[[Category:Crosscutting Issues]]

Materials and finishes - Internal Floor Finishes

2020-10-22T15:23:38Z

VSadiki:

CONTEXT

1. Overview: Finishes in the healthcare environment

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

“Flooring occupies every square inch of measured healthcare facility space

providing a major life cycle investment opportunity to help realise positive

healthcare outcomes.” (Centre for

Health Design, 2012)

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 it is a 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 (historically) where even more attention should be paid to

creating a caring atmosphere. “UNTIL THE GERM THEORY WAS DEVELOPED,

MORE MEN WERE DYING FROM SMALL It is this paradigm shift that is required when considering and WOUNDS AND DISEASES THAN FROM MAJOR selecting finishes. The role of finishes in a healthcare facility has TRAUMAS ON THE FRONTLINES. BUT AS SOON become as important an aspect of design as room sizes and AS GERM THEORY WAS DEVELOPED A WHOLE

NEW PARADIGM, A BETTER WAY OF

relationships. UNDERSTANDING WHAT WAS HAPPENING

MADE DRAMATIC SIGNIF ICANT MEDICAL

Building finishes are IMPROVEMENT POSSIBLE” (COVEY, 1992) 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.

FIGURE 1

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 to 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 Ceiling Finishes (draft document rev 4)

• 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’ floor 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 floor 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 which indicates the most relevant performance category.

3. Policy context

This document offers guidance on the selection of appropriate floor 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 the following:

• 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. Furthermore, the South African National Standards (SANS 10400) addresses numerous aspects involving materials and finishes. (Refer specifically to Parts J and T.) Current South African national standards applicable are as follows:

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, Rev. August 2004.

PART B - SELECTION CRITERIA

1. Scope

Flooring is probably the most important dimension of a health facility contributing to public and patient perceptions and affecting numerous other aspects, which will be examined under the selection criteria.

Floor finishes cannot be considered independently of their applicable subfloor, installation, adhesives or underlays and the relevant cleaning protocols. These integrated flooring systems need to be evaluated

FIGURE 2 as a whole in terms of the various

criteria.

In the flooring industry there are four main categories of floor finish:

Hard finishes

This would include rigid finishes such as porcelain or ceramic, marble tiles, or seamless coatings such as cementitious or epoxy coatings.

Resilient finishes

This would include flexible and semi-flexible sheeting such as vinyl, linoleum, rubber or cork.

Soft finishes

This would include textiles such as carpets as well as walk-off mats and antifatigue mats.

Hybrid finishes

This new generation floor finish combines various materials finished with a wear layer. These layers are fused under heat and pressure.

Each floor type has different applications and resultant benefits and disadvantages. The various characteristics would need to be weighed up against

the functions of the various rooms within a healthcare facility. Other important aspects to consider in flooring are skirting, transitions or changes in floor finishes, and changes in level including ramps and stairs. These are discussed in more detail under Section C5.

The following factors relating to construction and specification will also influence the floor finish:

• Specifications for substrate preparation and installation must be prepared in conjunction with the supplier of the floor finish, before construction commences

• Variance in floor finish thicknesses or falls in floors, e.g. rooms with floor drains may affect floor structure levels. Engineer input may be needed as it could potentially impact cover to reinforcement steel

• Structure and substrates, e.g. concrete floors during construction need to cure and dry adequately before the application of screeds and likewise, the screed, before the application of the final floor finish.

• Involvement of the floor finish supplier from specification, throughout construction and at final completion, i.e. sign-off

•

• Floor finish product guarantees, and prescriptive conditions that could have an impact on construction, such as quality of substrate, installation by approved installers, etc.

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 the following:

• 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

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

2.2. 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 require more frequent replacement in the building.

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)

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 importance of life cycle costs.

Sustainability should be considered in all four stages of product life:

• Manufacture

• Use

2.3. 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.

IEQ is measured in terms of the following:

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

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

• Volatile organic compounds (VOCs)

Materials such as paints and polyvinyl-chlorides 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 floor finishes will be installed, the finish as a whole – complete with sealants, substrate material and adhesives – 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.

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)

Every effort must be made when specifying materials and finishes in these facilities to ensure that materials and their junctions are well secured 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.

3. 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 Center for Health Design (CHD) Research

FIGURE 9

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 intersting results. These included:

• 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 soundabsorbing 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.

4. Selection criteria

4.1. 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 wellbeing 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.

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.

“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

The rising incidence of 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 flooring. The second is the ability to clean the finish, and this is discussed further in the next section.

The Center 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 floor 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 carpets acted as a reservoir for fungi and bacteria.

Anderson, et al., (1982) also carried out microbiological studies comparing patient rooms with and without carpets. The study found higher microbial counts and more E. coli and other organisms on carpet samples than bare floors.

There are two schools of thought in relation to the contentious issue of the use of carpets in healthcare facilities. The one approach builds on the studies listed above and cautions against the use of carpeting where spills would result in damp settings, which are then conducive to growth of bacteria. The role of cleaning in these circumstances would be paramount, but a study by Joseph (2006) found that contamination levels quickly returned to pre-cleaning status and hence were not a reliable means of maintaining a clean surface. The other approach maintains that carpets neatly trap micro-organisms, which can then be removed by HEPA

filter vacuum cleaners. This is compared to hard or resilient surfaces which encourage the redistribution of particles into the air during sweeping or mopping. (Radke, 1997)

The emphasis would then shift to cleaning protocols and management issues. Notwithstanding, it is recommended that carpets be avoided where patients are at greater risk of infection. Above is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories.

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. The available types of skirting to suit the floor finish chosen, must also be considered.

A note about skirtings

The specifier must ensure that there is proper detailing to the joint between the wall and floor finish. In high risk functional areas, such as an operating theatres, or where immunocompromised patients are accommodated (such as ICU wards), there should be no joint between the horizontal and vertical surfaces, but rather a rounded integral skirting as a continuation of the floor finish.

Skirting in clinical areas should be a minimum of 150 mm and 100 mm high in non-clinical areas.

Skirtings can be one of the following:

• Integral or coved skirting, which is achieved by installing the floor finish over a 20 to 35 mm radiuscoved fillet at the junction of the wall and floor, which supports the continuation of the floor finish up the wall surface for a short distance. This removes the edge of the floor-sheet, and the ‘joint’ with the wall finish from the corner and makes it more accessible and open for cleaning and maintenance. The top edge of the flooring must be finished with a capping strip, secured and sealed so as to not compromise infection control. This is achievable with sheeting products such as vinyl or linoleum.

• Pre-formed set-in skirtings can also be used, and are applied with adhesives, and seal the joint between floor and walls.

• Sit-on skirtings can vary, from timber to specially formed skirtings, which are not integral. Textile floor finishes are normally applied with a flat, i.e. not coved integral skirting.

Refer to Part D for the individual types of flooring and related skirting, applicable to each floor finish.

Floors that resist the spread of infection will have qualities that can be summarised as follows:

• Smooth

• Impervious

• Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, flooring will have the following properties:

• Perforated

• Textured

• Jointed

A note about antibacterial treatments and additives to flooring products:

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risk and benefit.

• The US Carpet and Rug Institute issued a technical bulletin in 2007 in this regard to curb ‘over-zealous marketing claims’ regarding these treatments and what they achieve. Since the treatment is applied to the carpet fibres or the backing – or both - no implicit human health claims can be made about the finished product unless that finished product has been tested and registered through an accredited “Over the last few years, some carpet manufacturers have independent testing organisation. treated their products with fungicidal and/or bactericidal

• Synthetic fibres, such as chemicals. Although these chemicals may help to reduce the

overall numbers of bacteria or fungi present in carpet, their use

polypropylene textile and vinyl does not preclude the routine care and maintenance of the sheeting for example, in themselves carpeting” do no provide a nutrient source Center for Disease Control –

which microbes need to survive, but Guideline for Environmental Infection Control: 2003 some finishes can trap soil, dust and moisture which do provide that source.

• The American Institute of architects has cautioned against the overzealous adoption of antimicrobial surface finishes without the existence and review of independently validated evidence for dosage, efficacy and efficacy claims.

• The application of antimicrobial surface finishes in is only recommended in South African burns units and where independently validated evidence of efficacy, dosage and safety are available, reviewed and approved.

4.2. Cleaning and maintenance

Cleaning and maintenance of floor finishes is interconnected to infection control, occupational health safety (OHS), slips, trips and falls (STFs) and life cycle costing.

The ability of the floor finish to be cleaned will define the extent to which infectious agents can be removed and prevented from multiplying. For cleaning to be effective, the floor finish must be able to withstand regular and fairly vigorous cleaning.

Sufficient access to all areas of the finish or adversely, the absence of any inaccessible gaps, voids, joints is of critical importance, to prevent breeding areas for bacteria, etc.

A further aspect to consider is the level of disruption required to carry out the cleaning of the floor finish regularly. While textile finishes can reduce cold and institutional environments, they would be totally unsuitable in areas with a high infection control risk and a high incidence of soiling.

Damage or shortened life spans of floor finishes are greatly reduced by dirt traps or walk-off carpets at main entrances. Refer to Section C5.

It is also important for the manufacturer of the floor finish to convey the cleaning and maintenance required for product guarantees to remain, to the end-user or institution. An effective cleaning regime is the primary means of defence in terms of controlling infection.

Floors that have a high priority for easy cleaning and low dirt retention can be

summarised as follows:

FIGURE 12 • Low maintenance

• Washable

4.3. Safety

Safety as a selection factor for floor finishes can be broadly discussed under the following subheadings:

• Slips, trips and falls (STF)

• Occupational health safety (OHS)

• Slip resistance

• Wheeled equipment use

• Fire performance

Slips, trips and falls (STF)

The following factors impact on the incidence and prevention of STFs:

• Frictional/slip resistance characteristics of the floor finish

• Presence of moisture or fluids, e.g., water, cleaning agents, blood, etc.

on the floor

• Cleaning of the floor

• Pedestrian footwear

• Human movement across floor, e.g., walking on crutches, pushing a bed/trolley, carrying objects • Lighting levels on floor

• Change in level of floor, e.g., ramps, stairs

• Change in floor finish

• Age of pedestrian – the aged and children are most prone to STFs

Occupational health safety (OHS)

For the purpose of this document, OHS is highlighted in terms of the safety of the staff working in the health facility.

Floor finishes can impact on staff as follows:

• Risk of STFs, as dealt with above

• Negative impacts on feet and legs from standing and walking

• Movability of wheeled equipment, such as trolleys and beds

• Risk of injury while cleaning surfaces

Hard surfaces such as porcelain tiles cause more feet and leg fatigue than resilient surfaces, such as vinyl and linoleum. Suitable footwear can also alleviate the fatigue.

Negative OHS impacts on cleaning staff tasked with regular cleaning of rough surfaces and should also be considered, such as possible arm and shoulder injuries.

Slip resistance

Slip resistance of a floor finish is impacted on the following basic factors:

• Surface macro roughness

• Surface micro roughness

• Surface profile

• Properties of the footwear in contact with the floor

• Slope or angle of the floor, e.g., ramps

• Potential for the presence of moisture through regular cleaning or by accidental spills e.g., blood)

The potential risk of reduced slip resistance, caused by cleaning operations, should be considered. Adequate visual notices such as: “Cleaning in progress/Caution wet floors” and the cordoning off of wet areas and allowing sufficient time for drying of the floor, are basic methods of managing the risk. Selecting the appropriate cleaning agent and applying it in correct concentration, also affects the slip resistance of a floor.

Wheeled equipment use

Wheeled equipment, such as beds, trolleys, wheelchairs, etc. are used

frequently in health facilities. The ease with which wheeled equipment can be used on a floor should be considered when selecting a finish. This is of critical importance to rehabilitation and acute departments. The movement of obese patients should also be considered generally.

A general rule is that the larger the wheels’ diameter, the more the manoeuvrability of the equipment increases.

The material that the wheels are made of also has an impact. Softer materials, like rubber and inflated wheels, suit hard or resilient finishes. Hard or solid wheel materials, like nylon, suit resilient finishes better. Damage can also be caused by wheeled equipment, particularly if heavy use levels occur or where heavy equipment, e.g. mobile X-Ray machine is used and this should be considered when the floor finish is selected.

Proper moisture control is essential in order to reduce health

risks and sick building syndrome in an enclosed space

Mortenson et al., 2005

This factor would be relevant where rooms may have a higher risk due to the above features, and in this instance, flooring with properties that could be beneficial in these circumstances would be indicated thus:

Safety

Note: The requirement for fire safety in respect will not vary much from room to room within a health facility, and is therefore considered a global requirement in the overall building, rather than a ‘selection criteria’ for an individual space. The specifier would need to consult the fire regulations applicable to the building type.

4.4. Indoor air quality

There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality.

• The first is the effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces.

• The second is the effect of the material on the floor material - namely the emission of volatile organic compounds (VOCs).

Humidity

Certain rooms and areas of health facilities are by nature of the function they house, wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture resistant finishes. If the floor finishes are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a floor finish, this property will be listed as:

• High humidity

Emissions from materials

As discussed under environmental aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off (commonly referred to as off-gassing) by one of the following:

• The product itself

• The adhesives used to fix the product

• The sealants used to finish

• The cleaning solutions required for regular maintenance

The smell of the interior of a new car – enjoyed by many – is an example of plasticisers that have evaporated – emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality.

The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 Category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels outlines. IEQ14 section measured the formaldehyde minimisation, which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used. It

should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.

Occupants with respiratory weaknesses such as asthma are most likely

to be affected by VOC-emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility.

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of vinyl sheeting, for example, may result in higher VOC emissions than say, ceramic tiles, but the infection control benefits of the seamless finish of the vinyl will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) 1999)

To achieve ‘low VOC emissions’ should be a global criterion for a healthcare building rather than for one or more specific rooms, and hence a separate criterion has not been listed for this item. More detail on the VOC-emissions of the individual flooring types is discussed under the Technical Section C.

4.5. Acoustics

Noise in health facilities is mainly generated by the following:

• Impact sounds, e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.

• Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LAeq) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization recommended LAeq value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November 2005, showing that chronic noise increased the risk of heartattack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. (2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

People who work in noisy environments for long shifts day in and day out, also have similar

stress-induced experiences. They

report everything from exhaustion to burnout, depression and

irritability”

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Flooring that absorbs sound, or at least does not contribute to noise levels, used in conjunction with sound absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In

areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:

• High acoustic

4.6. Aesthetics

Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results show that the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Paediatric wards particularly give an opportunity to set a playful scene and help little patients feel at ease. In public areas, more emphasis may also be required for an attractive and welcoming interior.

Colour and pattern can be used in floor finishes in health facilities for practical and aesthetical purposes:

• to improve the ‘institutional/cold’ interior look of the facility, room or area;

• for way-finding, e.g., colour-coding per department; or

• to create ‘spaces’ by giving individuality, e.g., to a specific area within a large open area.

However, the following is to be considered:

• Excessive combination of colours and patterns are inappropriate in certain areas/rooms, such as operating theatres.

• Some patterns and colours could impact negatively on certain patient groups, e.g., the aged or mentally ill.

Where aesthetics is a primary requirement, this factor will be listed as:

• High aesthetics

PART C - TECHNICAL INFORMATION – FLOORING TYPES

1. Hard finishes

Hard finishes are generally durable and easy to keep clean. As with any floor finish, a poor substrate will result in poor performance by the finish on the floor. The following factors should be considered in installation of any hard finish:

• The concrete floor slab should be sufficiently cured and have achieved the required moisture content before the screed is applied. These tests can be performed by hydro, Romus or Tramex meters.

• The screed specification to be adapted to suit the requirements of the manufacturer. Consider thickness, strength, levelness, panels etc. SANS 50197-1: 2000 and SANS 1083 refers.

• The specifier should consult with the manufacturer and obtain detailed installation methods and procedures confirming joint widths, joint material, adhesive, primers, recommended panel sizes, movement joints at wall perimeters, on panels and expansion joint sealers.

• It is useful to specify and include floor-traps in tiled floors for easy draining when cleaning, but ensure then that the screed is laid to fall to the floor drain.

1.1. Porcelain and ceramic tiles

General description and properties

Porcelain and ceramic tiles generally provide a durable, aesthetically acceptable floor finish that is moisture-resistant. A wide spectrum of tiles is available, with varying sizes, material composition, quality and cost, resulting in varying performance. Porcelain and/or ceramic tiles are most commonly used in health facilities in wet areas, such as bathrooms, kitchens, utility and cleaning areas due to the impervious quality and performance under wet conditions. The use of unglazed tiles not recommended in health facilities as these absorb moisture and other fluids which may be present in kitchens, mortuaries, etc.

The specifier should research the actual tile carefully, ascertain if the product is imported, what long-term stocks would be available, and ensure the tiles have been sufficiently cured. Where possible, the specifier should use full-bodied porcelain tiles rather than glazed porcelain or glazed ceramic tiles. This is evident in the comparison of the general properties of the two tile types as follows:

• Full-bodied porcelain tile:

• ‘Colour’ is throughout, as the term ‘full-bodied’ implies.

• ‘Squareness’ of tiles consistent with minor deviations.

• Tile sizes are consistent with minor deviations.

• Smaller joints can be used, due to tile size consistency.

• ‘Flatness’ of tile face consistent.

Glazed ceramic tile:

• ‘Colour’ is a glaze on top of tile that can wear or chip off.

• Tile sizes can vary.

• ‘Squareness’ of tiles can vary.

• Wider joints required, due to size and squareness inconsistencies.

• Tiles often not ‘flat’ and edge surfaces tend to dip resulting in uneven floors.

• Porcelain tiles carry a PEI-rating which will indicate the anticipated wear rating of that tile and what applications will be suitable. The ratings range from Class 0 (wall tile only – should not be used on floors) to Class 5, which is suited to heavy commercial and institutional floors subjected to heavy traffic. This Class 5 would be the required rating for hospitals or healthcare facilities.

The more highly polished the tile, the less slip resistance, so porcelain tiles should be used with careful consideration in health facilities. They could be used in a mortuary, hospital kitchen and laundry where nonslip tiles would be necessary and in non-circulation route public spaces, such as cafeterias.

Infection prevention

Although an individual tile unit complies with selection criteria such as being impervious, and easy to clean, a finished tiled floor - including grout and movement joints - provides a less favourable result in terms of:

• Grout in the joints is porous and can retain moisture which encourages the growth of mould.

• Grout joints pose a potential infection control risk in small cracks and openings that form between the tile edge and the body of the grout.

• Expansion joint material (polysulfide, etc.) is susceptible to damage, due to wear and mechanical cleaning.

• Tiles may crack and chip when items are dropped on them – creating small cracks where moisture can be retained and microbes can grow.

• Replacement of these damaged tiles, or re-grouting is disruptive to the daily operations of the facility.

• Antifungal grout will contribute to the control of mildew, but cannot replace good maintenance regimes.

Cleaning and maintenance

Porcelain tiled floors generally require to be cleaned with water and cleaning agent, using a map or similar. For specific spills in specialised areas, such as hospital kitchens and mortuaries, appropriate cleaning will be required. The ease of cleaning, as well as the durability of the tiles under rigorous cleaning regimes, makes a tiled floor suitable in areas where spills are common – such as kitchens and bathrooms.

Safety

Highly polished (especially porcelain-tiled) surfaces can be a slip hazard, particularly where frail or weak patients will navigate the area. This is amplified during cleaning procedures. High reflection and glare can also lead to disorientation. (Wilmott and Colleagues, 1986)

• Tiles with non-slip surfaces can be used where risks are higher, and the likelihood of water on the floor is more prevalent, but note that increasing the texture of the tile for slip resistance will also create a ‘cleanability’ issue.

• The potential for injury is also increased where slips or trips lead to falls on the unforgiving, hard surface.

• Tiled surfaces also contribute to staff fatigue more than softer finishes.

Indoor air quality: Humidity

The polished or glazed surfaces of the tiles make them highly suitable and unaffected by high humidity in the room. However, as mentioned above, the joints are susceptible to moisture retention and encourage mould and microbe growth in the minute cracks and gaps. Proper scrubbing and regular maintenance will inhibit fungal contamination.

Indoor air quality: Emissions

Porcelain tiles and cementitious grout (not recommended in health facilities) do not generate VOC emissions, but some adhesives, other grouts, sealants and cleaning agents do generate VOCs affecting the indoor air quality. The production of tiles has a high energy input, with high sustainability production ‘costs’ and production emissions.

Acoustics

Tiles contribute substantially to noise in the healthcare setting. This is due to the hard, reflective surfaces, as well as the small dips at the joints, which cause the clattering of trolley wheels common in these facilities. The specifier should consider the kind of traffic that will be using the space and the resultant acoustic effect.

Aesthetics

Tiles are available in a wide selection of colours, shapes and sizes. This allows for visually appealing non-institutional aesthetics in health facilities. Patterns can be used for wayfinding or demarcation of public and off-limit areas, as well as branding in foyers and front of house areas. Since the

surfaces do not scratch or scuff easily, the aesthetic appeal is FIGURE 23 durable.

Skirtings

Skirting on tiles floors can be formed by simply cutting floor tiles or using preformed ceramic or porcelain skirting tiles. Wall tiles are common in wet areas, running from ceiling to floor, and no separate skirting is needed. The joints between the wall and floor are however an infection control risk area, as these areas are not easy to clean or dry, and moisture retention leads to bacterial contamination.

FIGURE 24

Typical specifications for tiling – e.g., full-bodied porcelain

Allow all new concrete work and screeds to cure for at least 28 days before proceeding. All new concrete work and screeds must have a moisture content of 5% or less before tiling can be commenced. When tiling directly onto concrete, ensure that the surfaces are clean and free of all traces of shutter release and curing agents, laitance and any other surface contaminants, preferably by scarifying or sandblasting.

Full-bodied porcelain floor tiles PEI-rating Class 5, size 400 x 400 x 8 mm (confirm size) affixed to wood floated 1:4 cement and sand screed with manufacturer-approved rapid setting tile adhesive using a notched floor trowel with 3 mm joints continuous in both directions, grouted with fine epoxy grout as approved by the manufacturer. Allow a minimum 5 mm expansion joints at perimeter, and maximum 5 m centres internally in both directions and allow all structural expansion and construction joints to be carried through. (Confirm colour and code.)

1.2. Terrazzo, cementitious and seamless coatings

General description and properties

Terrazzo is a composite material, consisting of marble, quartz, granite, onyx and glass chips in a cement or resinous matrix, poured in situ. After curing, it is ground and polished to a smooth finish. Application requires skill and experience. The use of terrazzo in health facilities should be restricted to high volume ‘front of house’ areas, with careful consideration to slip resistance.

Cementitious and granolithic toppings generally provide a hard, durable and cost-effective finish. Grano requires a good specification, attention to aggregate selection and experience in application. These finishes are suited to use in plant rooms and external passages and provide a fairly slip-resistant finish.

Epoxy/polyurethane/resin coatings – This term encompasses a wide range of liquid or trowel applied products such as epoxy, polyurethane resins. Thicknesses of coatings vary. This provides a more impervious surface than cementitious coatings.

Infection prevention

Although these finishes produce continuous, seamless coatings, the product should be laid in panels according to the manufacturer’s instruction, and underslab joints must be carried through the finish. These finishes are commonly used in food process and pharmaceutical prep areas due to the high chemical resistance, abrasion and impact resistance.

Both cementitious and granolithic toppings are prone to fine, barely noticeable cracks and together with the ‘panel joints’ present weaknesses in terms of infection control as these areas can store moisture and encourage microbial growth.

Cleaning and maintenance

The impervious surface lends itself to easy cleaning and maintenance and the surface resists most chemicals and does not stain easily. The finish is able to withstand rigorous cleaning regimes and mild alkaline detergent used with a single- or double-head rotary scrubber is recommended for regular cleaning. With good maintenance, a life expectancy of 10 years is common.

Safety

Epoxy finishes present an increased risk of slips, trips and falls due to the smoothness of the surface, and this is amplified during cleaning. Nonslip finishes are available, but decrease ‘cleanability’ of the surface.

The hard surface increases the risk of injury when falls do happen, and staff fatigue is also increased due to the hardness underfoot. The installation process presents OHS risks during construction, e.g.: grinding of terrazzo, scarifying substrate to prepare for cementitious topping application, etc.

Indoor air quality: Humidity

These surfacbodes are durable in areas of high moisture/humidity and are easily dried with the appropriate mops, making them suitable for service areas. The fine cracks which can result will retain moisture, however, making them unsuitable for use where infection control is a high priority.

Indoor air quality: Emissions

Body The high synthetic content of epoxy and polyurethane coatings affect the indoor environment through VOC-emissions. These are most notable directly after installation, but these continue, albeit reduced, for the life span of the product. This does vary from one manufacturer to another, and most will claim low VOC emissions, and some even claim VOC--free products.

Acoustics

The hard reflective surface of this finish will contribute significantly to a noisy environment as very little sound absorption will take place. This finish is not suitable for use in sound-sensitive environments.

Aesthetics

Terrazzo coatings are available in vivid colours, and stone chip textures give a lively appearance below the glossy smooth surface. Vibrant patterns can be created for an impressive foyer for example. Most other epoxy and cementitious coatings are monochromatic, flat colours that appear quite utilitarian. They are most commonly used in plant rooms.

Skirtings

Integral skirting can be formed in one with the floor covering for a clean and tidy junction. Skill and experience is needed for a neat, durable result. The same tendency to crazing and cracks over long lengths will increase the infection control risk.

Typical specifications for terrazzo

Allow all new concrete work and screeds to cure for at least 28 days before proceeding, and ensure a minimum strength of 25 mPa is achieved. The surface is to be free from laitance, dust and any other contamination, and must not exceed relative humidity of 75%. The installation is to be carried out by a subcontractor approved by the product manufacturer only. Apply primer at 0.25 kg/m2 followed by 8 mm epoxy terrazzo topping including granite chips at a rate of 16.8 kg/m2, and an average density of 2.1 kg/litre (confirm colour.) The topping to be ground down to 6 mm, all joints grouted with manufacturer approved coloured grout, and the surface to be sealed in accordance with manufacturer’s instructions.

Typical specification for grano

Float up to 5 mm of finished surface with layers of concrete (grano) approximately 10 mm thick, composed 1 part cement, 2.5 parts concrete sand and 3.5 parts granite or other approved hard stone chippings. Form finished surface with 1 part cement and 1 part fine granite chippings or other approved hard stone (graded up to particles which will pass a 6 mm mesh) brought to a smooth surface with a steel trowel. Grano finish: 30 mpa (25 mm thick). The floating and finishing coats are to be performed in one operation. The grano-lithic work is to be carried out by experienced workmen and is to be laid in panels v-jointed and not exceeding 6 m2 in area unless otherwise specified. Thin strips of wood or other suitable materials are to be laid between panels to break contact. All granolithic floors are to be covered up and protected from damage and discoloration during the progress of the work. Allow for cleaning down and for one coat of architect approved wax polish, well rubbed into floor at completion. No dry cement powder or grout to be applied to surface preparation of surface beds.

Typical specification for epoxy paint (to be applied to grano)

Ensure grano substrate has a maximum moisture content of 4%. The surface is to be free from laitance, dust and any other contamination. The installation is to be carried out by a subcontractor approved by the product manufacturer only. Prime surface with manufacturer recommended clear primer (spread rate –

6 m²/litre). Apply three coats semi-gloss water-based epoxy coating (confirm colour) with a minimum dry film thickness of 60 microns thick per coat with a maximum over-coating time of 12 hours. Applied in accordance with approved manufacturer specifications.

2. Resilient finishes

Resilient finishes are generally flexible floor coverings that provide a continuous impervious finish well suited to the healthcare environment’s needs. The sheeting is seldom more than 5 mm thick and is therefore very dependent on the quality of the sub-base onto which it is laid.

Due to the comparatively thin, smooth, polished aesthetics of resilient flooring, it is critically important that the sub-base is of adequate strength, perfectly level and has controlled moisture content, as any failure in the substrate will affect the performance of the floor finish. Any imperfections will be emphasised, creating scuffing and uneven wear. Minor movements in substrate however can be tolerated in the flexibility of the sheeting.

In recent years, self-levelling screeds/compounds have been introduced prior to the installation of sheeting. A variety of products are available of varying strength, thicknesses, cost and drying periods. Generally, selflevelling screeds are fast-setting, allowing foot traffic within hours and sheeting application within short periods, from 24 hours to longer. Installers can lay around 200 m2/hour. Sheeting is applied with adhesives to the substrate as per the manufacturer’s specifications. Joints in resilient sheeting are formed by using welding rods and these are heat welded for a seamless finish.

Building expansion joints needs to be taken through the self-levelling and sheeting to allow movement and special cover-strips are used in these instances.

Typical screed specification

Screeds are a critical part of ensuring a successful floor covering, and where thin sheeting such as vinyl, etc. is to be applied to the surface, the specification of the screed must meet certain criteria. The four important aspects are:

• Strength – is it strong enough for its purpose?

• Levelness – is it level enough for its purpose?

• Moisture content – is there moisture present?

• Adhesion to the concrete slab – is it sticking to the slab?

To conduct the necessary tests takes time and costs money, but unless these tests are specified and priced as part of the tender documentation, the quality of the floor finish is left up to the installer, with no control measures for the specifier to check the quality, so it is essential that these specifications be included.

Typical self-levelling/Smoothing compound specification

Self-levelling compounds will improve the smoothness, and levelness of screeds, and these compounds are a pre-requisite by most manufacturers for the installation of resilient sheeting.

2.1. Vinyl sheeting

General description and properties

Vinyl sheeting is manufactured from a combination of vinyl resin and various additives such as the following:

• Plasticisers – used to make the sheet more flexible,

• Stabilisers – to minimise degradation and discoloration

• Pigments – for colours and patterns

• Fillers – such as lime, or other locally available material

Vinyl sheeting is generally 2 to 2.5 mm thick and depending on the manufacturer, is supplied in 1.2 m or 2 m wide rolls. It is commonly used as a floor finish in health facilities, because it provides a durable, resilient and impervious finish.

Vinyl is available in a range of types:

• Homogeneous: Sheet consists of a single layer of consistent materials, with the wear layer being the full sheet. It is uncoated and requires stripping and sealing unless it is supplied with a specialised surface treatment such as polyurethane reinforcement (PuR).

• Heterogeneous: Sheet consists of three to four different layers including the carrier, PVC-layers, printed film and a clear PVCwear layer. Good durability will be achieved with a 0.7 mm wear layer.

• Directional or non-directional patterns: This relates to the visual pattern which may mean laying all sheets in the same direction. Non-directional sheeting is less limiting in terms of the pattern, but the manufacturer’s instructions must still be adhered to when laying sheets.

• With or without PuR finish: Polyurethane reinforcement (PuR) is introduced in the manufacturing process and provides a ‘ready polished’ product. When sheeting has a PU-coating, stripping and sealing directly after installation is not essential. However, waterbased dressings and appropriate cleaning is still needed to maintain the product. The PU-coating also improves resistance to staining and cleaning chemicals and supports indentation recovery. It is also important to establish whether high-speed buffing machines are required for cleaning of the product, and whether the institution has this equipment available.

Infection prevention

Vinyl sheeting as a material has been found to inhibit the growth of bacteria, and particularly MRSAs. The welded joints prevent dust or dirt congregating in areas that are difficult to clean, and the integral skirting supports this seamless appeal. This has made vinyl sheeting very suitable for use in healthcare facilities. Some heterogeneous products also have silver-ions in the finishing layer to create an antibacterial surface.

Cleaning and maintenance

The sheeting is easily washed, which contributes to its performance as a hygienic flooring finish. Vinyl sheeting is not easily damaged, and when treated with a polymer dressing/surface treatment, is low maintenance. When maintained properly, the sheets have a long life span, and therefore fairly cost-effective by comparison to other floor finishes.

Products with PuR require only spray and dry buffing for general cleaning although water-based dressings are beneficial. Special cleaning solutions are used for heavy staining, but abrasive cleaning methods should not be used. No abrasive black or brown cleaning pads should be used on PU-coated floors as these will damage the surface and destroy the sheen. Only buffing and shampoo pads should be used.

Cleaning should always be carried out as per the manufacturer’s specifications, to comply with material warranties, and the specifier should ensure that these instructions are included in handover packs issued to the building owner/user when occupation takes place.

An effective entrance barrier/dirt trap mat can reduce cleaning by 65%. The highly-abrasive African soil conditions create an extremely aggressive environment that can shorten the life span of the floor-sheeting, and without removing the bulk of this dirt and grit at the entrance of the health facility, the vinyl floor will suffer.

Strip and seal procedures should not be done more than once or twice a year, even in high traffic areas. Discoloration is often a result of poor daily maintenance, leaving a dirty residue which binds to the finish. Dry buffing brings out the natural colours, and a sealant will give the high shine finish.

Safety

In terms of slips, trips and falls care must be taken where highly polished floors are used in wet areas. Attention also needs to be given to thresholds where floor finishes of differing thicknesses meet, as these can present a hazard if not detailed as a smooth transition.

In terms of use by staff, the sheeting is softer underfoot than hard finishes, reducing leg fatigue. The smooth finish is easy to use with wheeled equipment, which creates a safe and workable environment for staff in health facilities.

Vinyl sheeting is generally slip-resistant, and most manufacturers will indicate results from the wet pendulum test or the dry floor friction test. Specialised sheeting with surface textures and/or quartz additives helps improve traction and reduce slipperiness. Antistatic sheeting is also available when required.

In terms of SANS 10400, operating theatres, ICU, high-care or critical care units are required to have a floor finish with 120 minutes’ fire resistance. Compliance with this should be checked with the manufacturer.

Indoor air quality: Humidity

Vinyl sheeting is well suited to areas of high humidity, and wet areas such as sluice rooms. Spills should be wiped as quickly as possible though as condensation blooming can take place in the clear wear layer.

Indoor air quality: Emissions

Some manufacturers have addressed VOC emissions in their products and indicate a pass in VOC emissions tests as well as BRE A+ ratings. Materials are 100% recyclable and also contain a percentage of recycled materials. Each supplier will differ, and specifiers should check these aspects when considering a product. VOC emissions of adhesives and sealants, where applicable, are also to be considered.

Aesthetics

The wide variety of colourways available in vinyl sheeting allows for creative patterns to enhance the healing environment. Patterns can be used for wayfinding, signage (e.g., ward numbers), definition of public and staff only areas, or distinction between different departments.

In addition, creative floor patterns can present branding identity, and enhance the environment to set patients at ease. Complex patterns should be aquajet cut, and the related budget allowances made at design stage. Skilled installers are also able to create many designs by hand.

Acoustics

Vinyl sheeting is relatively soft underfoot, and has better sound absorption qualities than hard finishes. Specialised vinyl sheeting products created for acoustic control are thicker at around 3.7 mm, but the extra foam backing on these types of sheeting can hamper the use of wheeled equipment in these areas.

Skirtings

Vinyl sheeting can be laid with a variety of skirting solutions. The use of the flooring material as an integrally welded skirting, forming a coved joint between the wall and the floor is the best solution in terms of infection control as the joints are welded and the ‘corner’ is smooth, rounded and easy to clean. The cove former which supports the turn-up of the sheeting can be sealed off at

each end (supplied in approx. 25 m rolled lengths) to ensure there is no access FIGURE 24 into this gap.

Extruded PVC-skirting is also readily available, and these can either be set in to abut the floor-sheet, or simply glued on top of the sheet, with a small ‘foot’ taking the curve into the wall. The specifier must ensure that the thickness of the set in skirting matches the floor thickness. The set in skirting is welded against the floor-sheet.

Capping strips can be used with all these types to create a neat line on the top edge.

Typical specifications

Since there is a range of vinyl products available, the specifier will need to determine whether homogenous or heterogeneous vinyl sheeting is preferred, and whether a PuR-layer is required or not before making the selection. A typical specification for homogenous type sheeting with PuR treatment is supplied as an example,

but the specifier should always liaise with the manufacturer for project specification.

HOMOGENOUS VINYL SHEETING WITH PUR TREATMENT

Supply and fix 2/2.5 mm thick – (confirm thickness) x 2 m wide fully-flexible, nondirectional or marbleised pattern/directional - (select type) vinyl floor-sheeting with polyurethane reinforcement and surface treatment - abrasion group T/P (select group), and manufactured to EN 649.

Sheeting is to be laid in pressure-sensitive or acrylic adhesive (select type as approved by flooring manufacturer), with a notched trowel at the rate of 5.5 to 6.5 m2/litre on a previously prepared Class 1 sub-base elsewhere described and measured. The sheet is to be rolled in both directions with a 68 kg three-sectional metal floor roller, during the course of the installation, immediately after the sheeting is laid in the adhesive. Factory edges of vinyl sheeting are to be removed before laying (10 to 20 mm) – recommended by some manufacturers (select if applicable). Installation in accordance with SABS 786:2007. Specify colour: (confirm code). Joints are to be butted, grooved to about half the depth of the sheet, (about 1 mm) and heat welded, with a welding rod. The finished width of the weld should be a width of 3 mm, and ensure a minimum 70% bond with the sheeting – all in accordance with the manufacturer’s spec. No concave or convex joints allowed – the joints must finish flush with the sheeting. All welds to be glazed and checked prior to polishing. No cross-joins allowed. On completion, PuR treated sheeting is to be washed down, and two coats of matt sealant is to be applied. This will prolong the life of the floor.

(Note: No stripping to PuR finished floors as this will damage the sheeting.)

SPECIFICATIONS FOR VINYL SKIRTINGS – Select one option:

Coved floor-sheet skirting: Matching floor vinyl sheeting coved 150 mm high against walls to form coved skirting, and welded to floor-sheet. Coved skirting to be laid over preformed 20 x 20 mm cove former – with ends sealed with glue. Allow for butterfly corner method at all corners including at thresh-holds, all in accordance with manufacturer's specifications. Skirting to be finished with extruded capping strip (or clip-on capping strip with backing) to be supplied and fixed with manufacturer approved contact adhesive spread evenly and quickly onto both material and wall surface. Ensure that no gaps remain between the wall, the skirting and the floor.

Set-in: Extruded cove skirting to be supplied to abut flooring, and welded against the floor finish. The skirting is to be fixed with manufacturer approved contact adhesive spread evenly and quickly onto both material and wall surface. Once touch dry (approximately 15 minutes) cove skirting to be applied firmly working gradually along the length from one end to the other. Extruded capping strip (or clip-on capping strip with backing) to be supplied and fixed with manufacturer approved contact adhesive spread evenly and quickly onto both material and wall surface. Ensure that no gaps remain between the wall, the skirting and the floor.

Sit-on: Extruded cove skirting to be glued on top of floor-sheeting, and against wall. The skirting is to be fixed with manufacturer approved contact adhesive spread evenly and quickly onto both material and wall surface. Once touch dry (approximately 15 minutes) cove skirting to be applied firmly working gradually along the length from one end to the other. Extruded capping strip (or clip-on capping strip with backing) to be supplied and fixed with manufacturer approved contact adhesive spread evenly and quickly onto both material and wall surface. Ensure that no gaps remain between the wall, the skirting and the floor.

ADDITIONAL SPECIFICATIONS TO CONSIDER FOR VINYL SHEETING

Note -1: It is highly recommended to the specifier to include in the project costing, an item for the preparation of a mock-up area of a minimum of 10 m2 of flooring installation – complete with sub-base and skirting, to be inspected and approved prior to the main installation.

Note 2 – If patterns are anticipated, these must be designed or at least described in the specification, so that it can be measured or budgeted for at documentation stage.

2.2. Linoleum sheeting

General description and properties

Linoleum has been used as flooring for over 100 years. It is manufactured from 97% natural, raw materials that are renewable and undergo an eco-friendly manufacturing process which does not produce environmental contaminants. Linoleum is made from linseed oil, rosin (from pine trees), wood and cork flour, limestone, organic pigments (for colour) and jute, which forms the backing.

Linoleum is less flexible and more porous than vinyl. It is available in a thickness of 2.5 mm, generally in rolls of 2 m width.

Infection prevention

Bactericidal properties of linoleum prevent microorganisms from multiplying. This includes MRSAs and this has been tested and proven by TNO (Netherlands Organization for Applied Scientific Research) and NAMSA (US Scientific Institute) in 1998.

Joints can be welded giving a seamless and hygienic finish. Coved and welded integral skirting can be achieved, with skill and experience.

Cleaning and maintenance

New generation linoleum products come with a factoryapplied surface finish or shield, which includes a primer and tough top layer which enhance low maintenance properties, and are restorable. This floor finish requires no stripping upon installation and to do so will damage the sheeting. This linoleum should simply be cleaned after installation in accordance with manufacturer’s instructions.

Linoleum that is supplied without the surface shield will however still require stripping and sealing on installation where the sealant acts as a sacrificial coat. Ensure that the correct products and procedure – as approved by the manufacturer – are applied, as sealers for vinyl will stain linoleum sheeting. Compliance with cleaning and maintenance, as laid down by the manufacturer, is required, to avoid invalidating the product guarantees. No alkaline products should be used as these will damage the linoleum.

Linoleum is resistant to staining by blood or urine, but will discolour with iodine.

Bleach will cause deterioration and loss of gloss. It has a good resistance to chemicals, diluted acids, oils and fats, and is extremely wear-resistant. Dirt-trap matting is recommended at entrances to the facility, to reduce the effect of the aggressive African soil conditions.

Safety

Linoleum has slip-resistant properties, although with any smooth surface, care must be taken when cleaning. Attention must be given to thresholds where differing floor thicknesses meet, and a smooth transition should be formed.

Linoleum is soft underfoot, resulting in reduced staff leg fatigue when compared with hard finishes. The smooth finish, however, is easy to use with wheeled equipment, creating a safe and workable environment for the health facility.

According to EN 13501-1, linoleum is suitable for exit routes in terms of fire safety, and is classified CFL/S1.

Indoor air quality: Humidity

Although the floor installation is welded, the use of linoleum in wet areas is not recommended due to the jute/hessian backing.

Indoor air quality: Emissions

Linoleum is a nontoxic natural product that does not emit VOCs, and makes for a better indoor air quality than rooms finished with petroleum-based/synthetic materials such as vinyl sheeting – which do emit VOCs. The linoleum is fully recyclable, and will earn credits for green-rated projects. A 30 to40 -year life span is not uncommon where floors are properly maintained, making for a low life cycle cost.

According to C. Maloney (LEED Green Associate at Cornell University), linoleum is preferable to vinyl as a flooring product, because it is better for the environment, and also for the wellbeing of the occupants.

Acoustics

LINOLEUM SHEETING WITH PROTECTIVE TOP LAYER

Supply and fix 2.5 mm thick x 2 m wide linoleum sheeting manufactured to specification EN 548 (with double protective top layer), laid in manufacturer-approved acrylic adhesive, spread with a notched trowel having 2.1 mm in height x 2.7 mm in width at 2.3 mm centres at a rate of 3 m² per litre on a previously prepared Class 1 subfloor by builder, as described above and elsewhere measured, including all cutting and waste. All joints to be butted or grooved and heat-welded with approved welding rods, ensuring that the welding rod bonds to more than 70% of the sheet thickness. It is essential that during the course of installation the material be rolled in both directions with an articulated 68 kg three-sectional metal floor roller.

Regular linoleum has excellent sound absorption properties and produces results of around 5 dB when tested for acoustical impact noise reduction under EN ISO 7127-2. Specialised acoustic linoleum is even more effective in creating a calm, quiet environment. Cushion-backed flooring helps to dampen reverberation sounds, and patients respond well to the calming effect of the muffled sounds in usually noisy hospital environments.

Aesthetics

Linoleum is available in a wide range of colours and designs help create healing environments. Patterns include wood-grains, marble and other interesting designs. Patterns are easy to achieve. Budget provision must be made for aquajet cutting where more intricate patterns are desired.

Skirtings

Due to its reduced flexibility, integral skirting using the floor-sheet requires special skill to form. The cove must be supported, properly fixed and capped. Preformed skirting can be fitted where budgets allow.

Typical specification for linoleum flooring

2.3. Rubber flooring

General description and properties

Rubber flooring is formed by vulcanising and compressing natural rubber, which is extracted from the sap of the tropical rubber plant. It is a simple process. There is no PVC- content, and it is available in tile and sheeting approximately 3 to 3.5 mm thick. The product is not manufactured locally in South Africa, but is available imported through local suppliers.

European norms (ENs) that set the industry standard for rubber flooring include:

• EN 1817 – Homogenous and heterogeneous rubber flooring

• EN 1816 – as above, with foam backing

Rubber is an extremely dense, hard-wearing product which will handle forklift traffic and has an extended life cycle of 30 to40 years. The most common surface finish is the classic round raised pastille.

Some rubber is made from a combination of natural and synthetic rubber, and there are numerous interlocking tile products available that look similar to rubber, but are made of PVC.

Infection prevention

Rubber flooring is bacteriostatic and will prevent the growth of mould and fungus. This makes is suitable for use in healthcare environments. The joints between the tiles, however, do present a risk, and sheeting is preferable in this regard, as all seams can be welded. The ‘wall-floor’ joint can also be an area of risk as integral skirting is difficult since the material is very dense and has reduced flexibility (although not impossible with skill). This can be an area that forms a reservoir to moisture and growth spot for microbes, and hence its

SKIRTING - SELECT ONE

Coved floor-sheet skirting: Matching floor linoleum sheeting coved 150 mm high against walls to form coved skirting, and welded to floor-sheet. Coved skirting to be laid over pre-formed 20 x20 mm cove former – with ends sealed with glue. Allow for butterfly corner method at all corners including at thresholds, all in accordance with manufacturer's specifications. Skirting to be finished with extruded capping strip (or clip-on capping strip with backing) to be supplied and fixed with manufacturer-approved contact adhesive spread evenly and quickly onto both material and wall surface. Ensure that no gaps remain between the wall, the skirting and the floor. Sit on extruded coved PVC--skirting, followed by capping strip (confirm size of skirting, capping strip and colour), using manufacturer-approved contact adhesive, spread evenly and quickly with a brush onto both material and working surface. Allow both surfaces to become touch dry – approximately 15 minutes. Place material carefully into position at one end, and then work gradually along its length. When completely positioned, apply firm pressure along whole length to ensure perfect contact between the two adhesive surfaces. Ensure that no gaps remain between the wall, the skirting and the floor.

Clip-on capping strips with backing can also be specified – refer to manufacturers.

reduced application in health facilities.

Cleaning and maintenance

Rubber is extremely hard-wearing and durable and required uncomplicated maintenance with neutral detergents, rinsing and dry sweeping/vacuuming. As with any product, maintenance will prolong the life and enhance the appearance of the product.

Safety

The circular pastille pattern of tiles and the textured surface of the sheeting provide a slip-resistant surface which is suitable even in wet conditions. Good walking comfort is achieved with less leg fatigue than hard surfaces. The raised pattern will produce slightly more drag than a perfectly smooth surface when it comes to wheeled equipment being pushed across it.

Rubber is a Class BF1/S1 fire-retardant material in terms of the EN 13501-1 test method.

Indoor air quality: Humidity

Rubber is well suited for use in high-humidity/wet spill areas, as it is not adversely affected by moisture, and the slip-resistant surface makes it safe to use in these areas.

Indoor air quality: Emissions

Rubber is a natural product that does not emit toxic VOCs. No formaldehyde materials are used in the manufacture of rubber flooring, and in terms of EN 14041:2004, an E1 classification is achieved, which means emissions fall into the ‘less than 0.7 ppm (parts per million)’ category. Rubber does have a distinctive odour.

Acoustics

Rubber is an excellent absorber of sound, with a sound absorption value of between 6 to10 dB. Rougher textured tiles will absorb even more, and specialised acoustic products up to 20 dB. The muffling of impact sounds in a healthcare environment will clam patients and contribute to a quiet, peaceful space.

Aesthetics

Rubber is available in a limited range of monochromatic colours. Simple patterns can be achieved, but the single colour flooring can appear somewhat utilitarian – which may be suitable for specific areas. The durability of the flooring means that it maintains its appearance well, still visually appealing after many years of use.

Skirtings

Coving of the wall/floor joint is possible with rubber sheeting, but its reduced flexibility and thickness require expertise and special skills to achieve. Preformed skirting is more readily available. Rubber tiles are more commonly used in South Africa, and skirting then cannot be coved or welded to the flooring.

Typical specification for rubber sheeting

SPECIFICATION FOR RUBBER FLOOR-SHEETING:

Supply and fix 2.0 mm thick x 1.22 mm wide rubber floor-sheeting with a changing base colour, consisting of three harmoniously matched colour components and characteristic granule inclusions, laid into manufacturer approved contact adhesive spread according to manufacturer’s recommendations on a previously prepared Class 1 sub-floor by a builder, (specified above and elsewhere measured) , including all cutting and waste. Join sealing required, according to the manufacturer’s recommendations.

SKIRTING: SELECT ONE

Coved floor-sheet skirting: Matching floor-sheeting coved 150 to 200 mm (select) high against walls to form coved skirting, and welded to floor-sheet. Coved skirting to be laid over preformed 20 x 20 mm cove former – with ends sealed with glue. Skirting to be finished with extruded capping strip (or clip-on capping strip with backing) to be supplied and fixed with manufacturer-approved contact adhesive spread evenly and quickly onto both material and wall surface. Ensure that no gaps remain between the wall, the skirting and the floor.

(Confirm skirting set-in or sit-on) Supply and fix extruded coved fillet and capping strip (confirm skirting type, radius and size, colour, capping strip size and colour), using manufacturer-approved contact adhesive, spread evenly and quickly with a brush onto both material and working surface. Allow both surfaces to become touch dry – approximately 15 minutes. Place material carefully into position at one end, and then work gradually along its length. When completely positioned, apply firm pressure along whole length to ensure perfect contact between the two adhesive surfaces.

2.4. Cork flooring

General description and properties

Cork flooring is made from the bark of the cork oak tree, which is an evergreen tree common in Southern Europe and North Africa. The bark is ground and processed into sheets before being kiln-baked. The hand harvesting is strictly controlled, and since the bark grows back, this is a highly sustainable product.

The main constituent of cork is a waxy, rubbery substance called suberin. This hydrophobic substance gives cork flooring its elastic and impermeable quality.

The cork sheeting is most commonly formed into tiles or planks of between 4

to6 mm thick and varying sizes. The tiles are most commonly glued to the floor surface which must be free of imperfections, level dry and smooth. The tiles or planks are generally butt-jointed. Floating cork floors can be achieved by laying cork planks over timber floors. Interlocking, glue-less installation is also available. Cork is also formed into rolls for use as an underlay below other flooring materials to improve acoustic performance and prevent moisture ingress. It is recommended that cork suitable for commercial use (Class EN31-35) is used in healthcare facilities.

Cork and rubber have also been combined with polymers such as neoprene and nitrite to create tough, durable floor-sheeting. Cork has also been combined with linoleum to form flooring products that are imported. These imported products cater for residential, commercial and industrial grade applications. Although cork has predominantly been used in the residential sector in South Africa, it is beginning to find a place in the commercial, and particularly the healthcare sectors, where budgets allow.

Infection prevention

Cork is bacteriostatic and antifungal. Dirt and grime may collect, but not be trapped by the floor, and provided the floor is regularly swept or vacuumed, microbes will not be able to colonise, and the floor will prevent the spread of infection. Some manufacturers treat the cork with an additional antimicrobial sealant to prolong the durability of the product. Joints cannot be welded, and tiles are laid with butt joints. These joints can gather dust and moisture over time, and sealing the finished floor with a sealant is recommended.

Cleaning and maintenance

This is a low maintenance product, with simple cleaning procedures such as regular mopping and sweeping – no sophisticated equipment is needed. No harsh cleaning agents or polishing is required. Tiles usually come pre-sealed; however, application of an additional polyurethane sealant to cover the joints on the finished floor is recommended. Unless the floor is properly sealed, it can stain, and the sealant will need re-application periodically. The resilient nature of cork means it has excellent impact resistance. The 40 million microscopic air-pockets per cm3 allow cork to return easily to its original shape, even after pressure from furniture or heavy foot traffic.

Safety

Cork consists of 50% air, which is contained in the microscopic honeycomb compartments that make up the material. This makes cork a great shock-absorber, reducing leg fatigue as well as injuries where patients may fall (particularly the elderly). The cellular structure also makes it slip-resistant. Nanobead technology surface finishes are available which provide excellent traction to prevent slipping.

Indoor air quality: Humidity

Suberin is a natural waxy substance found in cork, and is responsible for the moisture repellent/resistant properties of cork. Cork is commonly used as an underlay to prevent the transfer of moisture to the floor finish. It is however not recommended to glue cork to consistently damp or wet areas as adhesive to the substrate may fail, and the moisture will divert to other finishes.

Indoor air quality: Emissions and insulation

Cork, and the process of producing cork flooring contains no formaldehyde or other toxic substances, and cork does not emit VOCs. However, adhesives, finishing/protection coats and sealants used with these flooring products may contain solvents and emit VOCs. Cork is also very lightweight due to the high air content and this reduces the transport costs and in turn the carbon cost of the product. Solvent- and formaldehyde-free polyurethane surface finishes are also available for commercial use (Class EN 32). The insulation properties of cork will produce good energy savings where heat load is a factor on the floor.

Acoustics

Impact sound reduction tests (in accordance with ISO140-8) show that cork can absorb and reduce sound by up to 16 dB. The air-filled compartments are excellent sound absorbers and will contribute to a calm, quiet environment. Sealants will reduce this capacity, but slightly increasing the reflectivity. ISO 10140-1:2010 indicated a 53% reduction in footfall sound.

Aesthetics

Cork, like timber, is a naturally-grown product and much of its aesthetic appeal comes from the uniqueness of each batch of cork. Colour variations add to the appeal, and are to be expected from different trees and harvests. The colours range from yellows to dark browns, although off-whites are also being achieved through treatment. Exposure to light will over time lead to some degree of fading. Engineered multilayered cork products will be more consistent in pattern and colour. These hybrid products are examined more under Section C4.

Skirtings

Cork cannot be coved or welded. Any suitable coved set-in skirting can be used, with the flooring abutting this skirting. The thickness of the cork tiles should be borne in mind when abutting a coved skirting, however, as the cork is thicker than most pre-moulded coved skirting on the market.

Typical specification for cork tiles

3. Soft finishes

3.1. Carpet textiles

General description and properties

Carpets are manufactured from fibres attached to a backing. The fibres range from natural wool to synthetically manufactured nylon or polypropylene fibres. Carpets can be made up of cut pile – individual strands, or tufted pile – which are closed loops. These are needle-punched into the backing. The heights of the tufts can be varied to create the striations and patterns commonly found in needle-punch carpets. The synthetic fibres are often treated to prevent the growth of mould and microbes, and make the carpet resistant to staining.

Traditional carpets had jute backings, but this organic material - which had limitations such as rotting when exposed to moisture, or encouraging microbe infestation, has largely been replaced by synthetic fibre or resin-based backings which are more durable, non-allergenic and can resist moisture.

Broadloom carpet widths are most commonly 3,66 m wide, but some manufacturers supply 4 m widths or narrower 1.8 m widths as well. Carpet tiles are generally 500 to600 mm square, but larger sizes and rectangular tiles are also available to order. A wide range of thicknesses are available – from 3 to 12 mm depending on the backing. Carpets are graded for various applications and traffic weights - from residential to heavy commercial. The colouring process ranges from pre-dyeing/injecting colour into the yarn, to continuous

Subfloors must be level, permanently dry, solid and free from cracks, dirt and adhesion inhibiting substances and not exceed a maximum humidity of 75% RH. Ensure that the subfloor is well absorbent. If the subfloor shows low absorbency or no absorbency, apply a high quality cement based levelling compound in a minimum thickness of 2 to 3 mm (measured elsewhere). Note that latex or acrylic levelling compounds will detrimentally affect the adhesion of the adhesives. Apply 600 x 300 x 3.2 mm thick cork panels consisting of 0.25 mm vinyl backing layer, 1.65 mm cork agglomerated core, 0.8 mm genuine cork veneer and 0.5 mm hard wearing surface, and prefinished with specialised surface treatment suitable for Class EN 33 Use (or equivalent). Panels are to be glued to the substrate (350 to400 g/m2 spread rate) with a notched trowel using adhesive as per the cork panel manufacturer’s recommendation. Ensure the adhesive ridges are compressed completely to an even adhesive film. Roll with a 50 kg multipart roller after a short period and repeat rolling after approx. one hour. If necessary, weigh down edges. The edges of flooring area are to be caulked before fitting the skirting. A 15-year warranty is to be provided on the flooring product.

dyeing – where dyes are rolled or sprayed onto the carpet or by boiling in vats of dye after the manufacturing process is complete.

The fibre weight varies from 400 gsm to 1 100 gsm, although this should be seen in relation to the overall weight of the carpet including the backing. The suitability of the carpet however, is reliant on its fitness for purpose, such as using the correct location grade, and the guarantees and warranties provided by the manufacturer.

Infection prevention

Although there is no direct evidence linking any flooring type directly to HAIs, the study by Sehulster and Chinn for Center for Disease Control (2003), recommended that carpets not be used in areas where spills are likely to occur, such as laboratories or cleaners rooms, nor where patients are at greater risk from infection from airborne pathogens, such as in burns units, ICUs and operating rooms. While fibres can trap pathogens (and thereby prevent them from circulating in the air), the proper cleaning of carpets and effective removal of these pathogens is difficult to check on a daily basis. In addition, the carpet is porous and permeable, (although some may have an impermeable backing) which is in conflict with the National Health requirements for these highrisk areas. Carpets in offices or waiting areas do provide a welcome relief from the noisy ward areas where harder surfaces are present.

Some manufacturers indicate the additional benefit of antimicrobial treatment using phosphate amines such as silver, zinc or copper to combat bacteria. The US Carpet and Rug Institute issued a technical bulletin in regard to these treatments and what they achieve. Since the treatment is applied to the carpet fibres or the backing – or both, no implicit human health claims can be made about the finished product unless that finished product has been tested and registered by accredited independent testing organizations. Synthetic fibres in themselves do no provide a nutrient source which microbes need to survive, but textiles can trap soil, dust and moisture, which do provide that source.

Cleaning and maintenance

The first means of protecting and extending the life of carpets is the use of dirt-trapping mats at all entrances to the facility. This will remove a substantial amount of soil and dirt carried in on shoes/feet from the exterior. Fine soil crystals damage the fibres as they are ground into the carpet pile, and this can be avoided with regular vacuuming. The build-up of soil over time will also dull the appearance of the carpet.

It is recommended that heavy traffic areas are vacuumed daily, while for other areas, once a week will suffice – depending on what function the room accommodates. Carpets should be professionally cleaned at least once a year – with products recommended by the manufacturer, as any sticky residue left behind after cleaning will only attract soil build-up. Facility managers must also ensure that vacuum cleaner filters are regularly cleaned and replaced when necessary, as this will also affect the efficacy of vacuuming. If vacuum cleaners are not well maintained, they may also aerosolise pathogens during vacuuming. Carpet protectors should also be used where chairs with castors are present – where recommended by the manufacturer.

Safety

Since slips usually occur when there is too little friction between feet and the walking surface, the rough texture of carpets results in a highly slip-resistant surface. The cushioned effect of some backing types also reduces leg fatigue. Too much cushioning can reduce roller mobility though, making carpets with plush fibre or thick cushioning unsuitable where trolleys or wheelchairs for example, need to traverse the floor.

Healthcare facilities are occupied by patients that are frail and sometimes non-ambulatory. With this in mind, the fire regulations for this occupancy code are more stringent in the National Building Regulations, and the specifier must ensure that the fire ratings of carpeting types comply with the relevant occupancy.

Indoor air quality: Humidity and insulation

Carpets are not suitable for use in high humidity areas for reasons discussed under infection control above. Carpeting is an effective insulation material, particularly when laid with an underlay.

Indoor air quality: Emissions

Studies conducted by the US Carpet and Rug Institute show that - despite the ‘new carpet smell’ - carpet is one of the lowest emitters of VOCs indoors, less than paints for example, and these odours dissipate within days. Most local manufacturers indicate that the VOC emissions meet the GBCSA Green Star Rating – check product specific literature for the carpet under consideration.

Since carpets are often glued-down installations, the adhesives are often the culprit with VOC emissions on these floors. The specifier should check with the manufacturers about the levels of emission on the recommended adhesives.

Aesthetics

Carpets are being manufactured in a diverse range of colours, patterns and textures. The variety allows for creative, non-institutional application. Tiles are usually laid tessellated, which also adds to the interesting texture of the floor. Patterns and borders are achievable with tiles and most broadloom carpet, and can contribute to a professional atmosphere in the administrative sections of the healthcare facility.

An interesting study by Harris (2011) recorded at the Centre for Disease Control demonstrated that the amount of time visitors spent in rooms with carpets was higher than they did in rooms with vinyl floor finishes – this is perhaps an indication of how an environmental aspect can influence behaviour, and could be linked to aesthetics, temperature comfort and sound attenuation.

Acoustics

According to the Center for Health Design, carpets have the highest noise reduction co-efficient (NRC) for impact noise of all flooring types. Note that this is in relation to impact noise only – sounds such as footfalls, and dropping of objects onto the floor. The ability of carpet to absorb airborne sound is however mediocre, and according to the technical brief: ‘Acoustic Environments’ by Green Guide for Healthcare (2007), the acoustical benefit of carpet is to reduce impact rather than airborne noise. The noise attenuation properties of flooring, is often a trade-off with infection control. According to a study by Sehulster and Chinn for CDC in 2003, carpet should be avoided in areas housing immuno-compromised patients.

Skirtings

Traditionally timber skirting has been most commonly installed with carpeted floors, but there are very few limitations on the size and type of skirting that can be fitted.

Typical specification for carpet (broadloom)

SPEC FOR CARPET BROADLOOM WITH UNDER-CUSHION

Fit heavy commercial (SABS location grade: 5) textile carpet sheeting, with solution dyed nylon fibres, plain cut pile/level cut loop/tufted cut pile (select) OR polypropylene structured needle-punch fibre and woven polypropylene backing - SABS Class 2 fire rating. Carpet thickness 7 mm to 10 mm (confirm) Carpet fibres are to be pretreated against stains, and guarantee and warranty supplied. Broadloom carpet sheeting to be laid in accordance with the manufacturer’s specification by an approved installer in accordance with SANS 10186:2010. Carpets are to be installed over commercial grade, non-allergic, latex foam under-cushion. (Optional) (Confirm colour and weight/m2 of carpet)

Typical specification for carpet tiles

SPEC FOR PLAIN-BACKED CARPET TILES FOR MEDIUM COMMERCIAL:

Plain backed carpet tiles, medium commercial (SABS use class U4), with needle-punched fibres, size 500 x 500 x 5 mm thick (confirm size and thickness) with SABS Class 2 fire rating, fibre weight of 700 g/m² and total weight of 940 g/m², (confirm weight). Carpet tiles manufactured in accordance with SANS 1415:2000, installed by an approved installer in accordance with SANS 10186:2010. Carpet fibres are to be pre-treated against stains, and guarantee and warranty supplied. Confirm colour and relevant code).

3.2. Flocked flooring

General description and properties

Flocked flooring falls under textiles in terms of definition, but also has characteristics of resilient flooring. It combines the acoustic properties and warm feel of textiles with the waterproof, durable and washable properties of resilient flooring.

Flocked flooring is manufactured by applying millions of short, cylindrical polyamide (nylon) fibres to an adhesive coated surface through an electrostatic process. The first electrostatically flocked flooring was made in 1960, so the technology is not new. The flooring consists of various layers including:

• Densely flocked polyamide fibres

• Waterproof PVC-adhesive

• Stable glass-fibre mesh interlays for strength and durability

• Cushioned waterproof, rot-resistant PVC--backing

The sheeting is available in 2 m wide lengths, and 4.3 mm total thickness. Tiles are 500 x 500 mm, and 5.3 mm thick. The tiles and sheet are suitable for heavy commercial grade application.

Infection prevention

Flocked flooring responds in a similar way to resilient flooring in terms of infection control. The flooring is fully waterproof and washable, being easily cleaned when wet spillages occur. This impermeable quality aids in infection control. The upright nylon fibres are very short when compared to other carpet fibres, and these more easily give up dirt that has fallen among the fibres, preventing microbes from settling in to grow. Like polypropylene fibres, the nylon fibres do not provide a source of nutrient for microbes, and the flooring is the only textile with the UK Allergy Approval certificate. The finished installation is not jointless however, as the joints are not welded, and the skirting is independent of the floor. These are areas that could be an infection risk.

Antibacterial treatment is also integrated into the manufacturing process. As discussed under Carpets, these may contribute to the reduction of fungus or bacterial growth, but cannot substitute for routine and regular cleaning and maintenance.

Cleaning and maintenance

As mentioned above, the finish is easily vacuumed, and wet spills are easy to clean up as the finish is waterproof. As with any floor, regular cleaning will extend the life and appearance of the product as the buildup of soil over time will dull the appearance. The use of dirt-trapping mats at all entrances to the facility will remove a substantial amount of soil and dirt carried in from the exterior. Because the product is easily vacuumed, it is less likely to trap soil or dirt long enough to encourage microbial growth on the particles of soil and moisture – both of which would need to be present since the nylon fibres themselves provide no nutrient value. Periodic professional cleaning will restore the appearance and this product has a far longer life span than regular carpet textiles.

Safety

Since flocked flooring provides very high slip-resistance, even where spills occur, this product is very safe for use in health facilities, and for many years has been used in the marine industry to finish decks on boats. The cushioned effect also reduces leg fatigue without reducing roller mobility as a result of the short straight fibres of nylon.

Healthcare facilities are occupied by patients that are frail and sometimes non-ambulatory. With this in mind, the fire regulations for this occupancy code are more stringent in the National Building Regulations, and the specifier must ensure that the fire ratings of carpeting types comply with the relevant occupancy. Flocked sheeting is Class BF1/S1 fire-retardant material in terms of the EN 13501-1 test method.

Indoor air quality: Humidity

Due to the waterproof characteristics of the flooring, flocked flooring is not adversely affected by wet areas and can tolerate humid conditions. However, special attention needs to be paid to sealing of joints and edges where moisture could get under the tiles or sheeting if the adhesive is not thoroughly applied.

Indoor air quality: Emissions

The manufacturers of flocked flooring indicate that VOC emissions are very low, and that certain ranges conform to all standards including the new VOC emissions classes in Europe. The specifics would be dependent on the product specified. Low-emission adhesives are also available. Responsible initiatives on the part of manufacturers include using recycled content in backing, and also supporting PVC-recycling projects.

Aesthetics

A wide selection of patterns and colourways are available, from natural tones to bright colours, monochrome to multiple colours, standard or purpose-designed - there is ample opportunity for creativity. Tiles can be laid checkerboard or broadloom style. Cutting designs into the sheeting can also be achieved for branding or more intricate patterns. Conventional rotary screen-printing builds colours up in successive layers before heat fixing the print permanently onto the fibres. Digital printing can also be achieved where budgets allow.

Acoustics

With around 70 million fibres/m2, the flooring is extremely dense, and it is this property that can substantially reduce impact sound. The flocked flooring has been tested under BS EN ISO 10140-2010 and proven to absorb 20 dB on the sheeting, and 17 dB on the tiles. The soft floor was also shown to absorb ambient noise. This finish would be appropriate in waiting areas or counselling rooms.

Skirting

Coved and welded skirting cannot be achieved with flocked flooring. Traditional timber skirting is suitable but as for carpeted floors, but there are very few limitations on the size and type of skirting that can be fitted.

Typical specification for flocked flooring (broadloom)

SPEC FOR FLOCKED FLOORING

Supply and fix 4.3 mm thick x 2 m wide electrostatically flocked textile floor-sheet covering, manufactured to specification EN 1307. Spread manufacturer approved acrylic adhesive on the exposed substrate with a trowel having triangular notches 1.78 x 1.78 x 1.6 mm at 3.0 mm centres at the rate of between 5.5 m² and 6.5 m² per litre depending on sub-floor porosity, on a previously prepared sub-floor by the builder, (as described) and elsewhere measured. Factory edges to be butted for seaming. It is essential that during the course of installation the product be rolled in both directions with an articulated 68 kg three-sectional metal floor roller immediately after it has been laid into the adhesive.

4. Hybrid floor finishes

Traditionally flooring types were limited to hard, resilient or soft finishes, but with new technology and manufacturing processes, a new class of flooring is beginning to surface – namely: hybrid floor finishes. The term refers to floors that are engineered from various layers, or combinations of various products. This could include hard, soft and resilient finishes. To some extent, flocked flooring could fall under this category as it crosses the boundary between resilient and soft finishes, but it has been classified as a textile at present. Laminated flooring is another such product. Laminated flooring consists of various layers which are compressed. There are two main types, namely those with a fibreboard substrate (like medium density fibreboard) and others with a vinyl substrate.

4.1. Laminated timber flooring: Fibreboard substrate

General description and properties

Laminated timber flooring has largely replaced traditional timber flooring and parquet products due to the reduced cost, ease of installation, wider range of wood grain aesthetics available, as well as the reduced impact on the use timber resources. Laminated timber flooring consists of four layers:

• A top layer/film of transparent aluminium oxide and melamine (the wear layer which makes the surface scratch- and scuff-resistant)

• The highly realistic photographic paper image of the wood

• the core layer of medium or high density fibreboard treated for water resistance

• A base layer of waterproof film for stability

These layers are fused under heat and high-pressure. The density of the fibreboard can vary substantially, and overall thicknesses range from 6 mm to 12 mm, but the industry recommendation is the 8 to9 mm plank for most applications. Plank sizes also vary in size, but generally are 200 mm x 1 300 mm. The interlocking system of the planks means that the floor finish can be installed without adhesives. The surface of the junction between planks can be a smooth butt-joint, a pronounced v-joint or fitted with a flush rubber strip for an anti-slip finish suited to wet areas. Expansion joints against walls are important, as is the laying of moisture barrier sheeting under the flooring. Sound-dampening underlays of 2 to 3 mm are also recommended.

The majority of laminated timber flooring is suited to residential applications, but commercial grades are also available. Flooring is graded for levels of use according to EN 685. Health facilities would require a minimum EN 31 Class: Commercial Moderate (for public and commercial use which is low or intermittent), but medium, heavy and intense traffic may be more suited to specific areas of the facility. (En Class 32, 33 and 34 respectively.) Abrasion Class 5 (AC5 EN 33) can be used in public and commercial areas with heavy traffic.

Abrasion Classes 1 to2 are for light domestic use only.

Infection prevention

Laminated floor planks can present an infection control risk in the small grooves of the interlocking joints which can trap small particles of dust and moisture, and are difficult to clean thoroughly. Open V-joints are easier to clean, but provide deeper ‘reservoirs’ for dust, and will need thorough and regular vacuuming or broom cleaning to remove dirt. While this flooring may not be suited to areas where infection control is a priority, it can be used in other areas of health facilities, such as offices or public recreational access areas such as coffee shops.

Cleaning and maintenance

Laminated timber floors should be dry-brushed and vacuumed regularly to remove dirt and grit which can lead to scratches. Spills should be wiped up immediately, and cleaning should never be done with large amounts of water. Slightly damp, well-squeezed dry laminate mops or cloths should be used with manufacturer approved cleaning agent. No abrasive cleaners should be used, and no stripping, sanding, waxing, polishing or varnishing is required.

Dirt trapping mats are the best investment in maintaining these floors. Felt

pads are recommended under the feet of furniture and soft tread castors FIGURE 36 should be used on chairs. Safety

Laminated flooring provides a smooth, sheer finish, which can present a slip hazard, particularly if spills occur. Floors with rubber inserts in the V-joints provide a slip-resistant surface. This hard floor finish can be fitted with underlays to reduce leg fatigue. Fire ratings vary substantially, depending on the product, and these should be checked with the manufacturer to ensure suitability for use in the health facility.

Indoor air quality: Humidity

Laminated timber floors are not suited to commercial areas where wet processes will take place. The junctions between planks are not sealed, and will allow moisture access. This will adversely affect the products – some of which have a fibreboard core.

Indoor air quality: Emissions

Medium-density fibreboard contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognised as being the highest formaldehyde-emitting pressed wood product. (Source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated though, and the glue-free installation of the interlocking planks means lower emissions when compared to a glued-down system using high-VOC adhesives.

Aesthetics

The popularity of laminated timber flooring has widened the range of ‘wood-look’ finishes available. The diversity of the timber grains and hues provides creative opportunities that echo a natural environment –albeit in appearance only. The move in healthcare to provide a more ‘homely’ residential appeal has also seen these timber laminates being used more in certain areas of health facilities.

Acoustics

Laminated flooring tends to amplify the sound of footfalls, but sound-deadening acoustic underlays should be used where possible. These loose-laid or glued-down sub-layers can improve the sound of impact by 20 dB, when used with the laminated flooring.

Skirtings

Matching moulded skirting is usually available in matching grains and colours to suit the floor panels. This independent skirting is not recommended in high infection control risk areas as the small crevices are difficult to clean, and will gather dust and moisture. Varnished timber skirting is also commonly used with the laminated flooring.

Typical specification for laminated timber flooring

4.2. Laminated flooring – PVC planks

General description and properties

Interlocking laminated floor planks are also manufactured from PVC-layers, which are more durable than the fibreboard core planks. In addition, the formaldehydes associated with MDF and HDF are avoided, and the performance under wet conditions is superior. This product is more suitable in heavy commercial applications than laminated timber planks, and in some ranges even suitable for light industrial applications. These ‘planks’ are actually small rigid vinyl sheets which are formed with an interlocking joint detail. These products are thinner than MDF laminates at 2.5 to 5 mm thick, but are available in similar sizes as the laminated timber planks (around 150 to 230 mm wide x 1 200 mm long). Some ranges are available in 600 x 600 tiles. The basic layers of the product include:

• A polyurethane reinforced surface treatment

• The embossed high-density wear layer of 0.4 to0.7 mm pure PVC (this makes the surface scratch- and scuff- resistant)

• The decorative layer with the highly realistic photographic paper image of the wood , stone or other graphic design

• The stabilising glass fibre fleece core layer (around 1 mm) for dimensional stability • A PVC-composite load-bearing base layer

These layers are fused under heat and high-pressure. The interlocking system of the planks means that the floor finish can be installed without adhesives – as a floating floor. This has advantages in terms of the VOCs given off where solvent adhesives are used. The surface of the junction between planks can be a smooth buttjoint, or a pronounced bevel/V-joint.

Glued-down planks/tiles are however also available (in 2.5 to3 mm thickness with 0.55 and 07 mm PU--wear layers respectively). Both are suitable for heavy commercial and the latter for light industrial use. The glueddown planks have a deep embossed finish giving a realistic appearance to the wood-grain, and improving slipresistance.

Flooring is graded for levels of use according to EN 685. Health facilities would require a minimum EN 31 Class: Commercial Moderate (for public and commercial use which is low or intermittent), but medium, heavy and intense traffic may be more relevant to specific areas of the facility. (En Class 32, 33 and 34 respectively.) Abrasion Class 5 (AC5 EN 33) can be used in public and commercial areas with heavy traffic. Abrasion resistance should meet Group T.

Infection prevention

Although the laminated vinyl floor planks do not provide a nutrient source for bacteria, this flooring can present an infection control risk in the small grooves of the interlocking joints which could trap small particles of dust and moisture, and are difficult to clean thoroughly. Open V-joints are easier to clean, but provide deeper ‘reservoirs’ for dust, and will need thorough and regular vacuuming or broom cleaning to remove dirt. A wellmaintained floor will however present an easy to clean, hygienic floor finish suited to the healthcare environment.

Cleaning and maintenance

The vinyl planks with PU-reinforcement make for a simple maintenance regime. The floor should be swept and vacuumed regularly, and washed periodically with water and manufacturer-approved cleaning agent. No abrasive cleaning agents or tools should be used, and no stripping, sanding, waxing, polishing or varnishing is required. Dirt trapping mats are the best investment in maintaining these floors.

The glued-down tiles/planks should not be washed for a few days after installation – in accordance with the manufacturer’s recommendations -to allow the planks to settle in the adhesive. Moisture exposure during this stage may also affect the adhesive bond.

Safety

Laminated vinyl planks are deeply embossed to enhance the realistic wood grain. This ridged surface provides good slip-resistance. The floating floor installation can be laid with sound-absorbing underlays, which also reduce leg-fatigue. Fire ratings vary substantially, depending on the product, and these should be checked with the manufacturer to ensure suitability for use in the health facility. The laminated vinyl plank is a Class BF1/S1 fire-retardant material in terms of the EN 13501-1 test method.

Indoor air quality: Humidity

Laminated vinyl planks can be used in areas where occasional spills occur, although spills should be wiped up immediately.

Indoor air quality: Emissions

The floating – interlocking planks will not require adhesives to fix the floor in place, and this will reduce the

VOC emissions when compared to glued-down systems. Certain vinyl planks have been certified with a Gold Indoor Air Comfort-rating which is awarded to products of very low VOC emissions where these are below any globally determined imit.

Aesthetics

The popularity of laminated flooring has widened the range of ‘wood-look’ finishes available. The diversity of the timber grains and hues provides creative opportunities that echo a natural environment –albeit in appearance only. The move in healthcare to provide a more ‘homely’ residential appeal has also seen these vinyl planks being used more in certain areas of health facilities. The grain should always be laid parallel to the direction of the natural light falling into the room.

Acoustics

Floating laminated flooring tends to amplify the sound of footfalls, but sound-deadening acoustic underlays should be used where possible. These loose-laid or glued-down sublayers can improve the sound of impact by 20 dB, when used with the laminated flooring. Glued-down systems have less echo effect for the sound of footfalls and impact.

Skirtings

The PVC-planks cannot be coved - more as a result of the directional pattern, but also the rigidity. Using a complementary colour vinyl skirting could still be used. This allows for a seamless skirting and hygienic finish. Matching moulded skirting can also be used in matching grains and colours to suit the floor panels. This independent skirting is not recommended in high infection control risk areas as the small crevices are difficult to clean, and will gather dust and moisture. Varnished timber skirting is also commonly used with the laminated flooring.

Typical specification for laminated vinyl planks

5. Flooring accessories

AC5 - EN 33 Class interlocking (or glued-down – specify) vinyl PVC--layered flooring plank 1 219 x228 x 5 mm thick (confirm size and thickness) in four-sided V-groove, bevel-edge joint (select edge detail), fixed floating (or laid in manufacturer approved adhesive). Expansion gaps between walls and floor to be provided in accordance with the manufacturer's recommendations. Installation only by manufacturer- approved installer. Supplier to provide 10year commercial warranty. (Confirm colour, texture, code.)

5.1. Walk-off dirt trapping mats

An effective entrance barrier or dirt trapping mat can reduce cleaning by up to 65%. The highly abrasive African soil conditions create an extremely aggressive environment that can shorten the life span of the floor-sheeting. Without removing the bulk of this dirt and grit at the entrance, the floor finish - whether hard, soft, resilient or hybrid - can be badly damaged by the dirt and grit that is carried in on visitors’ shoes.

Walk-off mats should be placed strategically at all entrances,

allowing a minimum of four to five paces, (around 3 m) across FIGURE 38 which people will walk. This will remove the majority of loose particles, and prolong the life of the floor finish.

Various types of entrance barrier matting are available including:

• Coarse carpet with ridged surface

• Coir bristle brush

• PVC-brush

• Aluminium structure with inserts of rubber

• Aluminium structure with inserts of carpet

A recess in the screed should be specified and/or detailed to the exact depth of the mat. This will ensure a flush finish at floor level, and prevent the mat from becoming a tripping hazard. If the mats are not recessed, they will need to be firmly anchored, and have bevelled edges on all sides.

5.2. Expansion joints

Expansion joints must be carried through the floor finish and screed from the slab below to prevent cracks in the finish. This applies to hard and resilient flooring. Soft finishes such as carpet, can be laid over the screed joint. These joints should be finished with purpose-designed expansion joint covers which will vary according to the type of finish laid, and include:

• Extruded PVC-covers that are glued to the floor either side of the joint

• Metal joint covers made of aluminium, stainless steel or brass with rubber inserts or metal clip-on covers

Where PVC joint covers are used with resilient sheeting, the joint must be filled to support the expandable section of the joint cover.

Preventing uneven surfaces is a priority, and every effort must be made to ensure a smooth transition over expansion joints to minimise tripping hazards.

Consult flooring manufacturers for appropriate treatment of expansion joint covers and ensure that these are specified at documentation stage.

5.3. Transition strips, stairs and ramps

Transitions:

The UK National Health Service identified uneven surfaces and changes in level as one of four main causes of “’slip and trip’ accidents in healthcare facilities. (Healey, 2007)

Changes in floor finish often mean a difference in levels of friction or surface resistance, which can lead to falls. It can also result in a slight change in floor level, if the floor finish thickness varies – as is often the case when sheeting meets a tiles floor for example. It is recommended that these transitions do not exceed 5 mm vertically, but a bevelled transition of 5 mm over 100 mm length (minimum) is less likely to cause tripping. Planning and detail design will reduce the risks.

By positioning the transition at a threshold also minimises risk as it is more expected here. Purpose-made cover strips are manufactured to link different types of floor finish and thickness and these should be selected, described at specification stage. These are available in metals, such as aluminium, brass, and stainless steel and these strips are also manufactured from extruded PVC.

In areas where highly sensitive patients (such as spinal surgery patients) are wheeled to theatre, transition strips, or any bumps or ridges, must be avoided as any unnecessary vibration can adversely affect the patient.

Stairs:

Stairways are also an area where trips and falls are more common, and need careful planning in terms of finish. Specifying stair nosing will:

• Provide good slip resistance to the leading edge of the step

• Visually define the step end

• Protect the exposed edge of the finish – irrespective of whether its tile, vinyl or carpet

Stair nosing is available in extruded and ridged PVC-strips, aluminium strips with rubber or carborundum inserts, or purpose-made step tiles with bull-nosed edges and non-slip grooves. Ensure that the treatment of the stair edge does not become a tripping hazard in itself. The stair nosing must finish as near to flush as possible to the finish on the tread itself.

Ramps:

The National Building Regulations give clear parameters for universal/wheelchair access. In addition, the use of wheeled equipment in hospital and healthcare facilities from beds to food trolleys to drip stands, means highvolume use of ramps. The potential for slipping increases due to the gradient. Finishes that provide reasonable slip-resistance are appropriate in this application.

5.4. C5.4 External finishes at entrances

Special attention should be paid to the external areas leading up to all entrances to health facilities bearing in mind that infirm patients will be using this access. At casualty/emergency units, patient drop-off zones, and ambulance bays, there is the additional need for stretchers, wheelchairs and emergency trolleys to be quickly and smoothly wheeled through these entrances. Bevel-edged pavers will add to the effort required to push a trolley over a pavement.

Stormwater grids and manhole covers should ideally not be located on these routes, and non-mountable kerbing or rainwater channels should also be avoided. Ramps and slopes should be suitably treated to avoid slipping in wet weather.

Areas set aside for helicopter landings, and the route from there to the casualty/emergency entrance should also be viewed with these comments in mind.

The properties described in the selection criteria in Section C above have been listed in Table 2 below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility

TABLE 2

FLOOR PROPERTIES PERFORMANCE CATEGORY

1 2 3 4

Smooth   O O

Impervious   O O

Jointless/seamless  O O O

Textured O  O O

Perforated O  O O

Jointed O O O O

Low maintenance    

Washable/easily cleaned    O

Suited to high humidity areas O 

O 

 

Acoustic priority O   

Aesthetic priority O   



Legend/Key:

indicates this property is required for the class

indicates this property is not required for the class

indicates this property is an optional requirement for the class

Examples of flooring materials or finishes for Class 1 (typical area – operating theatre or ward):

• Vinyl sheeting, linoleum sheeting, etc.

Examples of flooring materials or finishes for Class 2 (typical room – passage):

• Vinyl sheeting, linoleum sheeting, rubber sheeting, etc.

Examples of flooring materials or finishes for Class 3 (typical area – dirty utility):

• Vinyl sheeting or tiles, linoleum sheeting or tiles, rubber sheeting or tiles, ceramic tiles, porcelain tiles, etc.

Examples of flooring materials or finishes for Class 4 (typical area – office or waiting room):

• Vinyl Sheeting or tiles, linoleum sheeting or tiles, rubber sheeting or tiles, cork tiles, ceramic tiles, porcelain tiles, laminated flooring, carpets, etc.

Examples of flooring materials or finishes for Class 5(typical area – plant room):

• Epoxy paints, rubber sheeting or tiles, etc.

Refer to Table 3 Matrix of recommended floor performance categories to establish what performance category the floor of the room in question will require.

2. Performance categories recommended per room

TABLE 3 MATRIX OF RECOMMENDED FLOOR PERFORMANCE CATEGORIES

Department Room Name Floor Performance

1 2 3 4 5

Acute In-Patient Wards (Adults) Circulation Space     

Cleaners Room     

Consulting Room     

Day Lounge (patients)     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

General Ward (single or multi-bed)     

Isolation Ward     

Kit Room     

Linen Room     

Office     

Patient ablutions     

Patient Assisted Ablution     

Staff Ablutions     

Staff Change Room     

Staff Rest Room     

Surgical Sundries Store     

Treatment Room     

Waiting area (public)     

Ward Kitchen     

Ward Nurse Station     

    

Administration Department Circulation     

Cleaners Room     

Offices/ interview rooms     

Reception     

Boardroom     

Stores     

Kitchenette     

Records Room     

Print room     

Staff WC’s     

Waiting area (public)     

    

Casualty & Trauma Circulation     

Cleaners Room     

Consulting Room     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

Hazmat Shower     

Minor Theatre / Suture Room     

Observation Area     

Office     

Patient ablutions     

Department Room Name Floor Performance

1 2 3 4 5

Patient Assisted Ablution     

POPS Suite     

Public WC’s     

Reception/ Nurse Station     

Rehydration Area     

Resuscitation Area     

Scrub area     

Staff Ablutions & Ablutions     

Staff Rest Room     

Surgical Sundries Store     

Waiting area (public)     

    

Central Sterilising & Supply Department (CSSD) Dirty Utility     

Chemical Store     

Circulation     

Cleaner's Room     

Dirty Linen     

Office     

Packing     

Plant Room     

Staff Change Room     

Staff Rest Room     

Staff WC’s     

Sterile Storage     

Sterilization (Autoclaves)     

Trolley Wash     

Washing & Disinfecting Area     

    

Community Health Centre Circulation     

Cleaners Room     

Consulting Room     

Delivery Room     

Dental Surgery     

Dirty Utility Room (Sluice)     

Dispensary     

Duty Room     

Equipment Store     

Guard House or Security Kiosk     

Isolation/ Separate Nursing Ward     

Linen Store     

Observation Area     

Office     

Off-Loading or Holding area for Pharmacy     

PABX / Server Rooms     

Patient ablutions     

Patient Assisted Ablution     

Pharmacy     

Plant Room     

POPS Suite     

Public WC’s & change rooms     

Reception/ Nurse Station     

Records Room     

Recovery Area     

Rehydration Area     

Department Room Name Floor Performance

1 2 3 4 5

Resuscitation Area     

Staff Ablutions     

Staff Change Room     

Staff Rest Room     

Surgical Sundries Store     

Treatment Room     

Trolley Bay (entrances)     

Ultrasound Room     

Ward     

Waiting area (public)     

X-Ray Room     

    

Day Clinic (Department) Circulation Space     

Cleaners Room     

Consulting Room     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

General Ward (single or multi-bed)     

Kit Room     

Linen Room     

Office     

Operating Theatre     

Patient ablutions     

Patient Waiting     

Recovery Area     

Scrub Area     

Setting Area     

Staff Ablutions & Change Room     

Staff Rest Room     

Surgical Sundries Store     

Treatment Room     

Waiting area (public)     

Ward Kitchen     

Ward Nurse Station     

    

Dental Unit (Dept) Circulation Space     

Cleaners Room     

Consulting Room     

Dental Surgery     

Dirty Utility Room (Sluice)     

Equipment Store     

Panoral Room     

Patient ablutions     

Reception / Office     

Records Room     

Staff Ablutions     

Staff Rest Room     

Surgical Sundries Store     

Waiting Area (Public)     

    

High Care or Cardiac Care Unit (HC / CCU) Circulation     

Cleaners Room     

Dirty Utility     

Duty Room     

Department Room Name Floor Performance

1 2 3 4 5

Equipment Store     

Isolation Ward     

Linen Room     

Nurse Station     

Open Ward Area     

Patient Ablutions     

Staff Change Room     

Staff Rest Room     

Staff WC’s     

Surgical Sundries Store     

Ward Kitchen     

    

Intensive Care Unit (ICU) Circulation     

Cleaners Room     

Dirty Utility     

Duty Room     

Equipment Store     

Isolation Ward     

Linen Room     

Nurse Station     

Open Ward Area     

Patient Ablutions     

Staff Change Room     

Staff Rest Room     

Staff WC’s     

Surgical Sundries Store     

Ward Kitchen     

    

Kitchen – (Main Hospital) Bulk Dry Goods Store     

Chemical Store     

Cleaner's Room     

Cold Room/Freezer     

Cooking Area     

Cutlery/Crockery Store     

Dishwashing & Potwashing Area     

Food Preparation Area     

Office     

Plating /Serving Area     

Receiving Area     

Staff Ablutions     

Staff Rest Room     

Trolley wash area     

    

Laboratory

(Pathology/Cytology/Haemato logy/ Chemistry)

(Biosafety Level 2)

Blood and blood products store     

Cell and Tissue Laboratory     

Cytopathology Sample storage     

Clinical material store     

Disposal area (dangerous materials)     

Drug & Vaccines Store     

Flammable goods store (external)     

Gas Cylinder & Pressure Vessel store     

Hazardous substances store     

Histopathology Laboratory     

Microbiology Laboratory     

Department Room Name Floor Performance

1 2 3 4 5

Laboratory

(Pathology/Cytology/Haemato logy/ Chemistry)

(Biosafety Level 2)

Offices     

POCT consulting room     

Reagents / Chemical Stores     

Records Rooms     

Sample Collection laboratory     

Specimen Reception & Sorting rooms     

Stores (protective clothing/equipment)     

Staff Ablutions     

Staff Change Room incl. lockers     

Staff Rest Room     

    

Laundry – (Main Hospital) Assembly, packing and dispatch     

Chemical Store     

Circulation     

Cleaners Room     

Office     

Pressing     

Sorting     

Staff Ablutions     

Staff Rest Room     

Stores     

Washing Room     

    

Maternity / Delivery Department Baby bathing area     

Circulation     

Delivery Suite     

Dirty Utility Room     

Duty Room     

Equipment Store     

First Stage Room     

Kit Room     

Linen Store     

Milk Kitchen     

Nurse Station     

Nursery     

Patient Ablutions     

Staff Change room     

Staff Rest Room     

Staff WC’s     

Surgical Sundries Store     

Viewing Area     

Waiting Area     

Ward Kitchen     

Wards     

    

Mental Health Facility Body Room     

Children's Play Area     

Clean Utility     

Cleaner's Room/ Station     

Consulting Room     

Counselling Room     

Dirty Linen     

Dirty Utility (Sluice)     

Department Room Name Floor Performance

1 2 3 4 5

ECT procedure room     

En Suite bath/shower room     

Equipment Store     

Group Therapy Room     

Gymnasium (OT & Physio)     

IT Room     

Kit Room     

Linen Store     

Medicine Store     

Multi-Purpose Hall     

Nurse Station     

Office     

Patient Assisted Bathroom/Shower     

Patient Dining room     

Patient Laundry     

Patient Lounge     

Pharmacy     

Quiet Room     

Records Room     

Seclusion Room     

Security Control Room     

Security Search Room     

Staff Change Room & WC’s     

Surgical Sundries Store     

Treatment Room     

Wards     

Ward Kitchen     

Waste Disposal Room     

    

Mortuary Blue Room     

Circulation space     

Cleaner’s Room     

Dirty Utility     

Instruments Room     

Linen Room     

Medical Observation room     

Office     

Pathologist Change Room     

Post-Mortem Room     

Staff Change Room     

Staff WC’s     

Viewing Room     

Visitor’s Waiting Room     

    

Neo-Natal Intensive Care Unit

(NNICU) Circulation     

Cleaners Room     

Dirty Utility     

Duty Room     

Equipment Store     

Incubator Ward Area     

Isolation Ward     

Linen Room     

Milk Kitchen     

Mother’s Rest Area     

Nurse Station     

Department Room Name Floor Performance

1 2 3 4 5

Staff Change Room     

Staff Rest Room     

Staff WC’s     

Surgical Sundries Store     

    

Operating Theatre (Dept.) Circulation     

Cleaners Room     

Dirty Utility     

Duty Room     

Equipment Store     

Nurse Station     

Operating Theatre     

Post-Operative Recovery Area     

Pre-Operative Holding Area     

Scrub-up Area/Room     

Setting Room     

Staff Change Room     

Staff Rest Room     

Staff WC’s     

Surgical Sundries Store     

    

Outpatients Department Reception / Nurse Station     

Admissions Room     

Baby Changing area     

Children’s Play / waiting     

Circulation     

Consulting Room     

Dirty Utility Room     

Duty Room     

Equipment Store     

Kitchenette     

Linen Store     

Offices     

POPS Room     

Public Ablutions     

Records Room     

Staff Ablutions     

Staff Change room     

Staff Rest Room     

Surgical Sundries Store     

Treatment Room     

Waiting Areas (public)     

Wheelchair Storage area     

    

Paediatric Ward Child Assist Ablution     

Circulation Space     

Cleaners Room     

Consulting Room     

Dirty Utility - Isolation     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

General Ward (single or multi-bed)     

Isolation Ward     

Kit Room     

Department Room Name Floor Performance

1 2 3 4 5

Linen Room     

Milk / Ward Kitchen     

Nurse Station     

Office     

Parent Ablutions     

Play Area (patients)     

Staff Change Room     

Staff Rest Room     

Staff WC’s     

Surgical Sundries Store     

Treatment Room     

    

Pharmacy/ Dispensary Cleaner’s Room     

Bulk Stores     

Circulation space     

Counselling Cubicle     

Dispensary     

Liquid filling Room     

Office     

Off-Loading Bay     

Patient Waiting Room     

Schedule Drugs Strong Room     

Staff Change Room     

Staff WC’s     

Tablet Packing Room     

Vacolitre Stores     

    

Physiotherapy Department Audiology Testing     

Circulation     

Consulting Room     

Equipment Store     

Gymnasium     

Kitchenette     

Occupational Therapy room     

Patient Ablutions     

Reception     

Speech Therapy     

Staff Rest Room     

Staff WC’s     

Treatment room     

Waiting Area     

    

Primary Health Clinic Circulation     

Cleaners Room     

Consulting Room     

Delivery Room     

Dirty Utility Room (Sluice)     

Dispensary & Pharmacy     

Duty Room     

Equipment Store     

Guard House or Security Kiosk     

Linen Store     

Observation / Rehydration Area     

Office     

Public ablutions     

Department Room Name Floor Performance

1 2 3 4 5

Plant Room     

POPS Suite     

Reception/ Nurse Station     

Records Room     

Staff Ablutions & Change Room     

Staff Rest Room     

Surgical Sundries Store     

Treatment Room     

Trolley Bay (entrances)     

Waiting area (public)     

    

Radiology (Diagnostic) Bucky Room (general x-ray rm)     

Change cubicles     

Circulation     

Cleaners Room     

CT / MRI Scan Room     

Dirty Utility / Sluice     

Fluoroscopy Room     

Fluoroscopy Control Room     

In-patient waiting     

Kitchenette     

Linen Room     

Mammogram Room     

Office     

Patient ablutions     

Public waiting Area     

Porters & wheelchair/trolley parking     

Reception     

Records room     

Server Room     

Staff Rest Room     

Staff WC’s     

Stores (Equipment/ General)     

Ultrasound Room     

Telemedicine Room     

Viewing Room/ CR Room/ Reporting area     

    

Nurses Residence Ablutions     

Bedrooms     

Circulation     

Kitchenette     

Lounge     

Offices     

Public Ablutions     

Reception     

Stores     

Waiting Areas (public)     

    

DEFINITIONS

1. Terminology

Aggregation Collected together from different sources and considered a whole.

Ambulant/Ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.

Bacteriostatic A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.

Bariatric Describing the condition of obesity.

Bonded Chemically attached or fused in layers.

Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.

Heterogeneous Consisting of various layers or types throughout.

Homogenous Consisting of things of similar type throughout.

Hydrophobic Water-repellent.

Hygroscopic Readily absorbing moisture from the atmosphere.

Impervious Not allowing passage through (usually of water/moisture).

Interstices Small holes or perforations.

Jointed Junctions which may be open or covered, but not completely sealed and smooth.

Jointless Without joints or having joints which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.

Olfactory Relating to the smell or the sense of smell.

Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.

Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.

Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed. Resilient flooring refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.

Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.

Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the

material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail.

Smooth surface A flat surface without projections, indentations or perforations such as a brushpainted plastered surface.

Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.

Tufted A group of threads drawn through a fabric and tied securely beneath the surface.

Vitrified To change a material into glass, under high heat and other conditions.

Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.

Washable

A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.

2. Abbreviations

CCU Cardiac Care Unit

CHD Center for Health Design

CSSD Central Sterilising and Supply Department

EN European norms

ENT Ear, nose and throat

HAI Healthcare-associated infections

HC High care

HDF High-density fibreboard

IAQ Indoor air quality

ICU Intensive Care Unit

IEQ Indoor environmental quality

IUSS Infrastructure Unit Systems Support

MDF Medium-density fibreboard

MRSA Methicillin-resistant staphylococcus aureus, (a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria

NDoH National Department of Health

NICU Neonatal Intensive Care Unit

NRC Noise reduction coefficient

OHS Occupational health and safety

OoM Order of magnitude

PMIS Project Management Information System

PMSU Project Management Support Unit

PuR Polyurethane-resistant

PVC Polyvinylchloride

RC Recommendation Committee

STF Slips, trips and falls

TNO Netherlands Organization for Applied Scientific Research

VOC Volatile organic compound

REFERENCES

1. Bibliography

Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

Cement & Concrete Institute (CCI), 2009. Sand-cement screeds and concrete toppings for floors. [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. Floor coverings in healthcare buildings. (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Department of Health (DH), 2010. Core elements: Health Building Note 00-03: Clinical and clinical support spaces. UK: DH.

Department of Health (DoH), 1980. Regulations governing private hospitals and unattached operating theatres. (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Gateway Review, Estates & Facilities Division, 2011. Performance requirements for building elements used in healthcare facilities. (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes. Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. Sound practices: Noise control in the healthcare environment. (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. Healthcare environmental terms and outcome measures: An evidence-based design glossary. Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. Applied and Environmental Microbiology, 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, 18th CIB World Building Congress: Facilities management and maintenance. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. Achieving EBD goals through flooring selection & design. [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. Health Technical Memorandum (HTM) 56: Building component series: Partitions. UK: TSO.

NHS Estates, 2005. Health Technical Memorandum (HTM) 60: Ceilings. 2nd ed. UK: TSO.

NHS, National Services Scotland, 2006. Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring. Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2006. Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring. Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning. (Version 3). Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. The role of hospital design in the recruitment, retention and performance of NHS nurses in England. (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. Health Building Note 04-01: Adult in-patient accommodation. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. The Science of the Total Environment, 227(1999), pp.197-213.

2. Websites: Further reading

<nowiki>https://www.transparency.perkinswill.com</nowiki> <nowiki>http://www.gatech.edu</nowiki> <nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki> <nowiki>http://www.green-buildings.com</nowiki> <nowiki>http://www.healthcaredesignmagazine.com</nowiki> <nowiki>http://www.carpet-rug.org/documents/technical-bulletins</nowiki> <nowiki>http://www.amorimcork.co.za</nowiki> <nowiki>http://www.wicanders.com</nowiki>

<nowiki>http://envirocork.co.za</nowiki> <nowiki>http://www.building.co.uk</nowiki> <nowiki>http://www.floorworx.co.za</nowiki> <nowiki>http://www.flowcretesa.co.za</nowiki> <nowiki>http://www.polyflor.co.za</nowiki> <nowiki>http://www.belgotexcarpets.co.za</nowiki> <nowiki>http://www.vandykcarpets.com</nowiki>

3. PHOTOGRAPHIC AND ILLUSTRATION CREDITS

Cover photo: C. Hudson

Fig.1 to6 M. Swinney

Fig.7 G. Abbott- CSIR

Fig.8 R. Cubbin based on Life cycle Floor Cost Table – by Nora®, USA

Fig.9 M. Swinney

Fig.10 R. van Rensburg

Fig.11 to13 M. Swinney

Fig.14 R. van Rensburg

Fig.15 R. van Rensburg

Fig.16 M. Swinney

Fig.17 R. Cubbin

Fig.18 C. Hudson

Fig.19 C. Hudson

Fig.20 to26 M. Swinney

Fig.27 R. van Rensburg

Fig.28 to 36 M. Swinney

Fig.37 to 38 R. Cubbin

Fig.39 to 40 M. Swinney

Fig.41 R. Cubbin

Fig.42 R. van Rensburg

Fig.43 M. Swinney

Fig. 44 R. Cubbin

Fig.45 R. van Rensburg

Fig.46 M. Swinney

Fig.47 R. van Rensburg

<br />
[[Category:Crosscutting Issues]]

Materials and finishes - Internal Wall Finishes

2020-10-22T14:39:25Z

VSadiki:

CONTEXT

1. Overview – Finishes in the healthcare environment

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 accounts for 32% of the initial budget. Maintenance and cleaning of finishes adds 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 healthcare environment,

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

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)

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 it is a 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 paid MORE MEN WERE DYING FROM SMALL WOUNDS

AND DISEASES THAN FROM MAJOR TRAUMAS to creating a caring atmosphere.

ON THE FRONTLINES. BUT AS SOON AS GERM

It is this paradigm shift that is required when THEORY WAS DEVELOPED A WHOLE NEW considering and selecting finishes. The role of finishes in PARADIGM, A BETTER WAY OF UNDERSTANDING

WHAT WAS HAPPENING MADE DRAMATIC

a healthcare facility has become as important an aspect SIGNIFICANT MEDICAL IMPROVEMENT

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 forms 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.

• Internal Ceiling Finishes

• Joinery and Storage Systems (to follow)

• Doors and Ironmongery (to follow)

• Sanitary Ware (to follow)

• Signage and Way-finding (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’ wall 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 wall 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, which indicates the most relevant performance category. The guide also examines various protection types to walls, including bump-rails and corner protection.

3. Policy context

This document offers guidance on the selection of appropriate wall 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 the following:

• 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 February 1980 (updated March 1993) Regulation pertaining to control of private hospitals, (revised 5 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. Furthermore, the South African National Standard (SANS) 10400 addresses numerous aspects

involving materials and finishes. (Refer specifically to Parts J and T.) Current SANS applicable are as follows:

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, Rev. August 2004

PART B - SELECTION CRITERIA

1. Scope

Healthcare facilities are complex buildings with spaces varying from general offices to highly specialised treatment areas. Each of these spaces has a specific need in terms of how the wall finishes should perform and how they can affect the perceptions and comfort of the user. Of the three dimensions of wall, floor and ceiling, the walls are most likely to be touched by the occupants, making them an important factor in terms of infection control. These and other criteria are discussed in more detail under selection criteria (Section C).

The healthcare environment is increasingly becoming a ’wheeled‘ environment, with everything from patients to equipment being moved on wheeled chairs, beds or trolleys of some kind. The wall finishes should be able to resist the accidental impact of trolleys and other objects. This is achieved by the inclusion of wall protection at strategic points. This guide examines the range of protection types available, and the advantages and disadvantages of their applications in the healthcare

setting.

The type and scope of activity in a space is one of the main factors that

govern the selection of wall finishes in a healthcare facility.

(Onaran, 2009)

The following three basic categories of wall finishes should be considered:

1. Liquid applied coverings

This includes paints such as PVA and enamel.

2. Flexible coverings

This includes vinyl cladding, linoleum, cork, carpet or wallpaper.

3. Hard, pre-formed finishes

This includes timber panels, ceramic and porcelain tiles, and the use of glass/glazed panels.

Each wall finish has different applications, resultant benefits and disadvantages. The various characteristics would need to be weighed against the functions of the various rooms within a healthcare facility.

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 that covers the following:

• Embodied energy of materials

• Life cycle costing and sustainability

• Toxicity and the 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 the following:

• Harvesting/mining of the raw material

• Processing the material

• Manufacturing the product

• Transporting/delivering 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

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).

Buying locally produced materials is an easy and achievable way to lower the embodied energy of a building. The table below gives an indication of the embodied energy of various typical building materials. Embodied energy of common wall finishes (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 increasingly aim at reducing embodied energy and the carbon footprint in the manufacture of their products. This is driven by the market demand and designers can contribute by choosing materials that support green initiatives in this regard.

2.2. Lifecycle 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 lifespan. 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 lifespan costs – emphasising the importance of life cycle costs. Sustainability should be considered in all four stages of product life:

2.3. Toxicity and effects on indoor environment quality

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 the environmental performance of a building and/or materials. By improving the IEQ, the wellbeing of the occupant is protected.

IEQ is measured in terms of the following:

• 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 polyvinyl-chlorides can emit VOCs (gasses) when finishes are new and then reduce over the lifespan of the product. Sealants and adhesives also give off VOCs, thus having a negative effect on indoor air quality.

VOCs can cause irritation and odour annoyance and could lead to behavioural, neurotoxic, hemotoxic and genotoxic effects (Meininghaus et al., 2000;

Hoskins, 2003; Hodgson et al., 2000).

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound.

When considering the toxic impact on the environment in which the wall finish will be installed, the finish as a whole (complete with sealants, substrate material and adhesives) must be taken into account.

Another important aspect to consider is the use of nontoxic materials in mental health facilities, where

patients are prone to chew and ingest any material that can be uplifted off surfaces, from paint to flooring.

Every effort must be made when specifying materials and finishes in these facilities to ensure that materials and their junctions are well secured and cannot be peeled back or picked off by patients. The toxicity of the material and/or content should be carefully considered to ensure it is appropriate for its location. The specifier should clarify the toxic content with manufacturers to ensure that these materials are safe and fit for this purpose.

3. 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 the priorities in designing health facilities.

Extensive research by The Center for Health Design (CHD) FIGURE 5

Research Coalition on evidence-based Design 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 soundabsorbing 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; and 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).

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

cleanability, resistance to moisture and

reducing the risk of fungal

• 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).

An overview of these studies identified the following selection criteria:

• 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.

4. Selection criteria

4.1. 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 wellbeing 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.

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 the 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 on 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 finish. The second is the ability to clean the finish, which is discussed in the next section.

The Center 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 carpets acted as a

reservoir for fungi and bacteria.

Lankford et al. (2006) examined different wall finishes after inoculation with Vancomycin-resistant Enterococci (VRE) and compared the results after seven days. The types of wall finishes tested included latex-based paint, enamel paint, vinyl, micro-perforated vinyl (with paper backing) and textured wallpaper. The report showed that all finishes still harboured some VRE pathogens that could be transferred through hand contact. The wallpaper and micro-perforated vinyl (used for printing large-scale wallpaper graphics) showed no reduction at all, indicating that the pathogens were harboured by these finishes. After cleaning and disinfection, results showed that latex paints did not clean as well as enamel paints.

In order to keep wall finishes from transmitting harmful bacteria, they should be easy to clean and able to withstand

repetitive wear and frequent germicidal decontamination, and have the ability to repel moisture

(Lankford et al., 2006).

The selection of finishes is still strongly linked to adequate cleaning and disinfection routines, and the location

of the finish in terms of its performance. Notwithstanding, it is recommended that perforated finishes be avoided where patients are at greater risk of infection. Below is a table adapted from New South Wales Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Nosocomial infections can be acquired in hospitals, nursing homes, rehabilitation centres and extended care facilities. Especially susceptible patients are immuno-compromised patients, the elderly and young children. These infections can be caused by unclean or non-sterile environmental surfaces.

Wall finishes that resist the spread of infection have qualities that can be summarised as follows:

• Smooth

• Impervious

• Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, wall finishes have the following properties:

prevented from multiplying. For cleaning to be effective, the finish must be able to withstand regular and fairly vigorous cleaning.

Sufficient access to all areas of the finish or adversely the absence of any inaccessible gaps, voids and joints is of critical importance to prevent breeding areas for bacteria, etc.

A further aspect to consider is the level of disruption required to clean walls regularly. While textile finishes can reduce cold and institutional environments, they would be totally unsuitable in areas with a high infection control risk and a high incidence of soiling. It is also important for the paint or wall finish manufacturer to convey the cleaning and maintenance requirements to the end-user or institution for product guarantees to remain.. An effective cleaning regime is the primary means of defense in terms of controlling infection.

Wall finishes that are easily cleaned and have low dirt retention can be summarised as follows:

• Low maintenance

• Washable

4.3. Fire safety

The South African National Standard (SANS) 10400 lists specific requirements for hospitals and medical facilities with regard to the classification of internal finishes, irrespective of whether the area is sprinklerprotected or not. These materials are to achieve a Class 2 rating when tested in accordance with SANS 10177-3. The exceptions are the emergency routes where Class 1 is required.

Note that these requirements are not room-specific, and are therefore considered a global requirement in the overall building, rather than for an individual space. The specifier would need to consult the fire regulations applicable to the building type and confirm that the products meet these requirements. The definitions in SANS 10400: Part A read as follows:

E2 Hospital: Occupancy where people are cared for or treated because of physical or mental disabilities and where they are generally bedridden.

E3 Other institutional (residential): Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

E4 Healthcare: Occupancy which is a common place of long-term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

The requirements for finishes are set out in Part T of SANS 10400, and include the following: bathing or food preparation. These rooms generate more moisture than others, and as a result require moisture-resistant finishes. If the wall finishes are hygroscopic, these finishes can be prone to mildew and

mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus (Hodgson et al., 2000).

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in

the air, which can affect the health of people. Where this is a requirement in wall finishes, this property is listed as:

High humidity

High humidity is considered as 25–100% relative humidity over an air temperature range of 10–30°C. A suitable finish should be able to withstand sustained contact with water vapour/water in these conditions.

(Normal conditions would be considered as 25–65% relative humidity over air temperature range of 20–25 °C).

(National Health Services Health Technical Manual HTM56: Partitions)

Emissions from materials

As discussed under environmental aspects, the kind of wall finish installed can affect the environmental quality of the interior if VOCs are given off – commonly referred to as off-gassing.

These VOC emissions can be given off by:

• the product itself;

• the adhesives used to fix the product (for example, in the case of vinyl cladding or tiles);

Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space (Mortenson et al., 2005).

• the sealants/grouts used to finish; and

• the cleaning solutions required for regular maintenance.

The smell of the interior of a new car – enjoyed by many – is an example of plasticisers that have evaporated (emissions that affect the indoor air quality). Various methods for measuring VOCs have been developed since the increase in awareness of these emissions and their influence on indoor air quality. The Green Building Council of South Africa awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the indoor environmental quality (IEQ) levels as outlined.

The IEQ14 section measured the formaldehyde minimization, which is common with composite wood products. In addition, the MAT-7 section recognises the reduction of PVC products in the building materials used.

It should be noted that primary VOCs decline quickly in the short term (less than one year), while secondary emissions can continue for the lifespan of the product, and should also be kept in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.

Patients with respiratory weaknesses such as asthma are most likely to be

affected by VOC emissions. High-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility.

However, the ‘order of magnitude’ should also be applied when using low VOC emissions as a criterion to select finishes. The use of vinyl sheeting, for example, may result in higher VOC emissions than, for example, ceramic tiles, but the infection control benefits of the seamless finish of the vinyl will outweigh the risks of VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC-emissions issues.)

The achievement of low VOC emissions should be a global criterion for a healthcare building rather than for one or more specific rooms, hence a separate criterion has not been listed for this item. More details on the VOC emissions of the individual wall finish types are provided in Section C.

4.5. Acoustics

Noise in health facilities is mainly generated by the following:

• Impact sounds, for example, pedestrian and wheeled equipment, • bedrails moved up and down, doors closing and opening, footfalls, etc.

• Airborne sounds, for example, talking, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that the average (continuous level equivalent, LAeq) daytime hospital noise levels have risen from 57dBA in 1960 to 72dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (HermanMiller Healthcare, 2006). An average motorcycle noise level measures 85 dB. The World Health Organization recommended an LAeq value of 30 dBA for ward areas.

“People who work in noisy environments for long shifts day in and day out, also have similar

stress-induced experiences. They

report everything from exhaustion to burnout, depression and irritability.”

S. Mazer –

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November 2005, showing that chronic noise increased the risk of heart-attacks in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the

nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.

Long straight passages are perfect echo corridors, often amplifying noise levels. Disturbances in the sound path help limit the sound transmission by, for example, creating steps in the ceiling level or changing direction in the passageways.

According to Cmiel, et al. (2004), noise levels can reach those similar to jackhammer levels at nurses’ stations during shift changes Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy (where feasible) as sound intensity decreases with distance, provided that the room dimensions and surfaces are designed so that there is very little reverberation.

Wall finishes that absorb sound, or at least do not contribute to noise levels,

used in conjunction with sound-absorbent ceiling finishes should be used in key areas such as nurse restrooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction is rated as a high requirement (for example, ICU and general wards), this factor would be listed as “High acoustic”

4.6. Aesthetics

Research results from CABE, 2004 and 2005, King’s Fund, 2004, and Leather, Beale and Lee, 2000, all highlight the need for an integrated, holistic and sympathetic hospital aesthetic. Tofle et al. (2004) also emphasised the role of colour in healthcare environments. Key results show that the architectural setting, including finishes, has an effect on the patient’s experience, as well as the recruitment and retention of staff – a happy staff is more motivated to care for patients, who in turn recover more quickly. Paediatric wards particularly give an opportunity to set a playful scene and help young patients feel at ease. In public areas, more emphasis may be required for an attractive and welcoming interior.

Coloured and vinyl wallpaper can be used to good effect in passageways and public areas to set anxious patients at ease and create a cheerful atmosphere.

Colours and patterns can be used in wall finishes in health facilities for the following practical and aesthetical purposes:

• To improve the ‘institutional/cold’ interior look of the facility, room or area

• To be used for wayfinding, for example, colour-coding each department

• To create ’spaces’ by giving individuality to a specific area within a large open area

However, the following is to be considered:

• Excessive combination of colours and patterns is inappropriate in certain areas/rooms such as operating theatres.

• Some patterns and colours could impact negatively on certain patient groups, for example, the elderly or mentally ill.

• The wall finish must be adaptable should the space usage result in the need to change the aesthetics.

Where aesthetics is a primary requirement, this factor will be listed as:

• High aesthetics

PART C - TECHNICAL INFORMATION – WALL FINISH TYPES

1. Liquid coverings

The quality of the wall finish (especially with liquid finishes such as paint), are only as good as the quality of the substrate. A poor quality plaster will not only affect the aesthetics, but also the integrity of the smooth impervious finish. Plaster cracks will be carried through almost all paints, and any crack can become a reservoir for bacteria. Bonding liquids could be used to some extent, but due to poor plaster sands and a lack of plastering skills, it is recommended that double plaster or skimming to finish a plastered wall be specified at the outset. (If the first plaster skin is approved, the second coat could be omitted.)

1.1. Paint (emulsion or oil-based)

• General description and properties

Paint is easily applied by a roller to a plastered wall surface. Following a primer and undercoat, three coats of paint are usually applied. Two-coat plaster is especially recommended where enamel paints are used, as any defects will be highlighted with these highgloss type paints.

“Wall finishes do change, due to changes in management or taste,

and it is usually the first surface to be ’replaced’ or changed.”

(Vittori, 2002)

Paint types include emulsion paints which are water-based and produce a matt or silk effect – such as PVA. Oil-based paints like enamel dry to a hard, glossy finish that is impervious to water.

Paint is fairly inexpensive when compared to other wall finishes. FIGURE 14

Infection prevention

The seamless finish produced by painted plaster makes this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Any mechanical damage can, however, lead to small cracks, and it is important to protect vulnerable areas. This is discussed in more detail under ‘Protection’. Studies have shown that PVA can be degraded by filamentous fungi, such as algae, yeasts, lichens and bacteria (Cappilelli and Sorlini, 2008). Paints with mould inhibitors and nano-technology enhancements are available on the market. Oil-based paints are more suited to areas that require high infection prevention criteria as the surface is impervious to water, oil and other fluids.

Cleaning and maintenance

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant or impervious and therefore not suitable in treatment areas. Paint is a low maintenance finish that requires re-application every few years (more often if mechanical damage occurs). Special attention should be given to the placement of switches and sockets in walls, as these areas are regularly touched, and can become infection-control risk areas if not kept clean. The smoother the surface, the easier it is to clean.

Fire safety

Paint is considered a non-combustible finish as the thickness of the paint is usually less than 0.5 mm. Refer to the manufacturer’s specifications and consult with SANS Part T to check the compliance and fire-resistance.

Indoor air quality: Humidity

Paints are generally not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Oil-based enamel paints are more resistant to moisture when compared to water-based PVA-type paints, and are therefore more suitable in wet or humid environments.

Indoor air quality: Emissions

The strong odour of a newly painted room is an indication of the high VOC emissions. Low-odour paints are marketed by manufacturers, and products with reduced or zero VOCs are being produced. Due to the increasing range of products and suppliers, the level of emissions should be checked with the manufacturer (refer to product-specific literature).

Acoustics

The hard surface of painted walls reflects sound and does not contribute to the impact of noise reduction or absorption. Where acoustics is a priority in a room or facility, other sound-absorbing products and finishes should be combined with the painted walls to achieve improved acoustics.

Aesthetics

Paint is available in an extensive range of colours, and this is one of the great advantages of using paint. It provides a flexible means of adapting a space to suit the function of the room – from calming colours in a staff restroom, to cheerful and inviting colours in a doctor’s waiting room.

The effect of colour on healing has been well documented by Tofle et al. (2004).

Colour can also be used for the coding of areas – to demarcate different departments or floors of a multistorey building. It can be effective in establishing zones for public and staff use. Paint can also be used to introduce colour for features or emphasis.

Private sector health facilities often make use of colourbranding for their facilities, and the use of specific combinations of colours becomes identifiable with the brand.

In public health facilities, the support of the Department of Health in the use of colour in this regard is paramount, as historically, decisions about colour have been based on ease of maintenance and whether new paints can match existing colours.

The colour codes and type of paints should always be included in the as-built documents to assist managers to obtain the correct paint.

1.2. Epoxy coatings

General description and properties

There are two main types of epoxy coatings – water-borne and solvent-borne coatings. Both types have improved properties compared to water- or oil-based paints, including the following:

• Chemical and abrasion resistance

• Outstanding adhesion to a variety of substrates

• Excellent toughness, hardness and flexibility

• Superior dimensional stability

• Heat resistance

Water-dispersed epoxy coatings are resin-based wall coatings of between 0.3 and 0.5 mm thick. A primer or pore-filler coat is first applied to smooth plaster, followed by two coats of epoxy wall coating applied with a roller. This creates an impermeable seal on the wall surface with a gloss finish.

The use of water in lieu of solvent in the coating means less hazardous material for the environment, and reduced odours/fumes.

Solvent-borne epoxy paints are more economical, but should not be exposed to extensive sunlight as this leads to chalking and degradation. The solvent-based epoxy coating is also toxic when wet, unlike the water-borne version, but once dry, the solvent-borne epoxy coating is also non-toxic. Special precautions need to be taken when applying this product. Primers are also required, and solvent-based epoxy coatings can be applied with a roller, brush or airless spray.

Infection prevention

The water-borne epoxy resin coatings have been tested under ISO 14644, which classifies different materials according to their cleanliness in terms of the particle and airborne molecular contaminants that are emitted or released by the finished product. This is critical in industrial environments where optical or electronic goods are manufactured, or where food is processed. Water-dispersed epoxy resin wall coatings are one such product that satisfies the criteria and is approved for use in ‘cleanroom’ settings.

Cleaning and maintenance

The impermeable finish is smooth and non-porous, making it easy to clean, highly washable, durable and stain resistant. Colour variation in different batches of solvent-based epoxy coatings is expected.

Fire safety

Since the epoxy finish is less than 0.5 mm, it is considered a non-combustible finish (once dry). Refer to the manufacturer’s specifications, and consult with SANS Part T to check compliance and fire-resistance.

Indoor air quality: Humidity

Epoxy coatings have good water-resistance and are suitable for use in moist/humid areas as the finish is hydrophobic and prevents the ingress of moisture.

Indoor air quality: Emissions

Solvent-borne epoxy coatings produce a strong odour in a newly painted room, unlike water-dispersed epoxy coatings. The development of water-dispersed epoxy coatings has been hastened by the move away from VOC emissions in paints to meet air quality standards.

Acoustics

The hard surface of epoxy-painted walls reflects sound and does not contribute to the impact of noise reduction or absorption. Where acoustics is a priority in a room or facility, other sound-absorbing products and finishes should be combined with the painted walls to achieve improved acoustics.

Aesthetics

Epoxy coatings are available in a muted range of pastel colours. Although the colour range and variety is more limited than regular paints, the comparative expense of epoxy coatings usually means it is used for its superior performance properties, and less likely for its aesthetics.

2. Flexible sheeting

Vinyl wall cladding, as in the case of vinyl floor sheeting, is manufactured from a combination of vinyl resin and various additives, such as the following:

• Plasticisers – used to make the sheet more flexible.

• Stabilisers – to minimise degradation and discoloration.

• Pigments – for colours and patterns

• Fillers – such as lime or other locally available material

Vinyl cladding is generally 1.25 mm thick, but sheeting that is 2 mm in thickness can also be used. Depending on the manufacturer, it is supplied in 1.2 m- or 2 m-wide rolls. Vinyl cladding is sometimes used as a dado cladding in passageways or high-traffic areas due to its durable, resilient and impervious finish.

Vinyl cladding can be supplied with a specialised polyurethane-resistant (PUR) surface treatment. This coating improves resistance to staining and cleaning chemicals and supports indentation recovery.

Infection prevention FIGURE 18

Vinyl sheeting, as a material, has been found to inhibit the growth of

bacteria, and particularly Methicillin-resistant Staphylococcus aureus (MRSAs). The welded joints prevent dust or dirt from congregating in areas that are difficult to clean, and the integral skirting supports this seamless appeal. This has made vinyl sheeting very suitable for use in healthcare facilities. However, the adhesives behind the cladding are important for the success of this wall finish from an infection-prevention aspect, as any lifting away from the wall or failure in the application of the adhesive will create voids in which bacteria or insects can breed. If the wall is mechanically damaged in any way, even the finest of cracks will provide the access needed to these voids. Ends should be well sealed and any area at risk of being damaged should be protected. Refer to the section on bump-rails and protection.

Cleaning and maintenance

The cladding is easily washed, which contributes to its performance as a hygienic wall finish. Vinyl cladding is not easily damaged, and when treated with a polymer dressing/surface treatment, is low-maintenance. When maintained properly, the sheets have a long lifespan, and are therefore fairly cost-effective in comparison to other wall finishes. Cladding with PUR treatment requires only spray-and-dry buffing for general cleaning, although water-based dressings are beneficial. Special cleaning solutions are used for heavy staining, but abrasive cleaning methods should not be used. If portions of the wall cladding are damaged, replacement of a section is difficult as the stripping off of adhesives may require re-plastering prior to applying the new cladding.

This is also very disruptive in high-use areas. Colour matching is also difficult when replacing panels as colour batches will vary.

This is, however, a low-maintenance, flexible covering that is not likely to crack with small movements in the wall.

Cleaning should always be carried out in accordance with the manufacturer’s specifications to comply with material warranties. The specifier should ensure that these instructions are included in handover packs issued to the building owner/user when occupation takes place.

Fire safety

In terms of SANS 10400, operating theatres, ICUs, high-care or critical care units, and maternity delivery units are required to have walls with a fire-resistance of 120 minutes. The effect of the finish, in conjunction with the wall structure, should be checked with the manufacturer for compliance in this regard.

Indoor air quality – Humidity

Vinyl sheeting is well suited to areas of high humidity, and wet areas such as sluice rooms.

Indoor air quality – Emissions

Some manufacturers have addressed VOC emissions in their products and indicate a pass in VOC emissions tests as well as Building Research Establishment (BRE) A+ ratings. Materials are 100% recyclable or contain a percentage of recycled materials. Each supplier will differ, and the specifier should check these aspects when considering a product. VOC emissions of adhesives and sealants, where applicable, are also to be considered.

Aesthetics

Vinyl wall cladding is available in subtle pastel colours that can contribute to creating a calming/soothing effect. The application of cladding requires skill to apply and if the substrate plaster is not completely smooth below the surface, the vinyl cladding will amplify imperfections and could look unsightly.

Acoustics

Vinyl sheeting is softer than tiled surfaces, with better sound absorption qualities than hard finishes.

2.2. Wallpaper murals

General description and properties

Digitally printed wallpapers are becoming more popular in public areas of health facilities. These murals can be custom-sized and printed to any image and can make a strong contribution to introduce outdoor and nature scenes where external windows and natural light is not possible. The murals are supplied in panels that

generally overlap and are glued to a substrate that should be smooth, sound and dry. A lining paper can be applied prior to the finish paper. Wallpapers generally have a textured matt finish, which can be cleaned. Selfadhesive papers which are PVC-free are also manufactured. The wallpaper generally has a latex-saturated paper backing.

Infection prevention

While some wallpapers can be cleaned, micro-perforated vinyl, which is commonly used for large-scale digital prints, were found to perform poorly when inoculated with pathogens. These wallpaper murals should not be used in areas where patients are immuno-compromised, especially if the prints can be touched easily. The joints between the panels – although sealed with the glue used to affix the mural, mean that the surface is not seamless. By applying a clear varnish sealing coat over the product, the infection prevention is improved.

Cleaning and maintenance

Light cleaning with a soft, non-abrasive cloth – which can be damp – will allow for regular cleaning, but the wallpapers are susceptible to stains. Any mechanical damage to the mural will be difficult to repair. The location of these murals should be carefully considered, as the images will lose their effect if bump-rails run clear across the image. If well cared for, though, the murals require little maintenance.

Fire safety

Self-adhesive wallpapers have been tested in accordance with EN13501-1:2007 and were classified as B-s1, d0 (fire behaviour (B), smoke production (Class 1), flaming droplets(0)). In terms of SANS 10400, operating theatres, ICUs, high-care or critical care units and maternity delivery units are required to have walls with a fire-resistance of 120 minutes. The effect of the finish, in conjunction with the wall structure, should be checked with the manufacturer for compliance in this regard.

Indoor air quality: Humidity

The paper constituents of this product and the micro-perforations make it unsuitable for use in high-humidity areas.

Indoor air quality: Emissions

The adhesives used to install the wallpaper are often high in VOC emissions, although PVC-free self-adhesive papers are produced. In comparison to paints, however, the emissions are lower.

Acoustics

Wallpaper is softer than tiled surfaces, with better sound-absorption qualities than hard finishes. Thicker and heavily textured papers will aid sound absorption.

Aesthetics

The aspect of aesthetics is where wallpaper scores well. The use of high-resolution photographic images in murals can contribute almost as much as a real view of a natural environment. This is useful where external windows are not feasible. This can also be used to good effect in staff restroom areas, cafeterias or foyers.

3. Hard preformed coverings

3.1. Porcelain or ceramic tiles

General description and properties

Porcelain and ceramic tiles generally provide a durable, aesthetically acceptable wall finish that is moistureresistant. A wide spectrum of tiles is available in varying sizes, material composition, quality and cost, resulting in varying performance. Porcelain and/or ceramic tiles are most commonly used in health facilities in wet areas, such as bathrooms, kitchens, and utility and cleaning areas due to the impervious quality and performance under wet conditions. The use of unglazed tiles is not recommended in health facilities as these absorb moisture and other fluids, which may be present in kitchens, mortuaries, etc.

The specifier should research the actual tile carefully, ascertain if the product is imported, what long-term stocks would be available, and ensure the tiles have been sufficiently cured. Where possible, the specifier should use full-bodied porcelain tiles rather than glazed porcelain or ceramic tiles. This is evident in the following comparison between the general properties of the two tile types:

Full-bodied porcelain tile:

• Colour is throughout, as the term ’full-bodied‘ implies.

• Squareness of tiles is consistent with minor deviations.

• Tile sizes are consistent with minor deviations.

• Smaller joints can be used, due to tile size consistency.

• Flatness of tile face is consistent.

Glazed ceramic tile:

• Colour is a glaze on top of the tile that can wear or chip off.

• Tile sizes can vary.

• Squareness of tiles can vary.

• Wider joints are required, due to size and squareness inconsistencies.

• Tiles are often not flat and edged surfaces tend to dip, resulting in rough surfaces.

Infection prevention

Although an individual tile unit complies with selection criteria such as being impervious and easy to clean, a finished tiled wall, including grout and movement joints, provides a less favourable result in terms of the following:

• Grout in the joints is porous and can retain moisture, which encourages the growth of mould.

• Grout joints pose a potential infection-control risk in small cracks and openings that form between the tile edge and the body of the grout.

• Tiles may crack and chip when trolleys bump against them, creating small cracks where moisture can be retained and microbes can grow.

• Replacement of these damaged tiles or re-grouting is disruptive to the daily operations of the facility, and matching existing tiles can be difficult.

Anti-fungal grout will contribute to the control of mildew, but cannot replace good maintenance regimes.

Cleaning and maintenance

Porcelain wall tiles generally need to be cleaned with water and a cleaning agent. For oily spatter in hospital kitchens or body fluids or chemicals in laboratories or mortuaries, appropriate cleaning is required. The ease of cleaning, as well as the durability of the tiles under rigorous cleaning regimes, makes a tiled wall suitable in areas where splash-back is common – such as above sinks and hand basins.

Fire safety

Porcelain is non-combustible in terms of SANS 10400: Part T. In terms of SANS 10400, operating theatres, ICUs, high-care or critical care units and maternity delivery units are required to have walls with a fire resistance of 120 minutes. The effect of the finish, in conjunction with the wall structure, should be checked with the manufacturer for compliance in this regard.

Indoor air quality: Humidity

The polished or glazed surfaces of the tiles make them highly suitable and unaffected by high humidity in the room. However, as mentioned above, the joints are susceptible to moisture-retention and encourage mould and microbe growth in the minute cracks and gaps. Proper scrubbing and regular maintenance will inhibit fungal contamination. The use of epoxy grout is recommended (and not cementitious grout). Epoxy grouts are resinbased, and repel moisture, which inhibits the growth of mould.

Indoor air quality: Emissions

Porcelain tiles and cementitious grout (not recommended in health facilities) do not generate VOC emissions, but some adhesives, other grouts, sealants and cleaning agents generate VOC, which affect the indoor air quality. The production of tiles has a high-energy input, with high sustainability production costs and production emissions.

Acoustics

Tiled walls are hard surfaces that do not absorb any sound and will contribute substantially to noise in the healthcare setting. This is due to the reflective surfaces on walls, causing echoes. Where the function of the room does not warrant special attention to acoustics, and other criteria have priority, then tiled walls are suitable.

Aesthetics

Tiles are available in a wide selection of colours, shapes and sizes. This allows for visually appealing, non-institutional aesthetics in health facilities. Since the surfaces do not scratch or scuff easily, the aesthetic appeal is durable. A variety of stainless steel or PVC tile-in trims are available to finish the edges of tiles on walls or reveals. These also provide some protection to the exposed edge.

3.2. Timber panelling

General description and properties

Timber panelling creates a warm, welcoming environment and can be used in certain areas of healthcare facilities.

The most common locally available timber is meranti and pine, which is available in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of cladding walls or creating features from wood, ranging from standard tongue-and-groove planks to slatted battens and perforated acoustic panels. The timber is usually varnished or painted for internal use. Engineered timber products are also available with melamine and veneer finishes.

Infection prevention

Timber is a source of nutrients to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based anti-bacterial varnish may extend the lifespan of the timber.

Cleaning and maintenance

The timber panelling is usually finished with varnish or sealant that is water-resistant and therefore washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered medium-density fibreboard (MDF) wall panels do not require repainting if clad, but should not come into contact with water.

Fire safety

Timber is combustible, and in terms of SANS 10400: Part T, internal finishes can be combustible, but must comply with Class 2 (Part T: Table 9), except in emergency routes, where Class 1 is required. Specific requirements are listed for operating theatres, ICUs, high-care or critical care units and maternity delivery units in that these areas are required to have walls with a fire resistance of 120 minutes. The extent and effect of the timber finish, in conjunction with the wall structure, should be checked for compliance in this regard.

Indoor air quality: Humidity

Well-varnished timber will be protected from the effects of moisture, but generally timber should not be used in rooms where humid and moist conditions persist. MDF wall panels are not suitable for humid or wet areas.

Indoor air quality: Emissions

Timber is a natural product that does not emit VOCs, but the finishing specification, such as varnish, is often a source of VOCs. Engineered timber products, such as MDF board, contains a higher resin-to-wood ratio than any other urea-formaldehyde pressed wood product, and is recognised as being the highest formaldehydeemitting pressed wood product. (US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product-specific literature.

Aesthetics

The warmth of wood grains, with their natural beauty and range of timber hues, is a sought-after aesthetic that is being replicated in many other finishes, such as ceramic tiles, vinyl and wallpaper. Original wood finishes are unique without production pattern repetition. This is the appeal of timber.

Acoustics

Slatted or perforated timber panels are well suited to rooms that require acoustic performance, such as conference rooms, prayer rooms or quiet spaces. Perforated surfaces aid in reducing the retransmission of sound and can assist where many other surfaces are hard and reflective.

Glazed partitions

General description and properties

There are areas in the healthcare environment that can benefit from the use of glazed partitions to improve the visual supervision of the occupants – for example, in isolation or paediatric wards. All glass in healthcare facilities must have safety glazing, but some additional protection should be included at critical heights where bump-rails would normally be fixed. This can be done using the aluminium frames and mullions at the correct heights.

Provision must be made for blinds or curtains to allow for privacy or room darkening when needed. Glass also brings the opportunity to allow natural light into deep spaces where external windows cannot be accommodated. Alimoglu and Donmex (2005) reported that nurses’ daily exposure to daylight correlated positively with job satisfaction. Berry and Parish (2008) reported that nursing staff who worked in a new unit that featured (among other aspects) more natural light, were more satisfied and less stressed. Stress negatively reflects on staff job satisfaction, which in turn correlates with staff turnover.

Exposure to daylight reduces depression among patients, decreases length of stay, improves sleep and circadian rhythms, lessens agitation among dementia patients, and eases pain (Joseph 1999).

Infection prevention

Glass is impervious and unaffected by moisture or water, and is easy to clean, making this a useful wall finish in high-infection control areas. The key is in how the joints are treated. Welds on frames should be continuous – leaving no gaps or small apertures for moisture or bacteria to gain access. Gaskets in the aluminium frames must seal the junctions with glazed panels to support proper cleaning. Blinds should be encapsulated in double glazing to maintain the hygienic finish.

Micro-perforated vinyl stickers can retain moisture and harbour pathogens, and special attention to cleaning procedures for these areas should be highlighted.

Cleaning and maintenance

Glass walls require occasional washing, but the glass is waterproof and unaffected by most cleaning agents and acids. Glass can also be supplied with proprietary films that ’self-clean‘ by using sunlight and rain to wash off organic dirt. These are suitable for external glazing only.

Fire safety

Both glass and aluminium (cast or extruded) are categorised as non-combustible materials in terms of SANS 10177-5. Internal finishes can be combustible, but must comply with Class 2 (Part T: Table 9), except in emergency routes, where Class 1 is required. Specific requirements are listed for operating theatres, ICUs, high-care or critical care units and maternity delivery units in that these areas are required to have walls with a fire resistance of 120 minutes.

Indoor air quality: Humidity

Glazed walls are well suited to humid environments as they are unaffected by moisture.

Indoor air quality: Emissions

While the production of glass may emit VOCs, glass is inert and impermeable and does not emit VOCs. Coatings to the framework may, however, emit low VOCs. Refer to productspecific literature.

Aesthetics

In a well-maintained facility, glass walls can give a clean, open feel to the healthcare environment. The aesthetics can be improved by what lies beyond the glazing – especially if there is a view to be admired. An open configuration provides the caregiver or visitor with a more ‘global’ view of the unit, and allows immediate assessment of the status. This transparent

FIGURE 30 aesthetic can improve order and cleanliness standards in the facility.

Acoustics

Glass is a hard, reflective surface that will not absorb sound, but possibly add to noise scatter.

4. Bump-rails

Beds, food trolleys, medicine trolleys, drip stands, mop buckets and wheelchairs are just some of the types of wheeled equipment common in

the hospital or healthcare environment. This often leads to accidents and FIGURE 29 mechanical damage to walls, corners and exposed edges. Bump-rails should be specified and fitted in key areas to minimise repairs and prolong the wall finishes. In addition, bump-rails are useful behind chair-backs in waiting areas, where scuff marks are common.

Most damage to walls will be prevented by running a bump-rail at around 900 mm above the floor (to the centreline), with a depth of 200 –300 mm. The areas behind beds or cots can be deeper at around 600 mm. Some trolleys also have projections at low level, and the equipment to be used in the particular area should be considered when setting heights and spacing of bump-rails.

Some bump-rails simply consist of sheeting of only a few millimetres thick, cladding the wall at a particular height, but the offset type of rail that projects

FIGURE 31 away from the wall is more effective in protecting the surface, as the force of the impact is difficult to predict or contain. These projecting rails have the added benefit of providing a handhold for patients who are walking in the passage.

The different types of commonly used bump-rails are summarised below.

4.1. Laminated or solid timber bump-rails

General description and properties

Timber bump-rails are relatively inexpensive and easy to manufacture and fit. These can be routed, and shaped into solid timber sections, or smooth laminated timber sections. The benefit of using timber is that sections that may become damaged are easy to replace. The use of timber creates a warm, welcoming environment. The most common locally available timber is meranti and pine, which is available in various standards and quality. The timber is usually varnished for internal use.

Infection prevention

Timber is a source of nutrients to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to jointing, small ledges and recessed areas. Acrylic resin-based anti-bacterial varnish may extend the lifespan of the timber.

Cleaning and maintenance

The timber panelling is usually finished with varnish or sealant, which is water-resistant, and therefore washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas.

Aesthetics

The warmth of wood grains with their natural beauty and range of timber hues is a sought-after aesthetic, which is being replicated in many other finishes, such as ceramic tiles, vinyl and wallpaper. Original wood finishes are unique without production pattern repetition. This is the appeal of timber.

4.2. Extruded PVC bump-rails

General description and properties

Pre-formed rigid PVC bump-rails are fitted over aluminium retainers with rubber inserts, which help absorb any impact. The PVC covering is

scratch-resistant with a textured surface. These rails can either be flush-mounted against the wall with an overall thickness of about 20–35 mm, or mounted on aluminium brackets at regular centres, usually less than one metre apart, and standing 50–100 mm proud of the wall surface. Continuous timber backing rails can also be fitted where anti-ligature options are needed in mental health facilities.

The bump-rail size can vary between 50–200 mm in height. Injection- moulded plastic joiners and end-caps are available in matching colours.

Hollow, rigid extruded PVC bump-rails are also available, with PVC brackets, but these should only be used with solid timber inserts as the unsupported PVC has been known to become brittle over time. Flexible PVC hand-rail covers are also manufactured to fit over steel brackets, with a width of 50 mm.

Infection prevention

Vinyl/PVC provides no nutrient source for bacteria in which to thrive, and regular cleaning will ensure a hygienic product. Special attention should be paid to cleaning hand-rails as these have more angles and recesses and are more likely to be touched.

Cleaning and maintenance

The manufacturer’s instructions must be followed for cleaning procedures and products to prolong the lifespan of the bump-rails. If a section becomes damaged, the relevant section can be replaced, although colour may vary slightly.

Aesthetics

The PVC bump-rails are available in a wide range of colours to complement the interior colour scheme. Bump-rails also provide an opportunity to introduce bolder colours, and can be used as markers to follow or define different departments.

4.3. Tubular stainless steel bump-rails

General description and properties

Stainless steel bump-rails are sturdy, hard-wearing, easy to clean and an elegant solution for wall protection. Tubular bump-rails for internal areas should be manufactured from Grade 304 stainless steel, and are usually 32 mm in diameter. A wall thickness of 2 mm is recommended to withstand impact. External rails in coastal regions should be made from Grade 316 stainless steel. Material test certificates should be requested from the supplier to indicate the manufacturer, grade, chemical and mechanical specifications. All joints should be specified as fully seamwelded, including where stanchions are fixed to the rail and fixing plates. The screws/bolts and nuts used for fixing the flanges must be the same grade as the tubular rail. Flanges should be a minimum of 6 mm thick. All welded joints should be cleaned of residue prior to pickling and passivation. The TUNGSTEN INERT GAS (TIG) process of welding should be specified as this produces a better-quality weld on a wider range of thicknesses of stainless steel sheeting.

Best corrosion-resistance will be achieved by pickling all fabricated items using commercially available products. The item is then thoroughly rinsed with water to remove all traces of acid and is then passivated with nitric acid passivating solution, and rinsed again.

Infection prevention

Stainless steel provides no nutrient source for bacteria in which to survive, but dirt build-up on the surface can become a source of bacteria. Although copper has better anti-microbial properties than stainless steel (Noyce, Michels & Keevil, 2006), stainless steel is a more durable and costeffective solution and performs better than most other materials in terms of preventing the transmission of pathogens.

Cleaning and maintenance

Stainless steel is a very low-maintenance product that has longevity superior to most other products available. However, like any surface, the build-up of dirt and dust will affect the performance and lifespan of the product and regular cleaning is required. Stainless steel should be cleaned with a soft cloth, regular household dishwashing liquid and warm water. In coastal areas, stainless steel finishes should be cleaned every four weeks, and every 4–6 months in inland areas. Without regular cleaning, the protective chromium-oxide film will be contaminated by dirt build-up on the surface, thus trapping these corrosive agents.

Aesthetics

Stainless steel creates an impression of cleanliness, with its smooth, shiny surface. The seamless rails also add to the hygienic appeal. This bump-rail solution has been used widely in hospital environments.

4.4. Cladding to medium density fibreboard substrate

There are various cladding options when using MDF board as a substrate for bump-rails. The surface finish products can be moulded around the MDF substrate, and the shape and size is only limited by the ability of the cladding to follow the radii of corners and edges.

Suitable adhesives would need to be considered and should be checked with the respective manufacturers of the cladding product selected. The rear of the bump-rail should be fitted with melamine or similar covering to prevent moisture ingress and balance the board.

These bump-rails can be fitted flush against the wall, or fixed with a purpose-made bracket or timber spacer behind them.

Engineered timber products, such as MDF board, contain a higher resin-towood ratio than any other urea-formaldehyde pressed wood product, and is recognised as being the highest formaldehyde- emitting pressed wood product (US Environmental Protection Agency). These VOCs are fairly quickly dissipated.

The cladding options commonly used for bump-rails include the following:

Vinyl sheeting

The advantage of using vinyl on a bump-rail is that the joints can be welded for a seamless finish. This is beneficial in terms of infection control. Mechanical damage can cause fine cracks that would be difficult to repair without replacing a section. The vinyl finish can also match the floor sheeting if required.

Refer to sections on vinyl flooring or wall cladding for general descriptions and performance of vinyl.

Solid surfacing

These smooth resin-based finishes are heated and moulded to the substrate, allowing for seamless curves and corners. Small cracks due to mechanical damage on solid-surfacing can be easily repaired by sanding and resealing. These cracks could present an infection-control risk, as these fine apertures can be difficult to see, and moisture can penetrate to the substrate below and become a reservoir for bacteria.

The solid-surfacing is available in a wide range of colours from vibrant flat colours to stone-speckled patterns and translucent pigmented options. Since this product can be used on joinery and counters, the bump-rails can be made from matching or complementary colours.

Carpeting

Carpet cladding on bump-rails will contribute to sound absorption, but is not recommended in clinical areas as bacteria can be retained in the fibres, and these textile finishes are difficult to keep clean. Refer to sections on carpeting for general descriptions and performance of carpets.

Stainless steel cladding

Stainless steel sheeting can be bent or curved to follow simple profiles, and can be glued with appropriate adhesive, as well as mechanically fixed with screws. Edges should be sealed with silicone. The stainless steel cladding should not be less than 1.5–1.6 mm thick on bump-rails to be able to withstand impact. Standard finishes include brushed satin (matt) or a bright annealed (shiny) polished finish. A brushed satin finish will be less likely to show fingerprints, while a shiny finish will easily reveal fingerprints. Both finishes should be cleaned with a soft cloth, warm water and regular household dishwashing liquid at least once every four weeks.

Refer to the section above on stainless steel tubular bump-rails for general descriptions and performance of stainless steel.

5. Corner protection

Protection is needed on external corners and exposed edges of walls in healthcare facilities, as these areas are generally subject to more impact than walls in straight runs. The detail must be considered in conjunction with the bump-rail, as the two items will meet at the corner. The bump-rail can be continuous in the horizontal line, with the corner protection only covering the

FIGURE 41 wall below. Alternately, the corner protection can be continuous in the vertical line, and the bump-rail can stop short of the corner on each side. A projecting bump-rail will still afford some protection to the corner, over and above the corner protector plate.

Corner protectors should cover at least 1 m from the floor, but where taller food trolleys or laundry trolleys are used, the full height of the wall may need to be protected.

5.1. Stainless steel corner protectors

Stainless steel corner protectors are fitted to exposed corners using stainless steel screws and adhesive, and are usually 50 x 50 mm in size, depending on the detail of the bump-rail at the corner. The corner edges should be rounded as they can be very sharp.

A thickness of 1.5–1.6 mm is recommended to give best impact protection. Refer to the section above on tubular steel bump-rails for general properties, performance, cleaning and other recommendations for the specification of stainless steel. Grade 304 is recommended for internal areas. Screws used for fixings must be the same grade as the angle.

Columns are also high-impact areas in open spaces, and stainless steel sheeting provides a neat solution where rigid aluminium, timber or MDF substrates cannot be fitted to such tight curves.

5.2. Vinyl corner protectors

Proprietary systems of vinyl corner protection are available on the market in rigid extruded high-impact resistant PVC. Some systems can be supplied with aluminium retainers where higher impact is expected.

These PVC corner protectors have a fine textured scratch-resistant finish, and are available in 50 x 50 mm or 70 x 70 mm sizing and are 1.2 mm thick. Standard heights are 1.2 m high.

They are fixed using approved adhesives, but screws can also be used. A range of colours is available to match the PVC bump-rails.

PART D - PERFORMANCE

1. Performance categories

The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas in a healthcare facility.

TABLE 2

WALL PROPERTIES PERFORMANCE CATEGORY

1 2 3 4

Smooth   O O

Impervious   O O

Jointless/seamless  O O O

Textured O  O O

Perforated O  O O

Jointed O O O O

Low maintenance    

Washable/easily cleaned    O

Suited to high humidity areas O 

O 

 

Acoustic priority O   

Aesthetic priority O   



Legend/Key:

– indicates this property is required for the class

– indicates this property is not required for the class

O – indicates this property is an optional requirement for the class Examples of wall finishes for Class 1 (typical area – operating theatre):

• Enamel paint, epoxy coating, vinyl cladding or glazed partitions in special applications, etc.

Examples of wall finishes for Class 2 (typical area – dirty utility or ablution):

• Enamel paint, epoxy coating, porcelain or ceramic tiles, etc.

Examples of wall finishes for Class 3 (typical room – passage, restroom or waiting room):

• PVA paint, glazed partitions, wall-paper, timber panels or enamel paint, etc.

Examples of wall finishes for Class 4 (typical area – plant room):

• PVA paint, enamel paint, epoxy coating, etc.

Refer to Table 2 – Matrix of recommended wall performance categories to establish what performance category the wall of the room in question will require.

2. Performance categories recommended per room

Department Room Name Wall Performance

1 2 3 4 5

Acute Inpatient Wards (Adults) Circulation Space     

Cleaners’ Room     

Consulting Room     

Day Lounge (patients)     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

General Ward (single or multi-bed)     

Isolation Ward     

Kit Room     

Linen Room     

Office     

Patient Ablutions     

Patient-assisted Ablution     

Staff Ablutions     

Staff Change Room     

Staff Restroom     

Surgical Sundries Store     

Treatment Room     

Waiting Area (public)     

Ward Kitchen     

Ward Nurses’ Station     

    

Administration Department Circulation     

Cleaners’ Room     

Offices/interview rooms     

Reception     

Boardroom     

Stores     

Kitchenette     

Records Room     

Print room     

Staff WCs     

Waiting Area (public)     

    

Casualty and Trauma Circulation     

Cleaners’ Room     

Consulting Room     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

Hazmat Shower     

Minor Theatre /Suture Room     

Observation Area     

Office     

Patient Ablutions     

Patient-assisted Ablution     

POPS Suite     

Public WCs     

Reception/Nurses’ Station     

Rehydration Area     

Resuscitation Area     

Scrub Area     

Department Room Name Wall Performance

1 2 3 4 5

Staff Ablutions and Ablutions     

Staff Restroom     

Surgical Sundries Store     

Waiting Area (public)     

    

Central Sterilising and Supply Department (CSSD) Dirty Utility     

Chemical Store     

Circulation     

Cleaners’ Room     

Dirty Linen     

Office     

Packing     

Plant Room     

Staff Change Room     

Staff Restroom     

Staff WCs     

Sterile Storage     

Sterilisation (autoclaves)     

Trolley Wash     

Washing and Disinfecting Area     

    

Community Health Centre Circulation     

Cleaners’ Room     

Consulting Room     

Delivery Room     

Dental Surgery     

Dirty Utility Room (Sluice)     

Dispensary     

Duty Room     

Equipment Store     

Guard House or Security Kiosk     

Isolation/Separate Nursing Ward     

Linen Store     

Observation Area     

Office     

Offloading/Holding area for Pharmacy     

PABX /Server Rooms     

Patient Ablutions     

Patient-assisted Ablution     

Pharmacy     

Plant Room     

POPS Suite     

Public WCs and Change Rooms     

Reception/Nurses’ Station     

Records Room     

Recovery Area     

Rehydration Area     

Resuscitation Area     

Staff Ablutions     

Staff Change Room     

Staff Restroom     

Surgical Sundries Store     

Treatment Room     

Trolley Bay (entrances)     

Department Room Name Wall Performance

1 2 3 4 5

Ultrasound Room     

Ward     

Waiting Area (public)     

X-Ray Room     

    

Day Clinic (Department) Circulation Space     

Cleaners’ Room     

Consulting Room     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

General Ward (single or multi-bed)     

Kit Room     

Linen Room     

Office     

Operating Theatre     

Patient Ablutions     

Patient Waiting     

Recovery Area     

Scrub Area     

Setting Area     

Staff Ablutions and Change Room     

Staff Restroom     

Surgical Sundries Store     

Treatment Room     

Waiting Area (public)     

Ward Kitchen     

Ward Nurses’ Station     

    

Dental Unit (Department) Circulation Space     

Cleaners’ Room     

Consulting Room     

Dental Surgery     

Dirty Utility Room (Sluice)     

Equipment Store     

Panoral Room     

Patient Ablutions     

Reception /Office     

Records Room     

Staff Ablutions     

Staff Restroom     

Surgical Sundries Store     

Waiting Area (Public)     

    

High Care or Cardiac Care Unit (HC/CCU) Circulation     

Cleaners’ Room     

Dirty Utility     

Duty Room     

Equipment Store     

Isolation Ward     

Linen Room     

Nurses’ Station     

Open Ward Area     

Patient Ablutions     

Staff Change Room     

Department Room Name Wall Performance

1 2 3 4 5

Staff Restroom     

Staff WCs     

Surgical Sundries Store     

Ward Kitchen     

    

Intensive Care Unit (ICU) Circulation     

Cleaners’ Room     

Dirty Utility     

Duty Room     

Equipment Store     

Isolation Ward     

Linen Room     

Nurses’ Station     

Open Ward Area     

Patient Ablutions     

Staff Change Room     

Staff Restroom     

Staff WCs     

Surgical Sundries Store     

Ward Kitchen     

    

Kitchen – (Main Hospital) Bulk Dry Goods Store     

Chemical Store     

Cleaners’ Room     

Cold Room/Freezer specialised

Cooking Area     

Cutlery/Crockery Store     

Dishwashing and Potwashing Area     

Food Preparation Area     

Office     

Plating /Serving Area     

Receiving Area     

Staff Ablutions     

Staff Restroom     

Trolley Wash Area     

    

Laboratory

(Pathology/Cytology/

Haematology/Chemistry)

(Biosafety Level 2)

Blood and Blood Products Store     

Cell and Tissue Laboratory     

Cytopathology Sample Storage     

Clinical Material Store     

Disposal Area (dangerous materials)     

Drug and Vaccines Store     

Flammable Goods Store (external)     

Gas Cylinder and Pressure Vessel Store     

Hazardous Substances Store     

Histopathology Laboratory     

Microbiology Laboratory     

Offices     

POCT consulting room     

Reagents /Chemical Stores     

Records Rooms     

Sample Collection Laboratory     

Department Room Name Wall Performance

1 2 3 4 5

Specimen Reception and Sorting rooms     

Stores (protective clothing/equipment)     

Staff Ablutions     

Staff Change Room including lockers     

Staff Restroom     

    

Laundry – (Main Hospital) Assembly, Packing and Dispatch     

Chemical Store     

Circulation     

Cleaners’ Room     

Office     

Pressing     

Sorting     

Staff Ablutions     

Staff Restroom     

Stores     

Washing Room     

    

Maternity /Delivery Department Baby Bathing Area     

Circulation     

Delivery Suite     

Dirty Utility Room     

Duty Room     

Equipment Store     

First Stage Room     

Kit Room     

Linen Store     

Milk Kitchen     

Nurses’ Station     

Nursery     

Patient Ablutions     

Staff Change Room     

Staff Restroom     

Staff WCs     

Surgical Sundries Store     

Viewing Area     

Waiting Area     

Ward Kitchen     

Wards     

    

Mental Health Facility Body Room     

Children's Play Area     

Clean Utility     

Cleaners’ Room/Station     

Consulting Room     

Counselling Room     

Dirty Linen     

Dirty Utility (Sluice)     

ECT Procedure Room     

En Suite Bath/Shower Room     

Equipment Store     

Group Therapy Room     

Department Room Name Wall Performance

1 2 3 4 5

Gymnasium (OT and Physio)     

IT Room     

Kit Room     

Linen Store     

Medicine Store     

Multi-Purpose Hall     

Nurses’ Station     

Office     

Patient-assisted Bathroom/Shower     

Patient Dining Room     

Patient Laundry     

Patient Lounge     

Pharmacy     

Quiet Room     

Records Room     

Seclusion Room     

Security Control Room     

Security Search Room     

Staff Change Room and WCs     

Surgical Sundries Store     

Treatment Room     

Wards     

Ward Kitchen     

Waste Disposal Room     

    

Mortuary Blue Room     

Circulation Space     

Cleaners’ Room     

Dirty Utility     

Instruments Room     

Linen Room     

Medical Observation Room     

Office     

Pathologist Change Room     

Post-Mortem Room     

Staff Change Room     

Staff WCs     

Viewing Room     

Visitors’ Waiting Room     

    

Neonatal Intensive Care Unit (NNICU) Circulation     

Cleaners’ Room     

Dirty Utility     

Duty Room     

Equipment Store     

Incubator Ward Area     

Isolation Ward     

Linen Room     

Milk Kitchen     

Mothers’ Rest Area     

Nurses’ Station     

Staff Change Room     

Staff Restroom     

Staff WCs     

Surgical Sundries Store     

Department Room Name Wall Performance

1 2 3 4 5

    

Operating Theatre (Department) Circulation     

Cleaners’ Room     

Dirty Utility     

Duty Room     

Equipment Store     

Nurses’ Station     

Operating Theatre     

Post-Operative Recovery Area     

Pre-Operative Holding Area     

Scrub-up Area/Room     

Setting Room     

Staff Change Room     

Staff Restroom     

Staff WCs     

Surgical Sundries Store     

    

Outpatients Department Reception /Nurses’ Station     

Admissions Room     

Baby Changing Area     

Children’s Play /Waiting Area     

Circulation     

Consulting Room     

Dirty Utility Room     

Duty Room     

Equipment Store     

Kitchenette     

Linen Store     

Offices     

POPS Room     

Public Ablutions     

Records Room     

Staff Ablutions     

Staff Change Room     

Staff Restroom     

Surgical Sundries Store     

Treatment Room     

Waiting Areas (public)     

Wheelchair storage area     

    

Paediatric Ward Child-assist Ablution     

Circulation Space     

Cleaners’ Room     

Consulting Room     

Dirty Utility (Isolation)     

Dirty Utility Room (Sluice)     

Duty Room     

Equipment Store     

General Ward (single or multi-bed)     

Isolation Ward     

Kit Room     

Linen Room     

Milk /Ward Kitchen     

Nurses’ Station     

Office     

Department Room Name Wall Performance

1 2 3 4 5

Parent Ablutions     

Play Area (patients)     

Staff Change Room     

Staff Restroom     

Staff WCs     

Surgical Sundries Store     

Treatment Room     

    

Pharmacy/Dispensary Cleaners’ Room     

Bulk Stores     

Circulation Space     

Counselling Cubicle     

Dispensary     

Liquid Filling Room     

Office     

Offloading Bay     

Patient Waiting Room     

Schedule Drugs Strong Room     

Staff Change Room     

Staff WCs     

Tablet Packing Room     

Vacolitre Stores     

    

Physiotherapy Department Audiology Testing     

Circulation     

Consulting Room     

Equipment Store     

Gymnasium     

Kitchenette     

Occupational Therapy Room     

Patient Ablutions     

Reception     

Speech Therapy     

Staff Restroom     

Staff WCs     

Treatment Room     

Waiting Area     

    

Primary Health Clinic Circulation     

Cleaners’ Room     

Consulting Room     

Delivery Room     

Dirty Utility Room (Sluice)     

Dispensary and Pharmacy     

Duty Room     

Equipment Store     

Guard House or Security Kiosk     

Linen Store     

Observation /Rehydration Area     

Office     

Public Ablutions     

Plant Room     

POPS Suite     

Reception/Nurses’ Station     

Records Room     

Department Room Name Wall Performance

1 2 3 4 5

Staff Ablutions and Change Room     

Staff Restroom     

Surgical Sundries Store     

Treatment Room     

Trolley Bay (entrances)     

Waiting Area (public)     

    

Radiology (Diagnostic) Bucky Room (general X-ray Room)     

Change Cubicles     

Circulation     

Cleaners’ Room     

CT /MRI Scan Room     

Dirty Utility /Sluice     

Fluoroscopy Room     

Fluoroscopy Control Room     

Inpatient Waiting Area     

Kitchenette     

Linen Room     

Mammogram Room     

Office     

Patient Ablutions     

Public Waiting Area     

Porters and Wheelchair/Trolley Parking     

Reception     

Records Room     

Server Room     

Staff Restroom     

Staff WCs     

Stores (Equipment/General)     

Ultrasound Room     

Telemedicine Room     

Viewing Room/CR Room/Reporting Area     

    

Nurses’ Residences Ablutions     

Bedrooms     

Circulation     

Kitchenette     

Lounge     

Offices     

Public Ablutions     

Reception     

Stores     

Waiting Areas (public)     

    

DEFINITIONS

1. Terminology

Aggregation Collected together from different sources and considered a whole.

Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.

Bacteriostatic A word used to describe the property of a material that claims to inhibit the multiplication of bacteria.

Bariatric Describing the condition of obesity.

Bonded Chemically attached or fused in layers.

Emulsion In the context of paint – referring to water-based paint that is not shiny when dry.

Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.

Homogenous Consisting of things of similar type throughout.

Heterogeneous Consisting of various layers or types throughout.

Hygroscopic Readily absorbing moisture from the atmosphere.

Hydrophobic Water-repellent.

Impervious Not allowing passage through (usually of water/moisture).

Interstices Small holes or perforations.

Jointed Junctions which may be open or covered, but not completely sealed and smooth.

Jointless Without joints or having joints that are sealed by materials and methods that make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.

Olfactory Relating to the smell or the sense of smell.

Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.

Polyamide Aa synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.

Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched or squashed.

Seamless A surface without open joints or junctions, or where such joints are completely sealed and smoothed to create a continuous and whole membrane.

Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.

Textured A surface finish that is not smooth, but has a fissured/embossed or ridged finish.

Vitrified To change a material into glass, under high heat and other conditions.

Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.

Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a time-frame given at the time of purchase.

2. Abbreviations

BRE Building Research Establishment

CHD Center for Health Design

ENT Ear, Nose and Throat

HAI Healthcare-associated infections

HDF High-density fibreboard

IAQ Indoor Environmental Quality IEQ Indoor Environmental Quality

IUSS Infrastructure Unit Systems Support

MDF Medium-density fibreboard

MRSA Methicillin-resistant Staphylococcus Aureus, which is a common skin bacterium that is resistant to a range of antibiotics otherwise referred to as multi-drug resistant bacteria

NDoH National Department of Health

OoM Order of Magnitude

PMIS Project Management Information System

PMSU Project Management Support Unit

PUR Polyurethane-resistant

PVC Polyvinyl-chloride

RC Recommendation Committee

SANS South African National Standard

TIG Tungsten inert gas

VOC Volatile organic compound

VRE Vancomycin-resistant Enterococci (drug-resistant bacteria that can lead to HAIs)

REFERENCES

1. Bibliography

Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

Cement & Concrete Institute (CCI), 2009. Sand-cement screeds and concrete toppings for floors. [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. Floor coverings in healthcare buildings. (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. Finishes. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. Core elements: Health Building Note 00-03: Clinical and clinical support spaces. UK: DH.

Department of Health (DoH), 1980. Regulations governing private hospitals and unattached operating theatres. (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. Health

Technical Memorandum 61: Building component series flooring. [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. Performance requirements for building elements used in healthcare facilities. (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes. Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. Sound practices: Noise control in the healthcare environment. (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., 2006. The impact of light on outcomes in healthcare settings. Concord, CA: The Center for Health Design. Available at: <nowiki>http://www.healthdesign.org/sites/default/files/CHD_Issue_Paper2.pdf</nowiki> [Accessed 9 April 2014].

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. Healthcare environmental terms and outcome measures: An evidence-based design glossary. Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. Applied and Environmental Microbiology, 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, 18th CIB World Building Congress: Facilities management and maintenance. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. Achieving EBD goals through flooring selection & design. [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. Health Technical Memorandum (HTM) 56: Building component series: Partitions. UK: TSO.

NHS Estates, 2005. Health Technical Memorandum (HTM) 60: Ceilings. 2nd ed. UK: TSO.

NHS, National Services Scotland, 2006. Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring. Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning. (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring. Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. The role of hospital design in the recruitment, retention and performance of NHS nurses in England. (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Tofle, R.B., Schwartz, B., Yoon, S., Max-Royale, A., 2003. Color in healthcare environments: A critical review of the research literature. California: The Coalition for Health Environments Research (CHER).

Ulrich, R. S. P., Zimring, C. P., Zhu, X., Dubose, M., Seo, H. B., Choi, Y. S. and Joseph, A. P., 2008. A review of the research literature on evidence-based healthcare design (Part II). Health Environments Research & Design Journal, 1(2008), 61-125.

Welsh Health Estates, 2009. Health Building Note 04-01: Adult in-patient accommodation. Cardiff, Wales:Welsh Health Estates.

2. Websites: Further reading

Error! Hyperlink reference not valid.(Health Technical Manuals – United Kingdom)

Error! Hyperlink reference not valid.(Precautionary Lists of Building Ingredients related to health effects and risks)

Error! Hyperlink reference not valid.(Sustainable Flooring benefits Hospitals in a variety of ways) <nowiki>http://www.GreenhealthMagazine.org</nowiki>

<nowiki>http://greenhomeguide.com</nowiki> (Are Engineered wood products from Decorative Flooring a low VOC product? Joel Hirschberg, 2011) <nowiki>http://gbcsa.org.za</nowiki> (IEQ rating tools)

<nowiki>http://www.green-buildings.com</nowiki> (Green Flooring: Linoleum, Marmoleum and Vinyl – Claire Maloney, LEED Green Associate, Cornell University 2013)

<nowiki>http://www.healthcaredesignmagazine.com</nowiki> (Five need to know trends shaping healthcare Design – K. Edmundson, 2011) <nowiki>http://www.carpet-rug.org/documents/technical-bulletins</nowiki> (Carpet Treatments) <nowiki>http://www.floorworx.co.za</nowiki> (Vinyl wall cladding and protection manufacturer) <nowiki>http://www.polyflor.co.za</nowiki> (Vinyl wall cladding and protection manufacturer) <nowiki>http://www.sassda.co.za</nowiki> (South African Stainless Steel Development Association)

PHOTOGRAPHIC AND ILLUSTRATION CREDITS

Cover photo: R. van Rensburg

Fig.1-2 M. Swinney

Fig.3 G. Abbott- CSIR

Fig.4 R. Cubbin based on Life Cycle

Floor Cost Table – by Nora®,

USA

Fig.5 R. Cubbin

Fig.6-7 M. Swinney

Fig.8 R. van Rensburg

Fig.9-14 M. Swinney

Fig.15 R. van Rensburg

Fig.16 R. van Rensburg

Fig.17 R. van Rensburg

Fig.18-24 M. Swinney

Fig.25 R. van Rensburg

Fig.26-27 M. Swinney

Fig.28 C. Hudson

Fig.29 R. van Rensburg

Fig.30 M. Swinney

Fig.31 R. van Rensburg

Fig.32-34 M. Swinney

Fig.35 R. Cubbin

Fig.36-38 M. Swinney

Fig.39-40 R. van Rensburg

Fig.41 M. Swinney

Fig.42-44 R. van Rensburg

Fig.43 M. Swinney

Fig. 44 R. Cubbin

Fig.45 M. Swinney

<br />
[[Category:Crosscutting Issues]]

Materials and finishes

2020-10-22T12:46:06Z

VSadiki:

=Internal Ceiling Finishes in Healthcare Facilities=

=Context=

==Overview – finishes in the healthcare environment==
<br />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.
[[File:Facility finishes.png|thumb|none]]

==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.

'''How to use this document:'''

#Review the Selection Criteria - Part B
#Select a Room / Department name in Part D, and note Performance Category
#Refer to Table 1 for the Properties that make up that Performance category
#Refer to Part C to assess ceiling types that could satisfy those performance requirements.

'''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 <u>www.iussonline.co.za</u>

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.

==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:

SANS 204 Energy-Efficiency in buildings general

SANS 622 Gypsum cove cornice

SANS 637 Wood-wood panels (cement-bonded)

SANS 640 Flexible PU-foams

SANS 803 Fibre cement boards

SANS 1039 Wooden ceiling and panelling boards

SANS 1381 Materials for thermal insulation boards

SANS 1508 Expanded polystyrene thermal insulation boards

SANS 1783 Softwood brandering and battens

SANS 6013 Dimensional and mass stability of particle boards with varying humidy

SANS 6016 Transverse tensile strength of particle boards

SANS10177 Fire-testing of materials

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

=Selection Criteria=

==Scope==
A ceiling in any facility forms the third dimension in any given room area, along with the walls and the floor, and it sometimes separates the roof space from the occupied area below. The manner 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.
[[File:Ceiling.png|thumb|none]]
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.
[[File:Actual Soffit of structure overhead.png|thumb|none]]

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.
[[File:Membrane fixed directly to the structure overhead.png|thumb|none]]

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.
[[File:Membrane suspended from the structure overhea.png|thumb|none]]

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

==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

===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.

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

==Life cycle costing and sustainability==
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 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 importance of life cycle costs.
[[File:Capital outlay costs vs life span costs.png|thumb|none]]

Sustainability should be considered in all four stages of product life:

*Manufacture
*Use
*Maintenance
*Disposal

[[File:Product life sustainability.png|thumb|none]]

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.
[[File:Life cycle costing and sustainability diag.png|thumb|none]]

===Toxicity and effect on indoor environment===
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)
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.

'''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.
[[File:Toxicity and effect on indoor environment diag.jpg|thumb|none]]

==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)

[[File:Facility design.png|thumb|none]]

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.

==Selection criteria==

===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.”
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)
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.

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.
“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 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 also carried out microbiological studies comparing patient rooms with and without carpet. The study found higher microbial counts and more E.coli and other organisms on carpet samples than bare floors.

While this issue may not affect the selection of a ceiling finish, there are principles to be borne in mind when establishing what finish is best in high-risk environments.
[[File:Selection criteria diag.png|thumb|none]]

Below is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Although ceilings are out of reach and therefore less affected by regular touching, airborne bacteria can be carried on circulating mechanical ventilation, and aerosol contaminants which are distributed when water is splashed, (Ayliffe et al., 2000) can carry pathogens to ceiling level.

Ceiling materials and finishes that resist the spread of infection will have qualities that can be summarised as follows:

*Smooth
*Impervious
*Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, ceilings will have the following properties:

*Textured
*Perforated
*Jointed

[[File:Selection criteria diag 2.jpg|thumb|none]]

Certain materials have been shown to inhibit bacterial growth – such as vinyl, PuR and natural materials such as cork. This will also contribute to the prevention of infection. Ceilings with these properties will have the following quality:

*Bacteriostatic

'''A note about anti-bacterial treatments and additives to ceiling products:'''

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

Synthetic fibres such as polypropylene textile and vinyl for example, in themselves do no provide a nutrient source which microbes need to survive, but some finishes can trap soil, dust and moisture which do provide that source.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risks and benefits to healthcare users.

==Cleaning and maintenance==
Connected with infection prevention is the issue of cleaning. Ceilings tend to have ’reactive’ cleaning regimes, rather than regular cleaning programmes. This is partially because the ceiling gives an impression of cleanliness, but this can be misleading.

Whether the materials/finish of a ceiling can be cleaned thoroughly will define the extent to which infectious agents can be prevented from multiplying on a surface. Some materials can tolerate a reasonable amount of moisture, facilitating regular washing, while others would be adversely affected by it and can only be dusted or wiped.
[[File:Cleaning and maintenance diag.jpg|thumb|none]]

For cleaning to be effective, the surface must be able to withstand regular and fairly vigorous cleaning, with proper access to all surfaces. Where there are small recesses or difficult to reach corners, dirt is easily trapped providing dark, undisturbed conditions – the perfect breeding area for bacteria.

Information regarding cleaning materials should also be considered, as solvents and cleaning agents can quickly cause deterioration of the finish if it is not robust enough to withstand the cleaning required.

A further aspect to consider is the disruption that will be required to carry out the cleaning regime and possible maintenance. This is pertinent to areas such as operating theatres that may remain in use 24 hours a day.

Where there is a high requirement for regular cleaning of a ceiling in view of its location in a sensitive area, together with a need for minimal disruption for maintenance, the ceiling properties could be summarised as:

*Washable
*Low maintenance

[[File:Cleaning and maintenance diag 2.jpg|thumb|none]]

An additional consideration in the selection of ceiling finishes in health facilities in terms of maintenance is the provision of access to services in the ceiling void. Health facilities will generally require a high concentration of various services, most of which run in the ceiling void.

This will include electrical power and lighting, data, nurse call systems, medical gas and vacuum lines, air-conditioning and extract ducts, as well as hot water and waste pipes to name a few. Although service ducts and shafts can alleviate this congestion in the ceiling, distribution on the horizontal plane will nonetheless be required.

By selecting ceiling types that cater for easy access and giving thought to the best positions for these access panels - even marking these panels where necessary - this will facilitate easier maintenance of in-ceiling services during the life span of the building. This in turn will reduce ’downtime’, and disruption of the health facility.
[[File:Access panel.jpg|thumb|none]]

While the location of access panels is determined by the layout of services, certain rooms or areas will be more suitable for these panels.

*No combustible materials are permitted in ceilings or roof structures for buildings classified as hospitals.
*Medical facilities and healthcare categories are classified separately and have different requirements.
*Strict parameters are given for the depth of ceiling voids and this is related to the need for sprinklers when the voids exceed a given depth.
*Compartmentalisation of the ceiling void is required in area and distance, with fire stops.
*A dedicated section is written regarding operating theatres and intensive, high and critical care units, stipulating 120 min fire resistance for division separations.
*A full list of materials deemed to be non-combustible is provided.

This has been listed as the property:

*Access panels

===Safety===
Unlike floors which can prevent - or contribute to - falls by patients and staff, ceilings are largely out of reach and need not be assessed for safety as is relevant to floors. The safety aspect of fire performance does however need to be highlighted. The SANS 10400 lists specific requirements for hospitals and medical facilities with regard to ceilings. This is aimed at protecting the patients who are most likely frail, may not be able to walk, and would require assistance and more time to escape in the event of fire.

The definitions in the SANS 10400: Part A read:

*E2 Hospital

Occupancy where people are cared for or treated because of physical or mental disabilities, and where they are generally bedridden.

*E3 Other institutional (residential)

Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

*E4 Healthcare

Occupancy which is a common place of long term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

These requirements are set out in Part T of SANS 10400, and include:

All ceilings in hospitals would need to be non-combustible material. In other health facilities, such as community health centres or clinics, there are exceptions to the non-combustible requirement, subject to compliance with certain conditions. Since each project varies, the advice of a competent fire engineer should be obtained.

==Indoor air quality==
There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality. The first is he effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces, The second is the effect of the material on the floor material - namely the emission of volatile organic compounds.
[[File:Indoor air quality diag.jpg|thumb|none]]

===Humidity===
Certain rooms and areas of health facilities are by nature of the function they house - wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture-resistant finishes. If the ceiling panels or surfaces are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a ceiling finish, this property will be listed as:

*High humidity

===Emissions from materials===
As discussed under Environmental Aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off by – commonly referred to as off-gassing:

*The product itself, along with its structure
*The adhesives used to fix the product or its layers
*The paints or sealants used to finish
*The cleaning solutions required for regular maintenance

[[File:Emissions from materias diag 1.jpg|thumb|none]]

People who work in noisy environments for long shifts day in and day out, also have similar stress-induced experiences. They report everything from exhaustion to burnout, depression and irritability”
The smell of the interior of a new car - enjoyed by many is an example of plasticizers that have evaporated - emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality. The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels’ outlines.

IEQ14 section measured the formaldehyde minimisation which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used.

It should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.
Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space
Patients with respiratory weaknesses such as asthma are most likely to be affected by VOC emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility. Materials such as paints and polyvinyl-chlorides can emit VOCs which can have a negative effect on indoor air quality.

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. VOCs can also cause irritation and odour annoyance, and could lead to behavioural, neurotoxic, hepatoxic and genotoxic effects (Meininghaus et al., 2000; Hoskins, 2003; Hodgson et al., 2000.)
[[File:Emissions from materias diag 2.jpg|thumb|none]]

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of enamel paint on plaster, for example, may result in higher VOC emissions than say, a pre-finished lay-in ceiling board, but the infection control benefits of the seamless finish will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) Ceilings often present an opportunity to reduce the heat load on rooms from the roof space through insulation. This could form part of the ceiling material itself or be laid over the ceiling.

==Acoustics==
Noise in health facilities is mainly generated by:

*Impact sounds e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.
*Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LA<sub>eq</sub>) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization’s recommended LA<sub>eq</sub> value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November, 2005 showing that chronic noise increased the risk of heart-attack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.
[[File:Acoustics diag 1.jpg|thumb|none]]

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. 2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Sound-absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:
High acoustic
[[File:Acoustics diag 2.jpg|thumb|none]]

==Aesthetics==
Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results of a study by Becker and Douglass (2008), show that the physical appearance of the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Reflectivity of the ceiling material can boost natural light in a room or alternately produce glare - both of which have a direct impact on the comfort levels in the room. By ensuring skylights are oriented correctly, and shaded appropriately, natural light could be introduced through the ceiling.
[[File:Aesthetics diag.jpg|thumb|none]]

The ceiling surface finish should complement the function of the room, and monotony for the sake of economics should be avoided, bearing in mind that most patients will be focused on the ceiling for the duration of their stay.

Printed ceiling tiles, or polycarbonate panels with vinyl film images, behind which lighting can be introduced, could be used in key areas. This can transform a dull ward ceiling into a fascinating window to the outside world. CABE (2004) highlights the need for patients to have a ’connection with nature’, and these ceiling ‘windows’ are the ideal opportunity to supplement views to the exterior.

Natural light is a key factor in creating an environment for patient recovery. The occupants of the ward should be considered – paediatric wards are opportunities for playful scenes that will help little patients feel at ease.

In public areas where more emphasis might be placed on an attractive and welcoming interior than other factors, then this factor would be listed as:

   • High aesthetics

=Technical Information - Ceiling Types=

==Paint on seamless plaster==
'''General description and properties'''

Paint is easily applied by roller to a plastered ceiling soffit. The soffit could be constructed from plasterboard sheets, which are then skimmed or from concrete. Note that the structure onto which the plasterboard is fixed would need to be non-combustible if the facility is a hospital. Following a primer and undercoat, usually three coats of paint are applied. Two-coat plaster or skimming is highly recommended prior to painting, as defects will be highlighted with the high-gloss type paints.

Paint types that can be applied to the ceiling soffit will vary between oil-based and water-based types. Enamel paint dries to a hard, glossy, finish. It is usually oil-based. Velvet sheen paints are water-based, but produce a less glossy finish. PVA-paints are also water-based, but produce a matt finish. Paint is fairly inexpensive when compared to other ceiling finishes - excluding the structure.
[[File:Paint on seamless plaster diag.jpg|thumb|none]]

'''Infection prevention'''

The smooth seamless finish produced by painted concrete or plasterboard ceilings, make this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Paints with nanotechnology enhancements are also being developed. These paints inhibit the growth of algae and fungus.

'''Cleaning and maintenance'''

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant. Paint is a low maintenance finish which may require re-application every few years, unless latent defects arise.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Paint on a concrete soffit is considered a non-combustible finish as the thickness of the paint is usually less than

0.5 mm – refer to manufacturers’ specifications, and consult with the SANS Part T (4.13).

'''Indoor air quality: Humidity'''

Generally, paints are not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Enamel paints are most resistant to absorbing moisture, when compared to PVA-type paints.

'''Indoor air quality: Emissions and insulation'''

Paints are notorious for high VOC emissions, although manufacturers are now working on products with reduced or zero VOCs. Refer to product specific literature.

'''Acoustics'''

The hard surface of painted soffits reflects sounds and where acoustics are important, there are certainly better options available.

'''Aesthetics'''

While paint can be used effectively to introduce colour for features or emphasis, generally on ceilings in areas where infection prevention is important, the ceilings should be kept single colours - white or light colours – this ceiling would be used in areas where aesthetics is not the highest priority.

==Cementitious board – nail-up ceilings==
'''General description and properties'''

Plain and textured ceiling boards are available for nail-up applications where joints are not a problem. These boards are manufactured from a combination of cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses, and can be nailed at regular intervals to the overhead structure.

The joints between the ceiling boards can be finished using joiners or cover-strips. The ceiling boards can also be fixed between exposed beams.

Although no paint finish is required, paint can be applied. (Refer to comments on paint on plaster above.)
[[File:Cementitious board – nail-up ceilings diag.png|thumb|none]]

'''Infection prevention'''

The textured boards and the joining strips will create areas where microbes can grow. This ceiling finish is therefore not suitable for areas where infection prevention is critical.

'''Cleaning and maintenance'''

Nail-up cementitious boards are unaffected by moisture and resistant to corrosion. When painted they are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is possible if boards do get damaged, but this would be disruptive to the functioning of the room.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Nail-up cementitious boards are non-combustible.

'''Indoor air quality: Humidity'''

These painted boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the building from roof spaces where applicable. Fibres are safe and recyclable, and manufacturers claim low embodied energy used for assembly and construction. Refer to product specific literature. Emissions from paints should be considered.

'''Aesthetics'''

This type of ceiling board is aesthetically acceptable, and with paint, can be used to create an interesting functional ceiling.

'''Acoustics'''

The hard surface reflects sound and will not aid in sound absorption in the room it covers.

==Vinyl-clad ceiling tiles in suspended grid==
'''General description and properties'''

Vinyl-clad ceiling tiles are manufactured from cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses and are clad on the exposed surface with vinyl. They are suitable for 1 200 x 600mm or 600 x 600mm exposed ceiling grids. The grids are suspended from the structure above. The ceiling tiles can also be supplied with 25 mm insulation backing. No further painting or finishing is required.

'''Infection prevention'''

The vinyl finish is impervious, and vinyl inhibits the growth of bacteria. The boards are unaffected by moisture, and can be washed regularly. This makes them suitable for infection prevention. There are however joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

As mentioned, the vinyl-clad tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is very easy if boards do get damaged, with very little disruption to the room function.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Fire safety'''

Vinyl-clad boards are non-combustible; however, fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the room. Fibres are safe and recyclable, (no asbestos fibres) and manufacturers claim low embodied energy used for assembly and construction. However, the vinyl has low VOC emissions, when compared to some paints. Refer to product specific literature.

'''Aesthetics'''

This type of ceiling board gives a hygienic impression and is aesthetically acceptable. Tiles can also be printed with designs where budgets allow.

'''Acoustics'''

The surface is relatively hard, and does not assist with acoustic control or absorb sounds.
[[File:Vinyl-clad ceiling tiles in suspended grid.jpg|thumb|none]]

==Acoustic ceiling tiles in suspended grid==
'''General description and properties'''

These mineral fibre acoustic ceiling tiles – nominally 20 mm thick - have a pre-painted textured and perforated finish. The boards can be supplied with various edge finishes suitable for an exposed grid, or recessed grid with regular or chamfered edges. They are suitable for 1200 x 600mm or 600 x 600mm ceiling grids. The grids are suspended from the structure above. No further painting or finishing is required.

'''Infection prevention'''

The fissured surface may harbour dust and bacteria, making this type of ceiling board unsuitable for areas where infection prevention is critical – such as theatres. Some manufacturers do produce an ‘anti-microbial’ tile. Refer to the section on Selection Criteria- Infection Prevention for more discussion on this aspect. The boards cannot be washed as they will absorb moisture. Dirty or stained panels can be replaced easily. There are also joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

Since the boards are adversely affected by moisture, they can only be brush-cleaned and must be kept dry. Dirt often gathers where air-conditioning ducts blow across these tiles, and these then are difficult to clean. They are lightweight and fairly low maintenance. Replacement is very easy if boards do get damaged, with very little disruption to the room function, although batch colours and textures may vary.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Indoor air quality: Humidity'''

These boards are unsuited to areas of high humidity as they absorb moisture and will swell and droop over time when exposed to moist conditions.

'''Indoor air quality: Emissions and insulation'''

These boards provide some thermal insulation which will reduces the heat load of the building. The tiles do have low VOC emissions which will vary according to the manufacturer. Refer to product specific literature.

'''Aesthetics'''

The patterns of the fissures on this type of ceiling tile can create an interesting ceiling which is aesthetically acceptable.

'''Acoustics'''

The perforated surface is excellent for sound absorption and this product is well-suited to areas where noise reduction is prioritised.
[[File:Acoustic ceiling tiles in suspended grid.png|thumb|none]]

==Pressed metal ceiling tiles in suspended grid==
'''General description and properties'''

Pressed metal tiles are manufactured from galvanised steel, and are then epoxy-coated for a durable finish. The ceiling tiles are made to a variety of sizes. Stainless steel tiles are also available. Perforations are made in the surface – in different patterns and diameter to reduce the weight and improve acoustic performance. They are laid in a suspended ceiling grid, or can be hinged to the grid to open downwards. No further painting or finishing is required.

'''Infection prevention'''

The perforated surface may harbour dust and bacteria, and the joints mean the ceiling is not seamless. This type of ceiling is not suitable for areas where infection prevention is critical. The tiles are however washable.

'''Access to services'''

The hinged access tiles are purpose-made for access to services in the ceiling void as they are hinged to swing down leaving the void clear of grid transoms. The lay-in type of panel is also removable in a suspended grid ceiling, allowing for maximum flexibility for access to services in the ceiling void.

'''Cleaning and maintenance'''

The epoxy-coated tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stainresistant. They are robust and unlikely to be damaged easily, making them very low maintenance and durable. Replacement is easy if tiles do need replacing, with very little disruption to the room function.

'''Fire safety'''

Metal is listed as non-combustible in the SANS Part T as tested under 10177-5, however fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The metal tiles are generally made from recycled material and can also be recycled. Refer to product specific literature. The tile itself does not provide any insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically-pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics'''

The perforated surface contributes to sound absorption and compensates somewhat for the hard, reflective metal surface.
[[File:Pressed metal ceiling tiles in suspended grid.jpg|thumb|none]]

==Rigid extruded polystyrene panels (XPS)==
'''General description and properties'''

Polystyrene ceiling panels combine the aesthetic of a ceiling panel with the insulation properties of closed-cell insulation board. These panels are manufactured from high-density rigid extruded polystyrene. These can be supplied smooth for a flush appearance, bevelled to pronounce the 600 mm joint, or grooved at 100 mm intervals to resemble tongue and groove timber planks. Although neatly finished, painting with PVA is recommended. The boards can be fitted over-purlin, nailed-up to brandering, or between exposed trusses, and should be ordered in long lengths to avoid butt-joints on ends. The panels are available in thicknesses of 25, 30 or 40 mm.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the polystyrene itself is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. In certified tests, (by SANAS accredited laboratory) the rigid polystyrene showed no microbial growth and was declared suitable for use in the food industry. Since the surface is jointed, however, its use will be limited.

'''Access to services'''

Access panels need to be planned in the ceiling prior to installation. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They can however be mechanically damaged, and should preferably be fitted at high levels. Replacement of damaged panels would create a fair amount of disruption.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ’healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 – noncombustible materials only.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The insulation properties of the rigid polystyrene will reduce the heat load and act as a bulk insulator. The Rvalues increase with the thickness from 0.833 (for 25 mm thick board) to 2.667 for 80 mm thickness – double layer). Rigid polystyrene panels have no obvious odour, but under high heat conditions (near heat-generating light fitting , for example), some aromatic hydrocarbons are released. The manufacture of rigid polystyrene panels requires the use of HCFC-gasses, however, the measure of these gasses is at levels less than 150 ppm even where large quantities are stored. The VOC emissions of adhesives used to install the product should also be considered.

'''Aesthetics'''

The tongue and groove pattern creates interest in the surface of the ceiling, and can evoke a homely residential feel to the room/area. This can be used to good effect in healthcare facilities.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.
[[File:Rigid extruded polystyrene panels (XPS).jpg|thumb|none]]

==Expanded polystyrene panels (EPS)==
'''General description and properties'''

These laminated expanded polystyrene panels are made up of low-density fire-retardant board finished with a fire retardant PVC-foil, the surface of which can be embossed or smooth. The layers are bonded under high temperatures. The panels can be supplied full size in 4.8 x1.2 m boards for over-purlin fixing, or cut to suit a suspended ceiling grid (1 200 x 600mm). It can also be installed under purlin or between rafters. PVC H-joiners are used at junctions. Because the panels are very light, wire-hung suspended grids are not recommended, as these could result in drafts lifting the ceiling. Rigid steel battens are required. No further painting or finishing is required. The panels are generally available in 40 mm thickness.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the PVC-foil surface finish is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. Since the surface is jointed, however, its use will be limited to areas where ‘seamless’ ceiling surfaces are not required.

'''Access to services'''

Access panels are easily accommodated where the suspended grid system is utilised. Where nail-up systems are installed, access panels need to be planned in the ceiling prior to installation.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They do not require repainting or maintenance apart from occasional cleaning. Replacement of damaged panels in the suspended grid is not disruptive.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ‘healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 - noncombustible materials only. Fire-rating of the suspended grid should also be considered.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The excellent insulation properties of the polystyrene will reduce the heat load and act as a bulk insulator. The manufacture of expanded polystyrene panel does not require the use of CFCs and no adhesives are used to install the product.

'''Aesthetics'''

The wood-grain or random textured embossing creates interest in the surface of the ceiling. The board has a slightly shiny finish.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.

==Timber and timber composites==
'''General description and properties'''

Timber products have been used in ceilings for many generations. The most common locally available timber is maranti and pine - in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of fitting ceilings - from standard tongue and groove planks, to slatted battens. The timber is usually varnished or treated with a preservative. Engineered timber products are also available with melamine or veneer finishes.

'''Infection prevention'''

Timber is a source of nutrient to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based antibacterial varnish containing silver has superior microbial and chemical resistance, and will extend the life span of the timber. Medium-density fibreboards (MDFs) with melamine/veneer finishes could be installed in suspended grids.

'''Access to services'''

Access panels in a timber ceiling would need to be planned before the installation, and a purpose-made hinged or removable door created. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required. Where suspended grids are installed, this provides easy access to services.

'''Cleaning and maintenance'''

The timber slats or planks are washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered MDF ceiling panels do not require repainting and should not be put in contact with water, but cleaned by dry brushing/vacuuming. These panels can easily be replaced however, where installed in a suspended grid.

'''Fire safety'''

In terms of SANS 10400, timber is combustible and not permitted for use in ceilings for the Occupancy E2 (hospitals). It is however permitted under certain conditions for E3 and E4 occupancies.

'''Indoor air quality: Humidity'''

Well-varnished timber will be protected from the effects of moisture, but generally, timber should not be used in rooms where humid, moist conditions persist. MDF ceiling panels are not suitable for humid or wet areas.

'''Indoor air quality: Emissions and insulation'''

Timber is a natural product that does not emit VOCs. However, engineered timber products such as mediumdensity fibre-board contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognized as being the highest formaldehyde emitting pressed wood product. (source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product specific literature. The timber planks or engineered panels do not provide much insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics''' <br />The perforated surface of the slatted ceiling or MDF tiles aid in reducing the re-transmission of sound. MDF acoustic tiles are specifically manufactured for their superior performance in absorbing sound.
[[File:Timber and timber composites.jpg|thumb|none]]

=Performance=

==Performance categories==
The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility
[[File:Performance category.png|thumb|none]]

*Skimmed or plastered and painted – seamless ceiling

Examples of ceiling materials or finishes for Class 2 (typical room – general ward):

*Vinyl-clad or pressed metal tiles in grid, etc.

Examples of ceiling materials or finishes for Class 3 (typical area – dirty utility):

*Skimmed or plastered and painted – jointed, vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Examples of ceiling materials or finishes for Class 4 (typical area – office or waiting room):

*Acoustic ceiling tiles in grid; timber and composite panels, etc.

Examples of ceiling materials or finishes for Class 5 (typical area – plant room):

*Expanded or extruded polystyrene; skimmed or plastered and painted – jointed; vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Refer to Table 2 – Matrix of recommended performance categories to establish what performance category the ceiling of the room in question will require – this could be a number of options in some cases.

==Performance categories recommended per room==
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" |'''1 2 3 4'''
|'''5'''
|-
| rowspan="22" |'''Acute In-patient Wards (Adults)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Day Lounge (patients)'''
|
|
|
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurse Station '''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Administration Department'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Offices/Interview Rooms'''
|
|*
|*
|*
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Boardroom'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Print room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Casualty and Trauma'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Hazmat Shower'''
|*
|
|
|
|
|-
|'''Minor Theatre/Suture Room'''
|*
|
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="12" |
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs'''
|
|
|*
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Scrub area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Central Sterilising and Supply Department (CSSD)'''
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Packing'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Sterile Storage'''
|
|*
|
|
|
|-
|'''Sterilisation (autoclaves)'''
|
|*
|
|
|
|-
|'''Trolley Wash'''
|
|*
|
|
|
|-
|'''Washing and Disinfecting Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Community Health Centre'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dental Surgery'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Isolation/Separate Nursing Ward'''
|*
|
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|
|
|-
|'''Offloading or Holding Area for Pharmacy'''
|
|
|
|
|*
|-
|'''PABX/Server Rooms'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-Assisted Ablution'''
|
|
|*
|
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs and Change Rooms'''
|
|
|*
|
|
|-
|'''Reception/Nurses’ Station '''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="14" |

|'''Records Room'''
|
|
|*
|
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|*
|
|
|
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Ward'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''X-Ray Room'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Day Clinic (Department)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient Waiting '''
|
|
|
|*
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Scrub Area'''
|*
|
|
|
|
|-
|'''Setting Area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurses’ Station '''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''High Care or Cardiac Care Unit (HC/CCU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|}

{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
|
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="15" |'''Intensive Care Unit (ICU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Kitchen – (Main Hospital)'''
|'''Bulk Dry Goods Store'''
|
|*
|
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Cold Room/Freezer'''
| colspan="4" |specialised
|
|-
|'''Cooking Area '''
|
|*
|
|
|
|-
|'''Cutlery/Crockery Store'''
|
|*
|
|
|
|-
|'''Dishwashing and Potwashing Area'''
|
|*
|
|
|
|-
|'''Food Preparation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|
|*
|
|
|-
|'''Plating/Serving Area'''
|
|*
|
|
|
|-
|'''Receiving Area'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|*
|*
|
|-
|'''Trolley Wash Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="17" |'''Laboratory'''

'''(Pathology/Cytology/Haemato logy/Chemistry) '''

'''(Biosafety Level 2)'''

''' '''

''' '''
|'''Blood and Blood Products Store'''
|
|*
|
|
|
|-
|'''Cell and Tissue Laboratory'''
|
|*
|
|
|
|-
|'''Cytopathology Sample Storage'''
|
|*
|
|
|
|-
|'''Clinical Material Store'''
|
|*
|
|
|
|-
|'''Disposal Area (dangerous materials)'''
|
|
|
|
|*
|-
|'''Drug and Vaccines Store'''
|
|*
|
|
|
|-
|'''Flammable Goods Store (external)'''
|
|
|
|
|*
|-
|'''Gas Cylinder and Pressure Vessel Store'''
|
|
|
|
|*
|-
|'''Hazardous Substances Store'''
|
|
|
|
|*
|-
|'''Histopathology Laboratory'''
|
|*
|
|
|
|-
|'''Microbiology Laboratory'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POCT consulting room'''
|
|
|*
|
|
|-
|'''Reagents/Chemical Stores'''
|
|
|
|
|*
|-
|'''Records Rooms'''
|
|
|*
|
|
|-
|'''Sample Collection Laboratory'''
|
|*
|
|
|
|-
|'''Specimen Reception and Sorting Rooms'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="4" |
|'''Stores (protective clothing/equipment)'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room (including lockers)'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Laundry – (Main Hospital)'''
|'''Assembly, Packing and Dispatch'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|*
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pressing '''
|
|
|*
|
|
|-
|'''Sorting'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Washing Room'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="21" |'''Maternity/Delivery Department'''
|'''Baby Bathing Area'''
|
|
|*
|
|
|-
|'''Circulation '''
|
|
|
|*
|
|-
|'''Delivery Suite'''
|*
|
|
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''First Stage Room'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Nurse Station'''
|
|
|
|*
|
|-
|'''Nursery'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Viewing Area'''
|
|
|
|*
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="12" |'''Mental Health Facility'''
|'''Body Room'''
|
|*
|
|
|
|-
|'''Children's Play Area'''
|
|
|
|*
|
|-
|'''Clean Utility'''
|
|
|*
|
|
|-
|'''Cleaners’ Room/Station'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Counselling Room'''
|
|
|
|*
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Dirty Utility (Sluice)'''
|
|
|*
|
|
|-
|'''ECT Procedure Room'''
|
|*
|
|
|
|-
|'''En Suite Bath/Shower Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Group Therapy Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="24" |
|'''Gymnasium (OT and physio)'''
|
|*
|
|
|
|-
|'''IT Room'''
|
|
|*
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Medicine Store'''
|
|*
|
|
|
|-
|'''Multi-Purpose Hall'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient-Assisted Bathroom/Shower'''
|
|
|*
|
|
|-
|'''Patient Dining Room'''
|
|
|
|*
|
|-
|'''Patient Laundry'''
|
|*
|
|
|
|-
|'''Patient Lounge'''
|
|
|
|*
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Quiet Room'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Seclusion Room'''
|*
|
|
|
|
|-
|'''Security Control Room'''
|
|
|*
|
|
|-
|'''Security Search Room'''
|
|
|*
|
|
|-
|'''Staff Change Room and WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Waste Disposal Room'''
|
|
|
|
|*
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''Mortuary'''
|'''Blue Room'''
|
|*
|
|
|
|-
|'''Circulation Space'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Instruments Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Medical Observation Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pathologist Change Room'''
|
|
|*
|
|
|-
|'''Post-Mortem Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Viewing Room'''
|
|
|
|*
|
|-
|'''Visitors’ Waiting Room'''
|
|
|
|*
|
|-
|
|
|
|
|
|
|
|-
| rowspan="13" |'''Neonatal Intensive Care Unit'''

'''(NICU)'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Incubator Ward Area'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Mothers’ Rest Area'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="2" |
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Operating Theatre (Department)'''
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|*
|
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Nurses’ Station'''
|
|
|*
|
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Post-Operative Recovery Area'''
|
|*
|
|
|
|-
|'''Pre-Operative Holding Area'''
|
|*
|
|
|
|-
|'''Scrub-up Area/Room'''
|
|*
|
|
|
|-
|'''Setting Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="22" |'''Outpatients Department '''
|'''Reception/Nurses’ Station'''
|
|
|
|*
|
|-
|'''Admissions Room'''
|
|*
|*
|*
|
|-
|'''Baby Changing Area '''
|
|
|
|*
|
|-
|'''Children’s Play/Waiting Area'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POPS Room'''
|
|*
|
|
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|'''Wheelchair Storage Area'''
|
|
|*
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="11" |'''Paediatric Ward'''
|'''Child-Assist Ablution'''
|
|
|*
|
|
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility (isolation)'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="11" |
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk/Ward Kitchen'''
|
|*
|
|
|
|-
|'''Nurses’ Station '''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Parent Ablutions'''
|
|
|*
|
|
|-
|'''Play Area (patients)'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Pharmacy/Dispensary'''
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Bulk Stores'''
|
|
|
|
|*
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Counselling Cubicle'''
|
|
|
|*
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Liquid Filling Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Offloading Bay'''
|
|
|
|
|*
|-
|'''Patient Waiting Room'''
|
|
|*
|
|
|-
|'''Schedule Drugs Strong Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Tablet Packing Room'''
|
|*
|
|
|
|-
|'''Vacolitre Stores'''
|
|
|
|
|*
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Physiotherapy Department'''
|'''Audiology Testing'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Gymnasium'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Occupational Therapy Room'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Speech Therapy'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Primary Health Clinic'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary and Pharmacy'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation/Rehydration Area'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="12" |
|'''Office'''
|
|*
|*
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|
|
|
|*
|-
|'''Waiting Area (public)'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="25" |'''Radiology (Diagnostic)'''
|'''Bucky Room (general X-ray Room)'''
|
|*
|
|
|
|-
|'''Change Cubicles'''
|
|*
|
|
|
|-
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''CT/MRI Scan Room'''
|*
|
|
|
|
|-
|'''Dirty Utility/Sluice'''
|
|
|*
|
|
|-
|'''Fluoroscopy Room'''
|
|*
|
|
|
|-
|'''Fluoroscopy Control Room'''
|
|*
|
|
|
|-
|'''Inpatient Waiting Area'''
|
|*
|
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Mammogram Room'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Public Waiting Area'''
|
|*
|*
|
|
|-
|'''Porters and Wheelchair/Trolley Parking'''
|
|*
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Server Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Stores (Equipment/General)'''
|
|
|
|
|*
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Telemedicine Room'''
|
|
|
|*
|
|-
|'''Viewing Room/CR Room/Reporting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Residences (e.g., Nurses)'''
|'''Ablutions'''
|
|
|*
|
|
|-
|'''Bedrooms'''
|*
|*
|*
|*
|
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Lounge'''
|
|
|
|*
|
|-
|'''Offices'''
|
|
|
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|}

=Definitions=

==Terminology==
''Aggregation    Collected together from different sources and considered a whole.''

''Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.''

''Bacteriostatic    A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.''

''Bariatric Describing the condition of obesity.''

''Bonded Chemically attached or fused in layers.''

''Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.''

''Homogenous Consisting of things of similar type throughout.''

''Heterogeneous Consisting of various layers or types throughout.''

''Hygroscopic Readily absorbing moisture from the atmosphere.''

''Hydrophobic Water-repellent.''

''Impervious Not allowing passage through (usually of water/moisture).''

''Interstices Small holes or perforations. ''

''Jointed Junctions which may be open or covered, but not completely sealed and smooth.''

''Jointless Without joints or having joints, which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.''

''Olfactory Relating to the smell or the sense of smell.''

''Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.''

''Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.''

''Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed,'' '''resilient''' ''flooring'' ''refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.''

''Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.''

''Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail. ''

''Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.''

''Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.''

''Tufted A group of threads drawn through a fabric and tied securely beneath the surface.''

''Vitrified To change a material into glass, under high heat and other conditions.''

''Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.''

''Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.'' ''' '''

==Abbreviations==
{| class="wikitable"
|''CFC''
|''Chlorofluorocarbon''
|-
|''CHD''
|''Centre for Health Design''
|-
|''ENT''
|''Ear, nose and throat''
|-
|''HAI ''
|''Healthcare-associated infections ''
|-
|''HCFC''
|''Hydrochlorofluorocarbon''
|-
|''HDF''
|''High-density fibreboard''
|-
|''IEQ''
|''Indoor Environmental Quality''
|-
|''IUSS ''
|''Infrastructure Unit Systems Support''
|-
|''MDF''
|''Medium-density fibreboard''
|-
|''MRSA   ''
|''Methicillin-resistant staphylococcus aureus, (which is a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria''
|-
|''NDoH ''
|''National Department of Health''
|-
|''OoM ''
|''Order of Magnitude''
|-
|''PMIS ''
|''Project Management Information System''
|-
|''PMSU ''
|''Project Management Support Unit''
|-
|''PuR''
|''Polyurethane-resistant''
|-
|''PVC''
|''Polyvinylchloride''
|-
|''RC ''
|''Recommendation Committee''
|-
|''VOC   ''
|''Volatile organic compound''
|}

=References=

==Bibliography==
Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

AASA, the School Suprintendents Association, 2009. ''Improving indoor air quality: Materials selection.'' [online] Alexandria, Egypt: AASA. Available at: <nowiki>http://www.aasa.org/search.aspx?query=Materials+Selection+</nowiki>[Accessed 9 April 2014].

Cement & Concrete Institute (CCI), 2009. ''Sand-cement screeds and concrete toppings for floors.'' [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. ''Floor coverings in healthcare buildings.'' (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. ''Finishes''. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. ''Core elements: Health Building Note 00-03: Clinical and clinical support spaces''. UK: DH.

Department of Health (DoH), 1980. ''Regulations governing private hospitals and unattached operating theatres.'' (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. ''Health''

''Technical Memorandum 61: Building component series flooring.'' [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. ''Performance requirements for building elements used in healthcare facilities.'' (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. ''R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes.'' Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. ''Sound practices: Noise control in the healthcare environment.'' (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. ''Healthcare environmental terms and outcome measures: An evidence-based design glossary.'' Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. ''Applied and Environmental Microbiology'', 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, ''18th CIB World Building Congress: Facilities management and maintenance''. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. ''Achieving EBD goals through flooring selection & design.'' [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 56: Building component series: Partitions.'' UK: TSO.

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 60: Ceilings.'' 2<sup>nd</sup> ed. UK: TSO.

NHS, National Services Scotland, 2006. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. ''Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning.'' (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. ''The role of hospital design in the recruitment, retention and performance of NHS nurses in England.'' (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. ''Health Building Note 04-01: Adult in-patient accommodation''. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. ''The Science of the Total Environment,'' 227(1999), pp.197-213

==Websites: Further reading ==
<nowiki>https://www.transparency.perkinswill.com</nowiki>

<nowiki>http://www.gatech.edu</nowiki>

<nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki>

<nowiki>http://www.green-buildings.com</nowiki>

<nowiki>http://www.healthcaredesignmagazine.com</nowiki>

<nowiki>http://www.isoboard.com</nowiki>

<nowiki>http://www.isolite.co.za</nowiki>

<nowiki>http://www.everite.co.za</nowiki>

<nowiki>http://www.armstrong.com</nowiki>

<nowiki>http://www.owa.co.za</nowiki>

=Photographic and illustration credits=
Cover photo: M. Swinney
{| class="wikitable"
|Fig.1
|M. Swinney
|-
|Fig.2 to 5
|Diagram by C. Hiralal
|-
|Fig.6
|R.Cubbin based on Lifecycle Floor Cost Table – by Nora®, USA
|-
|Fig.7
|G. Abbott- CSIR
|-
|Fig.8
|R.Cubbin
|-
|Fig.9
|M. Swinney
|-
|Fig.10
|R. van Rensburg
|-
|Fig.11
|M. Swinney
|-
|Fig.12
|R. van Rensburg
|-
|Fig.13 to20
|M. Swinney
|-
|Fig.21
|R. van Rensburg
|-
|Fig.22
|M. Swinney
|-
|Fig.23
|R. Cubbin
|-
|Fig.24
|M. Swinney
|-
|Fig.25
|R. Cubbin
|-
|Fig.26 to28
|M. Swinney
|}
<br />{{Expand}}
{{DEFAULTSORT:Materials and finishes - Internal ceiling finishes}}
[[Category:Crosscutting Issues]]

Materials and finishes - Internal Floor Finishes

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Materials and finishes - Internal Wall Finishes

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[[Category:Crosscutting Issues]]

Materials and finishes - Internal Wall Finishes

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Materials and finishes - Internal Wall Finishes

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Materials and finishes

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=Internal Ceiling Finishes in Healthcare Facilities=

=Context=

==Overview – finishes in the healthcare environment==
<br />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.
[[File:Facility finishes.png|thumb|none]]

==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.

'''How to use this document:'''

#Review the Selection Criteria - Part B
#Select a Room / Department name in Part D, and note Performance Category
#Refer to Table 1 for the Properties that make up that Performance category
#Refer to Part C to assess ceiling types that could satisfy those performance requirements.

'''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 <u>www.iussonline.co.za</u>

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.

==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:

SANS 204 Energy-Efficiency in buildings general

SANS 622 Gypsum cove cornice

SANS 637 Wood-wood panels (cement-bonded)

SANS 640 Flexible PU-foams

SANS 803 Fibre cement boards

SANS 1039 Wooden ceiling and panelling boards

SANS 1381 Materials for thermal insulation boards

SANS 1508 Expanded polystyrene thermal insulation boards

SANS 1783 Softwood brandering and battens

SANS 6013 Dimensional and mass stability of particle boards with varying humidy

SANS 6016 Transverse tensile strength of particle boards

SANS10177 Fire-testing of materials

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

=Selection Criteria=

==Scope==
A ceiling in any facility forms the third dimension in any given room area, along with the walls and the floor, and it sometimes separates the roof space from the occupied area below. The manner 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.
[[File:Ceiling.png|thumb|none]]
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.
[[File:Actual Soffit of structure overhead.png|thumb|none]]

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.
[[File:Membrane fixed directly to the structure overhead.png|thumb|none]]

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.
[[File:Membrane suspended from the structure overhea.png|thumb|none]]

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

==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

===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.

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

==Life cycle costing and sustainability==
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 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 importance of life cycle costs.
[[File:Capital outlay costs vs life span costs.png|thumb|none]]

Sustainability should be considered in all four stages of product life:

*Manufacture
*Use
*Maintenance
*Disposal

[[File:Product life sustainability.png|thumb|none]]

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.
[[File:Life cycle costing and sustainability diag.png|thumb|none]]

===Toxicity and effect on indoor environment===
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)
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.

'''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.
[[File:Toxicity and effect on indoor environment diag.jpg|thumb|none]]

==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)

[[File:Facility design.png|thumb|none]]

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.

==Selection criteria==

===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.”
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)
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.

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.
“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 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 also carried out microbiological studies comparing patient rooms with and without carpet. The study found higher microbial counts and more E.coli and other organisms on carpet samples than bare floors.

While this issue may not affect the selection of a ceiling finish, there are principles to be borne in mind when establishing what finish is best in high-risk environments.
[[File:Selection criteria diag.png|thumb|none]]

Below is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Although ceilings are out of reach and therefore less affected by regular touching, airborne bacteria can be carried on circulating mechanical ventilation, and aerosol contaminants which are distributed when water is splashed, (Ayliffe et al., 2000) can carry pathogens to ceiling level.

Ceiling materials and finishes that resist the spread of infection will have qualities that can be summarised as follows:

*Smooth
*Impervious
*Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, ceilings will have the following properties:

*Textured
*Perforated
*Jointed

[[File:Selection criteria diag 2.jpg|thumb|none]]

Certain materials have been shown to inhibit bacterial growth – such as vinyl, PuR and natural materials such as cork. This will also contribute to the prevention of infection. Ceilings with these properties will have the following quality:

*Bacteriostatic

'''A note about anti-bacterial treatments and additives to ceiling products:'''

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

Synthetic fibres such as polypropylene textile and vinyl for example, in themselves do no provide a nutrient source which microbes need to survive, but some finishes can trap soil, dust and moisture which do provide that source.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risks and benefits to healthcare users.

==Cleaning and maintenance==
Connected with infection prevention is the issue of cleaning. Ceilings tend to have ’reactive’ cleaning regimes, rather than regular cleaning programmes. This is partially because the ceiling gives an impression of cleanliness, but this can be misleading.

Whether the materials/finish of a ceiling can be cleaned thoroughly will define the extent to which infectious agents can be prevented from multiplying on a surface. Some materials can tolerate a reasonable amount of moisture, facilitating regular washing, while others would be adversely affected by it and can only be dusted or wiped.
[[File:Cleaning and maintenance diag.jpg|thumb|none]]

For cleaning to be effective, the surface must be able to withstand regular and fairly vigorous cleaning, with proper access to all surfaces. Where there are small recesses or difficult to reach corners, dirt is easily trapped providing dark, undisturbed conditions – the perfect breeding area for bacteria.

Information regarding cleaning materials should also be considered, as solvents and cleaning agents can quickly cause deterioration of the finish if it is not robust enough to withstand the cleaning required.

A further aspect to consider is the disruption that will be required to carry out the cleaning regime and possible maintenance. This is pertinent to areas such as operating theatres that may remain in use 24 hours a day.

Where there is a high requirement for regular cleaning of a ceiling in view of its location in a sensitive area, together with a need for minimal disruption for maintenance, the ceiling properties could be summarised as:

*Washable
*Low maintenance

[[File:Cleaning and maintenance diag 2.jpg|thumb|none]]

An additional consideration in the selection of ceiling finishes in health facilities in terms of maintenance is the provision of access to services in the ceiling void. Health facilities will generally require a high concentration of various services, most of which run in the ceiling void.

This will include electrical power and lighting, data, nurse call systems, medical gas and vacuum lines, air-conditioning and extract ducts, as well as hot water and waste pipes to name a few. Although service ducts and shafts can alleviate this congestion in the ceiling, distribution on the horizontal plane will nonetheless be required.

By selecting ceiling types that cater for easy access and giving thought to the best positions for these access panels - even marking these panels where necessary - this will facilitate easier maintenance of in-ceiling services during the life span of the building. This in turn will reduce ’downtime’, and disruption of the health facility.
[[File:Access panel.jpg|thumb|none]]

While the location of access panels is determined by the layout of services, certain rooms or areas will be more suitable for these panels.

*No combustible materials are permitted in ceilings or roof structures for buildings classified as hospitals.
*Medical facilities and healthcare categories are classified separately and have different requirements.
*Strict parameters are given for the depth of ceiling voids and this is related to the need for sprinklers when the voids exceed a given depth.
*Compartmentalisation of the ceiling void is required in area and distance, with fire stops.
*A dedicated section is written regarding operating theatres and intensive, high and critical care units, stipulating 120 min fire resistance for division separations.
*A full list of materials deemed to be non-combustible is provided.

This has been listed as the property:

*Access panels

===Safety===
Unlike floors which can prevent - or contribute to - falls by patients and staff, ceilings are largely out of reach and need not be assessed for safety as is relevant to floors. The safety aspect of fire performance does however need to be highlighted. The SANS 10400 lists specific requirements for hospitals and medical facilities with regard to ceilings. This is aimed at protecting the patients who are most likely frail, may not be able to walk, and would require assistance and more time to escape in the event of fire.

The definitions in the SANS 10400: Part A read:

*E2 Hospital

Occupancy where people are cared for or treated because of physical or mental disabilities, and where they are generally bedridden.

*E3 Other institutional (residential)

Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

*E4 Healthcare

Occupancy which is a common place of long term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

These requirements are set out in Part T of SANS 10400, and include:

All ceilings in hospitals would need to be non-combustible material. In other health facilities, such as community health centres or clinics, there are exceptions to the non-combustible requirement, subject to compliance with certain conditions. Since each project varies, the advice of a competent fire engineer should be obtained.

==Indoor air quality==
There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality. The first is he effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces, The second is the effect of the material on the floor material - namely the emission of volatile organic compounds.
[[File:Indoor air quality diag.jpg|thumb|none]]

===Humidity===
Certain rooms and areas of health facilities are by nature of the function they house - wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture-resistant finishes. If the ceiling panels or surfaces are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a ceiling finish, this property will be listed as:

*High humidity

===Emissions from materials===
As discussed under Environmental Aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off by – commonly referred to as off-gassing:

*The product itself, along with its structure
*The adhesives used to fix the product or its layers
*The paints or sealants used to finish
*The cleaning solutions required for regular maintenance

[[File:Emissions from materias diag 1.jpg|thumb|none]]

People who work in noisy environments for long shifts day in and day out, also have similar stress-induced experiences. They report everything from exhaustion to burnout, depression and irritability”
The smell of the interior of a new car - enjoyed by many is an example of plasticizers that have evaporated - emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality. The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels’ outlines.

IEQ14 section measured the formaldehyde minimisation which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used.

It should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.
Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space
Patients with respiratory weaknesses such as asthma are most likely to be affected by VOC emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility. Materials such as paints and polyvinyl-chlorides can emit VOCs which can have a negative effect on indoor air quality.

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. VOCs can also cause irritation and odour annoyance, and could lead to behavioural, neurotoxic, hepatoxic and genotoxic effects (Meininghaus et al., 2000; Hoskins, 2003; Hodgson et al., 2000.)
[[File:Emissions from materias diag 2.jpg|thumb|none]]

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of enamel paint on plaster, for example, may result in higher VOC emissions than say, a pre-finished lay-in ceiling board, but the infection control benefits of the seamless finish will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) Ceilings often present an opportunity to reduce the heat load on rooms from the roof space through insulation. This could form part of the ceiling material itself or be laid over the ceiling.

==Acoustics==
Noise in health facilities is mainly generated by:

*Impact sounds e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.
*Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LA<sub>eq</sub>) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization’s recommended LA<sub>eq</sub> value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November, 2005 showing that chronic noise increased the risk of heart-attack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.
[[File:Acoustics diag 1.jpg|thumb|none]]

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. 2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Sound-absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:
High acoustic
[[File:Acoustics diag 2.jpg|thumb|none]]

==Aesthetics==
Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results of a study by Becker and Douglass (2008), show that the physical appearance of the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Reflectivity of the ceiling material can boost natural light in a room or alternately produce glare - both of which have a direct impact on the comfort levels in the room. By ensuring skylights are oriented correctly, and shaded appropriately, natural light could be introduced through the ceiling.
[[File:Aesthetics diag.jpg|thumb|none]]

The ceiling surface finish should complement the function of the room, and monotony for the sake of economics should be avoided, bearing in mind that most patients will be focused on the ceiling for the duration of their stay.

Printed ceiling tiles, or polycarbonate panels with vinyl film images, behind which lighting can be introduced, could be used in key areas. This can transform a dull ward ceiling into a fascinating window to the outside world. CABE (2004) highlights the need for patients to have a ’connection with nature’, and these ceiling ‘windows’ are the ideal opportunity to supplement views to the exterior.

Natural light is a key factor in creating an environment for patient recovery. The occupants of the ward should be considered – paediatric wards are opportunities for playful scenes that will help little patients feel at ease.

In public areas where more emphasis might be placed on an attractive and welcoming interior than other factors, then this factor would be listed as:

   • High aesthetics

=Technical Information - Ceiling Types=

==Paint on seamless plaster==
'''General description and properties'''

Paint is easily applied by roller to a plastered ceiling soffit. The soffit could be constructed from plasterboard sheets, which are then skimmed or from concrete. Note that the structure onto which the plasterboard is fixed would need to be non-combustible if the facility is a hospital. Following a primer and undercoat, usually three coats of paint are applied. Two-coat plaster or skimming is highly recommended prior to painting, as defects will be highlighted with the high-gloss type paints.

Paint types that can be applied to the ceiling soffit will vary between oil-based and water-based types. Enamel paint dries to a hard, glossy, finish. It is usually oil-based. Velvet sheen paints are water-based, but produce a less glossy finish. PVA-paints are also water-based, but produce a matt finish. Paint is fairly inexpensive when compared to other ceiling finishes - excluding the structure.
[[File:Paint on seamless plaster diag.jpg|thumb|none]]

'''Infection prevention'''

The smooth seamless finish produced by painted concrete or plasterboard ceilings, make this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Paints with nanotechnology enhancements are also being developed. These paints inhibit the growth of algae and fungus.

'''Cleaning and maintenance'''

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant. Paint is a low maintenance finish which may require re-application every few years, unless latent defects arise.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Paint on a concrete soffit is considered a non-combustible finish as the thickness of the paint is usually less than

0.5 mm – refer to manufacturers’ specifications, and consult with the SANS Part T (4.13).

'''Indoor air quality: Humidity'''

Generally, paints are not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Enamel paints are most resistant to absorbing moisture, when compared to PVA-type paints.

'''Indoor air quality: Emissions and insulation'''

Paints are notorious for high VOC emissions, although manufacturers are now working on products with reduced or zero VOCs. Refer to product specific literature.

'''Acoustics'''

The hard surface of painted soffits reflects sounds and where acoustics are important, there are certainly better options available.

'''Aesthetics'''

While paint can be used effectively to introduce colour for features or emphasis, generally on ceilings in areas where infection prevention is important, the ceilings should be kept single colours - white or light colours – this ceiling would be used in areas where aesthetics is not the highest priority.

==Cementitious board – nail-up ceilings==
'''General description and properties'''

Plain and textured ceiling boards are available for nail-up applications where joints are not a problem. These boards are manufactured from a combination of cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses, and can be nailed at regular intervals to the overhead structure.

The joints between the ceiling boards can be finished using joiners or cover-strips. The ceiling boards can also be fixed between exposed beams.

Although no paint finish is required, paint can be applied. (Refer to comments on paint on plaster above.)
[[File:Cementitious board – nail-up ceilings diag.png|thumb|none]]

'''Infection prevention'''

The textured boards and the joining strips will create areas where microbes can grow. This ceiling finish is therefore not suitable for areas where infection prevention is critical.

'''Cleaning and maintenance'''

Nail-up cementitious boards are unaffected by moisture and resistant to corrosion. When painted they are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is possible if boards do get damaged, but this would be disruptive to the functioning of the room.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Nail-up cementitious boards are non-combustible.

'''Indoor air quality: Humidity'''

These painted boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the building from roof spaces where applicable. Fibres are safe and recyclable, and manufacturers claim low embodied energy used for assembly and construction. Refer to product specific literature. Emissions from paints should be considered.

'''Aesthetics'''

This type of ceiling board is aesthetically acceptable, and with paint, can be used to create an interesting functional ceiling.

'''Acoustics'''

The hard surface reflects sound and will not aid in sound absorption in the room it covers.

==Vinyl-clad ceiling tiles in suspended grid==
'''General description and properties'''

Vinyl-clad ceiling tiles are manufactured from cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses and are clad on the exposed surface with vinyl. They are suitable for 1 200 x 600mm or 600 x 600mm exposed ceiling grids. The grids are suspended from the structure above. The ceiling tiles can also be supplied with 25 mm insulation backing. No further painting or finishing is required.

'''Infection prevention'''

The vinyl finish is impervious, and vinyl inhibits the growth of bacteria. The boards are unaffected by moisture, and can be washed regularly. This makes them suitable for infection prevention. There are however joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

As mentioned, the vinyl-clad tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is very easy if boards do get damaged, with very little disruption to the room function.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Fire safety'''

Vinyl-clad boards are non-combustible; however, fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the room. Fibres are safe and recyclable, (no asbestos fibres) and manufacturers claim low embodied energy used for assembly and construction. However, the vinyl has low VOC emissions, when compared to some paints. Refer to product specific literature.

'''Aesthetics'''

This type of ceiling board gives a hygienic impression and is aesthetically acceptable. Tiles can also be printed with designs where budgets allow.

'''Acoustics'''

The surface is relatively hard, and does not assist with acoustic control or absorb sounds.
[[File:Vinyl-clad ceiling tiles in suspended grid.jpg|thumb|none]]

==Acoustic ceiling tiles in suspended grid==
'''General description and properties'''

These mineral fibre acoustic ceiling tiles – nominally 20 mm thick - have a pre-painted textured and perforated finish. The boards can be supplied with various edge finishes suitable for an exposed grid, or recessed grid with regular or chamfered edges. They are suitable for 1200 x 600mm or 600 x 600mm ceiling grids. The grids are suspended from the structure above. No further painting or finishing is required.

'''Infection prevention'''

The fissured surface may harbour dust and bacteria, making this type of ceiling board unsuitable for areas where infection prevention is critical – such as theatres. Some manufacturers do produce an ‘anti-microbial’ tile. Refer to the section on Selection Criteria- Infection Prevention for more discussion on this aspect. The boards cannot be washed as they will absorb moisture. Dirty or stained panels can be replaced easily. There are also joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

Since the boards are adversely affected by moisture, they can only be brush-cleaned and must be kept dry. Dirt often gathers where air-conditioning ducts blow across these tiles, and these then are difficult to clean. They are lightweight and fairly low maintenance. Replacement is very easy if boards do get damaged, with very little disruption to the room function, although batch colours and textures may vary.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Indoor air quality: Humidity'''

These boards are unsuited to areas of high humidity as they absorb moisture and will swell and droop over time when exposed to moist conditions.

'''Indoor air quality: Emissions and insulation'''

These boards provide some thermal insulation which will reduces the heat load of the building. The tiles do have low VOC emissions which will vary according to the manufacturer. Refer to product specific literature.

'''Aesthetics'''

The patterns of the fissures on this type of ceiling tile can create an interesting ceiling which is aesthetically acceptable.

'''Acoustics'''

The perforated surface is excellent for sound absorption and this product is well-suited to areas where noise reduction is prioritised.
[[File:Acoustic ceiling tiles in suspended grid.png|thumb|none]]

==Pressed metal ceiling tiles in suspended grid==
'''General description and properties'''

Pressed metal tiles are manufactured from galvanised steel, and are then epoxy-coated for a durable finish. The ceiling tiles are made to a variety of sizes. Stainless steel tiles are also available. Perforations are made in the surface – in different patterns and diameter to reduce the weight and improve acoustic performance. They are laid in a suspended ceiling grid, or can be hinged to the grid to open downwards. No further painting or finishing is required.

'''Infection prevention'''

The perforated surface may harbour dust and bacteria, and the joints mean the ceiling is not seamless. This type of ceiling is not suitable for areas where infection prevention is critical. The tiles are however washable.

'''Access to services'''

The hinged access tiles are purpose-made for access to services in the ceiling void as they are hinged to swing down leaving the void clear of grid transoms. The lay-in type of panel is also removable in a suspended grid ceiling, allowing for maximum flexibility for access to services in the ceiling void.

'''Cleaning and maintenance'''

The epoxy-coated tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stainresistant. They are robust and unlikely to be damaged easily, making them very low maintenance and durable. Replacement is easy if tiles do need replacing, with very little disruption to the room function.

'''Fire safety'''

Metal is listed as non-combustible in the SANS Part T as tested under 10177-5, however fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The metal tiles are generally made from recycled material and can also be recycled. Refer to product specific literature. The tile itself does not provide any insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically-pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics'''

The perforated surface contributes to sound absorption and compensates somewhat for the hard, reflective metal surface.
[[File:Pressed metal ceiling tiles in suspended grid.jpg|thumb|none]]

==Rigid extruded polystyrene panels (XPS)==
'''General description and properties'''

Polystyrene ceiling panels combine the aesthetic of a ceiling panel with the insulation properties of closed-cell insulation board. These panels are manufactured from high-density rigid extruded polystyrene. These can be supplied smooth for a flush appearance, bevelled to pronounce the 600 mm joint, or grooved at 100 mm intervals to resemble tongue and groove timber planks. Although neatly finished, painting with PVA is recommended. The boards can be fitted over-purlin, nailed-up to brandering, or between exposed trusses, and should be ordered in long lengths to avoid butt-joints on ends. The panels are available in thicknesses of 25, 30 or 40 mm.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the polystyrene itself is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. In certified tests, (by SANAS accredited laboratory) the rigid polystyrene showed no microbial growth and was declared suitable for use in the food industry. Since the surface is jointed, however, its use will be limited.

'''Access to services'''

Access panels need to be planned in the ceiling prior to installation. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They can however be mechanically damaged, and should preferably be fitted at high levels. Replacement of damaged panels would create a fair amount of disruption.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ’healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 – noncombustible materials only.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The insulation properties of the rigid polystyrene will reduce the heat load and act as a bulk insulator. The Rvalues increase with the thickness from 0.833 (for 25 mm thick board) to 2.667 for 80 mm thickness – double layer). Rigid polystyrene panels have no obvious odour, but under high heat conditions (near heat-generating light fitting , for example), some aromatic hydrocarbons are released. The manufacture of rigid polystyrene panels requires the use of HCFC-gasses, however, the measure of these gasses is at levels less than 150 ppm even where large quantities are stored. The VOC emissions of adhesives used to install the product should also be considered.

'''Aesthetics'''

The tongue and groove pattern creates interest in the surface of the ceiling, and can evoke a homely residential feel to the room/area. This can be used to good effect in healthcare facilities.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.
[[File:Rigid extruded polystyrene panels (XPS).jpg|thumb|none]]

==Expanded polystyrene panels (EPS)==
'''General description and properties'''

These laminated expanded polystyrene panels are made up of low-density fire-retardant board finished with a fire retardant PVC-foil, the surface of which can be embossed or smooth. The layers are bonded under high temperatures. The panels can be supplied full size in 4.8 x1.2 m boards for over-purlin fixing, or cut to suit a suspended ceiling grid (1 200 x 600mm). It can also be installed under purlin or between rafters. PVC H-joiners are used at junctions. Because the panels are very light, wire-hung suspended grids are not recommended, as these could result in drafts lifting the ceiling. Rigid steel battens are required. No further painting or finishing is required. The panels are generally available in 40 mm thickness.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the PVC-foil surface finish is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. Since the surface is jointed, however, its use will be limited to areas where ‘seamless’ ceiling surfaces are not required.

'''Access to services'''

Access panels are easily accommodated where the suspended grid system is utilised. Where nail-up systems are installed, access panels need to be planned in the ceiling prior to installation.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They do not require repainting or maintenance apart from occasional cleaning. Replacement of damaged panels in the suspended grid is not disruptive.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ‘healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 - noncombustible materials only. Fire-rating of the suspended grid should also be considered.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The excellent insulation properties of the polystyrene will reduce the heat load and act as a bulk insulator. The manufacture of expanded polystyrene panel does not require the use of CFCs and no adhesives are used to install the product.

'''Aesthetics'''

The wood-grain or random textured embossing creates interest in the surface of the ceiling. The board has a slightly shiny finish.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.

==Timber and timber composites==
'''General description and properties'''

Timber products have been used in ceilings for many generations. The most common locally available timber is maranti and pine - in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of fitting ceilings - from standard tongue and groove planks, to slatted battens. The timber is usually varnished or treated with a preservative. Engineered timber products are also available with melamine or veneer finishes.

'''Infection prevention'''

Timber is a source of nutrient to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based antibacterial varnish containing silver has superior microbial and chemical resistance, and will extend the life span of the timber. Medium-density fibreboards (MDFs) with melamine/veneer finishes could be installed in suspended grids.

'''Access to services'''

Access panels in a timber ceiling would need to be planned before the installation, and a purpose-made hinged or removable door created. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required. Where suspended grids are installed, this provides easy access to services.

'''Cleaning and maintenance'''

The timber slats or planks are washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered MDF ceiling panels do not require repainting and should not be put in contact with water, but cleaned by dry brushing/vacuuming. These panels can easily be replaced however, where installed in a suspended grid.

'''Fire safety'''

In terms of SANS 10400, timber is combustible and not permitted for use in ceilings for the Occupancy E2 (hospitals). It is however permitted under certain conditions for E3 and E4 occupancies.

'''Indoor air quality: Humidity'''

Well-varnished timber will be protected from the effects of moisture, but generally, timber should not be used in rooms where humid, moist conditions persist. MDF ceiling panels are not suitable for humid or wet areas.

'''Indoor air quality: Emissions and insulation'''

Timber is a natural product that does not emit VOCs. However, engineered timber products such as mediumdensity fibre-board contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognized as being the highest formaldehyde emitting pressed wood product. (source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product specific literature. The timber planks or engineered panels do not provide much insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics''' <br />The perforated surface of the slatted ceiling or MDF tiles aid in reducing the re-transmission of sound. MDF acoustic tiles are specifically manufactured for their superior performance in absorbing sound.
[[File:Timber and timber composites.jpg|thumb|none]]

=Performance=

==Performance categories==
The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility
[[File:Performance category.png|thumb|none]]

*Skimmed or plastered and painted – seamless ceiling

Examples of ceiling materials or finishes for Class 2 (typical room – general ward):

*Vinyl-clad or pressed metal tiles in grid, etc.

Examples of ceiling materials or finishes for Class 3 (typical area – dirty utility):

*Skimmed or plastered and painted – jointed, vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Examples of ceiling materials or finishes for Class 4 (typical area – office or waiting room):

*Acoustic ceiling tiles in grid; timber and composite panels, etc.

Examples of ceiling materials or finishes for Class 5 (typical area – plant room):

*Expanded or extruded polystyrene; skimmed or plastered and painted – jointed; vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Refer to Table 2 – Matrix of recommended performance categories to establish what performance category the ceiling of the room in question will require – this could be a number of options in some cases.

==Performance categories recommended per room==
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" |'''1 2 3 4'''
|'''5'''
|-
| rowspan="22" |'''Acute In-patient Wards (Adults)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Day Lounge (patients)'''
|
|
|
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurse Station '''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Administration Department'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Offices/Interview Rooms'''
|
|*
|*
|*
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Boardroom'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Print room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Casualty and Trauma'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Hazmat Shower'''
|*
|
|
|
|
|-
|'''Minor Theatre/Suture Room'''
|*
|
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="12" |
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs'''
|
|
|*
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Scrub area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Central Sterilising and Supply Department (CSSD)'''
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Packing'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Sterile Storage'''
|
|*
|
|
|
|-
|'''Sterilisation (autoclaves)'''
|
|*
|
|
|
|-
|'''Trolley Wash'''
|
|*
|
|
|
|-
|'''Washing and Disinfecting Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Community Health Centre'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dental Surgery'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Isolation/Separate Nursing Ward'''
|*
|
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|
|
|-
|'''Offloading or Holding Area for Pharmacy'''
|
|
|
|
|*
|-
|'''PABX/Server Rooms'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-Assisted Ablution'''
|
|
|*
|
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs and Change Rooms'''
|
|
|*
|
|
|-
|'''Reception/Nurses’ Station '''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="14" |

|'''Records Room'''
|
|
|*
|
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|*
|
|
|
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Ward'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''X-Ray Room'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Day Clinic (Department)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient Waiting '''
|
|
|
|*
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Scrub Area'''
|*
|
|
|
|
|-
|'''Setting Area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurses’ Station '''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''High Care or Cardiac Care Unit (HC/CCU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|}

{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
|
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="15" |'''Intensive Care Unit (ICU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Kitchen – (Main Hospital)'''
|'''Bulk Dry Goods Store'''
|
|*
|
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Cold Room/Freezer'''
| colspan="4" |specialised
|
|-
|'''Cooking Area '''
|
|*
|
|
|
|-
|'''Cutlery/Crockery Store'''
|
|*
|
|
|
|-
|'''Dishwashing and Potwashing Area'''
|
|*
|
|
|
|-
|'''Food Preparation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|
|*
|
|
|-
|'''Plating/Serving Area'''
|
|*
|
|
|
|-
|'''Receiving Area'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|*
|*
|
|-
|'''Trolley Wash Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="17" |'''Laboratory'''

'''(Pathology/Cytology/Haemato logy/Chemistry) '''

'''(Biosafety Level 2)'''

''' '''

''' '''
|'''Blood and Blood Products Store'''
|
|*
|
|
|
|-
|'''Cell and Tissue Laboratory'''
|
|*
|
|
|
|-
|'''Cytopathology Sample Storage'''
|
|*
|
|
|
|-
|'''Clinical Material Store'''
|
|*
|
|
|
|-
|'''Disposal Area (dangerous materials)'''
|
|
|
|
|*
|-
|'''Drug and Vaccines Store'''
|
|*
|
|
|
|-
|'''Flammable Goods Store (external)'''
|
|
|
|
|*
|-
|'''Gas Cylinder and Pressure Vessel Store'''
|
|
|
|
|*
|-
|'''Hazardous Substances Store'''
|
|
|
|
|*
|-
|'''Histopathology Laboratory'''
|
|*
|
|
|
|-
|'''Microbiology Laboratory'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POCT consulting room'''
|
|
|*
|
|
|-
|'''Reagents/Chemical Stores'''
|
|
|
|
|*
|-
|'''Records Rooms'''
|
|
|*
|
|
|-
|'''Sample Collection Laboratory'''
|
|*
|
|
|
|-
|'''Specimen Reception and Sorting Rooms'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="4" |
|'''Stores (protective clothing/equipment)'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room (including lockers)'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Laundry – (Main Hospital)'''
|'''Assembly, Packing and Dispatch'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|*
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pressing '''
|
|
|*
|
|
|-
|'''Sorting'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Washing Room'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="21" |'''Maternity/Delivery Department'''
|'''Baby Bathing Area'''
|
|
|*
|
|
|-
|'''Circulation '''
|
|
|
|*
|
|-
|'''Delivery Suite'''
|*
|
|
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''First Stage Room'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Nurse Station'''
|
|
|
|*
|
|-
|'''Nursery'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Viewing Area'''
|
|
|
|*
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="12" |'''Mental Health Facility'''
|'''Body Room'''
|
|*
|
|
|
|-
|'''Children's Play Area'''
|
|
|
|*
|
|-
|'''Clean Utility'''
|
|
|*
|
|
|-
|'''Cleaners’ Room/Station'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Counselling Room'''
|
|
|
|*
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Dirty Utility (Sluice)'''
|
|
|*
|
|
|-
|'''ECT Procedure Room'''
|
|*
|
|
|
|-
|'''En Suite Bath/Shower Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Group Therapy Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="24" |
|'''Gymnasium (OT and physio)'''
|
|*
|
|
|
|-
|'''IT Room'''
|
|
|*
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Medicine Store'''
|
|*
|
|
|
|-
|'''Multi-Purpose Hall'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient-Assisted Bathroom/Shower'''
|
|
|*
|
|
|-
|'''Patient Dining Room'''
|
|
|
|*
|
|-
|'''Patient Laundry'''
|
|*
|
|
|
|-
|'''Patient Lounge'''
|
|
|
|*
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Quiet Room'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Seclusion Room'''
|*
|
|
|
|
|-
|'''Security Control Room'''
|
|
|*
|
|
|-
|'''Security Search Room'''
|
|
|*
|
|
|-
|'''Staff Change Room and WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Waste Disposal Room'''
|
|
|
|
|*
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''Mortuary'''
|'''Blue Room'''
|
|*
|
|
|
|-
|'''Circulation Space'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Instruments Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Medical Observation Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pathologist Change Room'''
|
|
|*
|
|
|-
|'''Post-Mortem Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Viewing Room'''
|
|
|
|*
|
|-
|'''Visitors’ Waiting Room'''
|
|
|
|*
|
|-
|
|
|
|
|
|
|
|-
| rowspan="13" |'''Neonatal Intensive Care Unit'''

'''(NICU)'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Incubator Ward Area'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Mothers’ Rest Area'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="2" |
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Operating Theatre (Department)'''
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|*
|
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Nurses’ Station'''
|
|
|*
|
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Post-Operative Recovery Area'''
|
|*
|
|
|
|-
|'''Pre-Operative Holding Area'''
|
|*
|
|
|
|-
|'''Scrub-up Area/Room'''
|
|*
|
|
|
|-
|'''Setting Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="22" |'''Outpatients Department '''
|'''Reception/Nurses’ Station'''
|
|
|
|*
|
|-
|'''Admissions Room'''
|
|*
|*
|*
|
|-
|'''Baby Changing Area '''
|
|
|
|*
|
|-
|'''Children’s Play/Waiting Area'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POPS Room'''
|
|*
|
|
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|'''Wheelchair Storage Area'''
|
|
|*
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="11" |'''Paediatric Ward'''
|'''Child-Assist Ablution'''
|
|
|*
|
|
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility (isolation)'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="11" |
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk/Ward Kitchen'''
|
|*
|
|
|
|-
|'''Nurses’ Station '''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Parent Ablutions'''
|
|
|*
|
|
|-
|'''Play Area (patients)'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Pharmacy/Dispensary'''
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Bulk Stores'''
|
|
|
|
|*
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Counselling Cubicle'''
|
|
|
|*
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Liquid Filling Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Offloading Bay'''
|
|
|
|
|*
|-
|'''Patient Waiting Room'''
|
|
|*
|
|
|-
|'''Schedule Drugs Strong Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Tablet Packing Room'''
|
|*
|
|
|
|-
|'''Vacolitre Stores'''
|
|
|
|
|*
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Physiotherapy Department'''
|'''Audiology Testing'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Gymnasium'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Occupational Therapy Room'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Speech Therapy'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Primary Health Clinic'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary and Pharmacy'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation/Rehydration Area'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="12" |
|'''Office'''
|
|*
|*
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|
|
|
|*
|-
|'''Waiting Area (public)'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="25" |'''Radiology (Diagnostic)'''
|'''Bucky Room (general X-ray Room)'''
|
|*
|
|
|
|-
|'''Change Cubicles'''
|
|*
|
|
|
|-
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''CT/MRI Scan Room'''
|*
|
|
|
|
|-
|'''Dirty Utility/Sluice'''
|
|
|*
|
|
|-
|'''Fluoroscopy Room'''
|
|*
|
|
|
|-
|'''Fluoroscopy Control Room'''
|
|*
|
|
|
|-
|'''Inpatient Waiting Area'''
|
|*
|
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Mammogram Room'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Public Waiting Area'''
|
|*
|*
|
|
|-
|'''Porters and Wheelchair/Trolley Parking'''
|
|*
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Server Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Stores (Equipment/General)'''
|
|
|
|
|*
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Telemedicine Room'''
|
|
|
|*
|
|-
|'''Viewing Room/CR Room/Reporting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Residences (e.g., Nurses)'''
|'''Ablutions'''
|
|
|*
|
|
|-
|'''Bedrooms'''
|*
|*
|*
|*
|
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Lounge'''
|
|
|
|*
|
|-
|'''Offices'''
|
|
|
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|}

=Definitions=

==Terminology==
''Aggregation    Collected together from different sources and considered a whole.''

''Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.''

''Bacteriostatic    A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.''

''Bariatric Describing the condition of obesity.''

''Bonded Chemically attached or fused in layers.''

''Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.''

''Homogenous Consisting of things of similar type throughout.''

''Heterogeneous Consisting of various layers or types throughout.''

''Hygroscopic Readily absorbing moisture from the atmosphere.''

''Hydrophobic Water-repellent.''

''Impervious Not allowing passage through (usually of water/moisture).''

''Interstices Small holes or perforations. ''

''Jointed Junctions which may be open or covered, but not completely sealed and smooth.''

''Jointless Without joints or having joints, which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.''

''Olfactory Relating to the smell or the sense of smell.''

''Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.''

''Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.''

''Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed,'' '''resilient''' ''flooring'' ''refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.''

''Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.''

''Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail. ''

''Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.''

''Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.''

''Tufted A group of threads drawn through a fabric and tied securely beneath the surface.''

''Vitrified To change a material into glass, under high heat and other conditions.''

''Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.''

''Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.'' ''' '''

==Abbreviations==
{| class="wikitable"
|''CFC''
|''Chlorofluorocarbon''
|-
|''CHD''
|''Centre for Health Design''
|-
|''ENT''
|''Ear, nose and throat''
|-
|''HAI ''
|''Healthcare-associated infections ''
|-
|''HCFC''
|''Hydrochlorofluorocarbon''
|-
|''HDF''
|''High-density fibreboard''
|-
|''IEQ''
|''Indoor Environmental Quality''
|-
|''IUSS ''
|''Infrastructure Unit Systems Support''
|-
|''MDF''
|''Medium-density fibreboard''
|-
|''MRSA   ''
|''Methicillin-resistant staphylococcus aureus, (which is a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria''
|-
|''NDoH ''
|''National Department of Health''
|-
|''OoM ''
|''Order of Magnitude''
|-
|''PMIS ''
|''Project Management Information System''
|-
|''PMSU ''
|''Project Management Support Unit''
|-
|''PuR''
|''Polyurethane-resistant''
|-
|''PVC''
|''Polyvinylchloride''
|-
|''RC ''
|''Recommendation Committee''
|-
|''VOC   ''
|''Volatile organic compound''
|}

=References=

==Bibliography==
Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

AASA, the School Suprintendents Association, 2009. ''Improving indoor air quality: Materials selection.'' [online] Alexandria, Egypt: AASA. Available at: <nowiki>http://www.aasa.org/search.aspx?query=Materials+Selection+</nowiki>[Accessed 9 April 2014].

Cement & Concrete Institute (CCI), 2009. ''Sand-cement screeds and concrete toppings for floors.'' [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. ''Floor coverings in healthcare buildings.'' (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. ''Finishes''. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. ''Core elements: Health Building Note 00-03: Clinical and clinical support spaces''. UK: DH.

Department of Health (DoH), 1980. ''Regulations governing private hospitals and unattached operating theatres.'' (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. ''Health''

''Technical Memorandum 61: Building component series flooring.'' [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. ''Performance requirements for building elements used in healthcare facilities.'' (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. ''R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes.'' Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. ''Sound practices: Noise control in the healthcare environment.'' (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. ''Healthcare environmental terms and outcome measures: An evidence-based design glossary.'' Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. ''Applied and Environmental Microbiology'', 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, ''18th CIB World Building Congress: Facilities management and maintenance''. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. ''Achieving EBD goals through flooring selection & design.'' [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 56: Building component series: Partitions.'' UK: TSO.

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 60: Ceilings.'' 2<sup>nd</sup> ed. UK: TSO.

NHS, National Services Scotland, 2006. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. ''Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning.'' (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. ''The role of hospital design in the recruitment, retention and performance of NHS nurses in England.'' (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. ''Health Building Note 04-01: Adult in-patient accommodation''. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. ''The Science of the Total Environment,'' 227(1999), pp.197-213

==Websites: Further reading ==
<nowiki>https://www.transparency.perkinswill.com</nowiki>

<nowiki>http://www.gatech.edu</nowiki>

<nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki>

<nowiki>http://www.green-buildings.com</nowiki>

<nowiki>http://www.healthcaredesignmagazine.com</nowiki>

<nowiki>http://www.isoboard.com</nowiki>

<nowiki>http://www.isolite.co.za</nowiki>

<nowiki>http://www.everite.co.za</nowiki>

<nowiki>http://www.armstrong.com</nowiki>

<nowiki>http://www.owa.co.za</nowiki>

=Photographic and illustration credits=
Cover photo: M. Swinney
{| class="wikitable"
|Fig.1
|M. Swinney
|-
|Fig.2 to 5
|Diagram by C. Hiralal
|-
|Fig.6
|R.Cubbin based on Lifecycle Floor Cost Table – by Nora®, USA
|-
|Fig.7
|G. Abbott- CSIR
|-
|Fig.8
|R.Cubbin
|-
|Fig.9
|M. Swinney
|-
|Fig.10
|R. van Rensburg
|-
|Fig.11
|M. Swinney
|-
|Fig.12
|R. van Rensburg
|-
|Fig.13 to20
|M. Swinney
|-
|Fig.21
|R. van Rensburg
|-
|Fig.22
|M. Swinney
|-
|Fig.23
|R. Cubbin
|-
|Fig.24
|M. Swinney
|-
|Fig.25
|R. Cubbin
|-
|Fig.26 to28
|M. Swinney
|}
<br />{{Expand}}
[[Category:Crosscutting Issues|Materials and finishes - Internal Ceiling Finishes]]
{{DEFAULTSORT:Materials and finishes - Internal ceiling finishes}}

Materials and finishes

2020-10-22T12:34:59Z

VSadiki:

=Internal Ceiling Finishes in Healthcare Facilities=

=Context=

==Overview – finishes in the healthcare environment==
<br />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.
[[File:Facility finishes.png|thumb|none]]

==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.

'''How to use this document:'''

#Review the Selection Criteria - Part B
#Select a Room / Department name in Part D, and note Performance Category
#Refer to Table 1 for the Properties that make up that Performance category
#Refer to Part C to assess ceiling types that could satisfy those performance requirements.

'''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 <u>www.iussonline.co.za</u>

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.

==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:

SANS 204 Energy-Efficiency in buildings general

SANS 622 Gypsum cove cornice

SANS 637 Wood-wood panels (cement-bonded)

SANS 640 Flexible PU-foams

SANS 803 Fibre cement boards

SANS 1039 Wooden ceiling and panelling boards

SANS 1381 Materials for thermal insulation boards

SANS 1508 Expanded polystyrene thermal insulation boards

SANS 1783 Softwood brandering and battens

SANS 6013 Dimensional and mass stability of particle boards with varying humidy

SANS 6016 Transverse tensile strength of particle boards

SANS10177 Fire-testing of materials

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

=Selection Criteria=

==Scope==
A ceiling in any facility forms the third dimension in any given room area, along with the walls and the floor, and it sometimes separates the roof space from the occupied area below. The manner 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.
[[File:Ceiling.png|thumb|none]]
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.
[[File:Actual Soffit of structure overhead.png|thumb|none]]

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.
[[File:Membrane fixed directly to the structure overhead.png|thumb|none]]

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.
[[File:Membrane suspended from the structure overhea.png|thumb|none]]

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

==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

===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.

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

==Life cycle costing and sustainability==
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 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 importance of life cycle costs.
[[File:Capital outlay costs vs life span costs.png|thumb|none]]

Sustainability should be considered in all four stages of product life:

*Manufacture
*Use
*Maintenance
*Disposal
[[File:Product life sustainability.png|thumb|none]]

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.
[[File:Life cycle costing and sustainability diag.png|thumb|none]]

===Toxicity and effect on indoor environment===
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)
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.

'''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.
[[File:Toxicity and effect on indoor environment diag.jpg|thumb|none]]

==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)
[[File:Facility design.png|thumb|none]]

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.

==Selection criteria==

===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.”
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)
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.

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.
“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 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 also carried out microbiological studies comparing patient rooms with and without carpet. The study found higher microbial counts and more E.coli and other organisms on carpet samples than bare floors.

While this issue may not affect the selection of a ceiling finish, there are principles to be borne in mind when establishing what finish is best in high-risk environments.
[[File:Selection criteria diag.png|thumb|none]]

Below is a table adapted from NSW Health: Infection Control Policy (PD 2007-035), which sets out patient risk categories:

When selecting finishes for a room/area that has an extreme or high infection control risk, special care has to be taken to select an appropriate finish. Although ceilings are out of reach and therefore less affected by regular touching, airborne bacteria can be carried on circulating mechanical ventilation, and aerosol contaminants which are distributed when water is splashed, (Ayliffe et al., 2000) can carry pathogens to ceiling level.

Ceiling materials and finishes that resist the spread of infection will have qualities that can be summarised as follows:

*Smooth
*Impervious
*Joint-less/seamless

On the opposite side of this spectrum, where infection prevention is the lowest priority, ceilings will have the following properties:

*Textured
*Perforated
*Jointed
[[File:Selection criteria diag 2.jpg|thumb|none]]

Certain materials have been shown to inhibit bacterial growth – such as vinyl, PuR and natural materials such as cork. This will also contribute to the prevention of infection. Ceilings with these properties will have the following quality:

*Bacteriostatic

'''A note about anti-bacterial treatments and additives to ceiling products:'''

Some manufacturers tout the additional benefit of anti-microbial treatment in paints or grout to combat bacteria. The use of antimicrobial additives in the built environment is growing, for example - the impregnation of wood framing with silver nitrate to prevent microbial and mould growth, and extend the life span of the wood.

Synthetic fibres such as polypropylene textile and vinyl for example, in themselves do no provide a nutrient source which microbes need to survive, but some finishes can trap soil, dust and moisture which do provide that source.

The CDC HICPAC guidelines (CDC 2003) indicate that there is no evidence that antimicrobial-impregnated articles will prevent disease. There is a need for further research on products treated with these chemicals in terms of their potential risks and benefits to healthcare users.

==Cleaning and maintenance==
Connected with infection prevention is the issue of cleaning. Ceilings tend to have ’reactive’ cleaning regimes, rather than regular cleaning programmes. This is partially because the ceiling gives an impression of cleanliness, but this can be misleading.

Whether the materials/finish of a ceiling can be cleaned thoroughly will define the extent to which infectious agents can be prevented from multiplying on a surface. Some materials can tolerate a reasonable amount of moisture, facilitating regular washing, while others would be adversely affected by it and can only be dusted or wiped.
[[File:Cleaning and maintenance diag.jpg|thumb|none]]

For cleaning to be effective, the surface must be able to withstand regular and fairly vigorous cleaning, with proper access to all surfaces. Where there are small recesses or difficult to reach corners, dirt is easily trapped providing dark, undisturbed conditions – the perfect breeding area for bacteria.

Information regarding cleaning materials should also be considered, as solvents and cleaning agents can quickly cause deterioration of the finish if it is not robust enough to withstand the cleaning required.

A further aspect to consider is the disruption that will be required to carry out the cleaning regime and possible maintenance. This is pertinent to areas such as operating theatres that may remain in use 24 hours a day.

Where there is a high requirement for regular cleaning of a ceiling in view of its location in a sensitive area, together with a need for minimal disruption for maintenance, the ceiling properties could be summarised as:

*Washable
*Low maintenance
[[File:Cleaning and maintenance diag 2.jpg|thumb|none]]

An additional consideration in the selection of ceiling finishes in health facilities in terms of maintenance is the provision of access to services in the ceiling void. Health facilities will generally require a high concentration of various services, most of which run in the ceiling void.

This will include electrical power and lighting, data, nurse call systems, medical gas and vacuum lines, air-conditioning and extract ducts, as well as hot water and waste pipes to name a few. Although service ducts and shafts can alleviate this congestion in the ceiling, distribution on the horizontal plane will nonetheless be required.

By selecting ceiling types that cater for easy access and giving thought to the best positions for these access panels - even marking these panels where necessary - this will facilitate easier maintenance of in-ceiling services during the life span of the building. This in turn will reduce ’downtime’, and disruption of the health facility.
[[File:Access panel.jpg|thumb|none]]

While the location of access panels is determined by the layout of services, certain rooms or areas will be more suitable for these panels.

*No combustible materials are permitted in ceilings or roof structures for buildings classified as hospitals.
*Medical facilities and healthcare categories are classified separately and have different requirements.
*Strict parameters are given for the depth of ceiling voids and this is related to the need for sprinklers when the voids exceed a given depth.
*Compartmentalisation of the ceiling void is required in area and distance, with fire stops.
*A dedicated section is written regarding operating theatres and intensive, high and critical care units, stipulating 120 min fire resistance for division separations.
*A full list of materials deemed to be non-combustible is provided.

This has been listed as the property:

*Access panels

===Safety===
Unlike floors which can prevent - or contribute to - falls by patients and staff, ceilings are largely out of reach and need not be assessed for safety as is relevant to floors. The safety aspect of fire performance does however need to be highlighted. The SANS 10400 lists specific requirements for hospitals and medical facilities with regard to ceilings. This is aimed at protecting the patients who are most likely frail, may not be able to walk, and would require assistance and more time to escape in the event of fire.

The definitions in the SANS 10400: Part A read:

*E2 Hospital

Occupancy where people are cared for or treated because of physical or mental disabilities, and where they are generally bedridden.

*E3 Other institutional (residential)

Occupancy where groups of people who either are not fully fit, or who are restricted in their movements or their ability to make decisions, reside and are cared for.

*E4 Healthcare

Occupancy which is a common place of long term or transient living for a number of unrelated persons consisting of a single unit on its own site who, due to varying degrees of incapacity, are provided with personal care services or are undergoing medical treatment.

These requirements are set out in Part T of SANS 10400, and include:

All ceilings in hospitals would need to be non-combustible material. In other health facilities, such as community health centres or clinics, there are exceptions to the non-combustible requirement, subject to compliance with certain conditions. Since each project varies, the advice of a competent fire engineer should be obtained.

==Indoor air quality==
There are two critical aspects to be considered when selecting floor finishes under the heading of indoor air quality. The first is he effect of the functions in that environment on the flooring material - namely water/moisture in wet spaces, The second is the effect of the material on the floor material - namely the emission of volatile organic compounds.
[[File:Indoor air quality diag.jpg|thumb|none]]

===Humidity===
Certain rooms and areas of health facilities are by nature of the function they house - wet spaces. These are spaces specifically used for the purpose of cleaning, washing, bathing or food preparation. These rooms will generate more moisture than others, and as a result will require moisture-resistant finishes. If the ceiling panels or surfaces are hygroscopic, these finishes can be prone to mildew and mould growth. Surfaces must remain dry and clean in order to prevent the growth of fungus. (Hodgson et al., 2000)

Non-porous materials that do not absorb water are essential in these areas. These materials should also withstand regular cleaning, and should be able to withstand regular exposure to the moisture. Indoor air quality (IAQ) may be compromised by microbial contaminants such as mould, bacteria, allergens, chemicals, etc. in the air, which can affect the health of people. Where this is a requirement in a ceiling finish, this property will be listed as:

*High humidity

===Emissions from materials===
As discussed under Environmental Aspects, the kind of flooring installed can affect the environmental quality of the interior if VOCs are given off by – commonly referred to as off-gassing:

*The product itself, along with its structure
*The adhesives used to fix the product or its layers
*The paints or sealants used to finish
*The cleaning solutions required for regular maintenance
[[File:Emissions from materias diag 1.jpg|thumb|none]]

People who work in noisy environments for long shifts day in and day out, also have similar stress-induced experiences. They report everything from exhaustion to burnout, depression and irritability”
The smell of the interior of a new car - enjoyed by many is an example of plasticizers that have evaporated - emissions that affect the indoor air quality. Various methods for measuring VOCs have been developed in recent years since the increase in awareness that these emissions exist and can have an influence on the indoor air quality. The Green Building Council of South Africa (GBCSA) awards points in the IEQ13 category where interior finishes minimise the contribution and levels of VOCs in buildings – with reference to paints, adhesives/sealants and carpets/flooring, where these products meet the IEQ levels’ outlines.

IEQ14 section measured the formaldehyde minimisation which is common with composite wood products. In addition, MAT-7 section recognises the reduction of PVC-products in the building materials used.

It should be noted that primary VOCs decline quickly in the short-term (<1 year), while secondary emissions can continue for the life span of the product, and should also be borne in mind when assessing this aspect of materials. Timing of the testing will yield very diverse results.
Proper moisture control is essential in order to reduce health risks and sick building syndrome in an enclosed space
Patients with respiratory weaknesses such as asthma are most likely to be affected by VOC emissions, and high-risk patients would benefit from materials that do not contribute to their condition. The ultimate goal of reducing emissions in the manufacture of building products should be to create a better and healthier environment for the patients and users of the facility. Materials such as paints and polyvinyl-chlorides can emit VOCs which can have a negative effect on indoor air quality.

According to Hoskins (2003), VOCs can be carcinogenic, depending on the compound. VOCs can also cause irritation and odour annoyance, and could lead to behavioural, neurotoxic, hepatoxic and genotoxic effects (Meininghaus et al., 2000; Hoskins, 2003; Hodgson et al., 2000.)
[[File:Emissions from materias diag 2.jpg|thumb|none]]

However, the ‘order of magnitude’ should also be applied when using ‘low VOC emissions’ as a criterion to select finishes. The use of enamel paint on plaster, for example, may result in higher VOC emissions than say, a pre-finished lay-in ceiling board, but the infection control benefits of the seamless finish will outweigh the risks from VOC emissions. (More fatalities in patients have been linked to infection control issues than to VOC emissions issues.) Ceilings often present an opportunity to reduce the heat load on rooms from the roof space through insulation. This could form part of the ceiling material itself or be laid over the ceiling.

==Acoustics==
Noise in health facilities is mainly generated by:

*Impact sounds e.g., pedestrian and wheeled equipment, bedrails moved up and down, doors closing and opening, footfalls, etc.
*Airborne sounds, e.g., speech, medical equipment bleeps and alarms, nurse calls, PA system, etc.

Acoustical engineers at John Hopkins University found that average (continuous level equivalent, LA<sub>eq</sub>) daytime hospital noise levels have risen from 57 dBA in 1960, to 72 dBA in 2006, with night-time sounds increasing from 42 dBA to 60 dBA over the same period. (Sound Practices: Noise Control in the Healthcare Environment – Research Summary, 2006, Herman Miller Healthcare). An average motorcycle noise level measures 85 dB. The World Health Organization’s recommended LA<sub>eq</sub> value for ward areas is 30 dBA.

Studies have shown that high levels of noise have negative physical and psychological effects on patients, disrupting sleep, increasing stress and raising blood pressure levels (Cmiel et al., 2004). The University of Michigan released a news brief in November, 2005 showing that chronic noise increased the risk of heart-attack in patients by 50% for men and 75% for women. The negative effect of chronic noise extends to staff as well. While the presence of electronic devices and healthcare apparatus, designed to give audible signals and alarms to the nursing staff of the patient’s vital signs, architects and health facility planners need to make an effort to minimise this effect of noise and alarm fatigue.
[[File:Acoustics diag 1.jpg|thumb|none]]

Long straight passages are perfect echo corridors, often amplifying noises. Disturbances in the sound path help limit the sound transmission, for example by creating steps in the ceiling level or changes of direction in the passageways.

Nurses’ stations during shift change are areas where noise levels can reach those similar to jack-hammer levels, according to Cmiel, et al. 2004). Consideration should be given to applying acoustic materials to these areas to maximise sound absorption where possible.

Recesses to accommodate noisy equipment can also be treated acoustically to reduce reverberation. Distance is also a good strategy where feasible as sound intensity decreases with distance, provided that the room dimensions and surfaces are such that there is very little reverberation.

Sound-absorbent ceiling finishes should be used in key areas such as nurses’ rest rooms or waiting areas where infection control requirements would not be as critical. In areas where sound reduction rates highly as a requirement (e.g. ICU and general wards), then this factor would be listed as:
High acoustic
[[File:Acoustics diag 2.jpg|thumb|none]]

==Aesthetics==
Research results from CABE (2004 and 2005), King’s Fund (2004) and Leather, Beale and Lee (2000) all highlight the need for an integrated, holistic and sympathetic hospital aesthetic.

Key results of a study by Becker and Douglass (2008), show that the physical appearance of the architectural setting, including finishes, has an effect on the patient’s experience as well as the recruitment and retention of staff – happy staff are more motivated to care for patients, who in turn recover more quickly.

Reflectivity of the ceiling material can boost natural light in a room or alternately produce glare - both of which have a direct impact on the comfort levels in the room. By ensuring skylights are oriented correctly, and shaded appropriately, natural light could be introduced through the ceiling.
[[File:Aesthetics diag.jpg|thumb|none]]

The ceiling surface finish should complement the function of the room, and monotony for the sake of economics should be avoided, bearing in mind that most patients will be focused on the ceiling for the duration of their stay.

Printed ceiling tiles, or polycarbonate panels with vinyl film images, behind which lighting can be introduced, could be used in key areas. This can transform a dull ward ceiling into a fascinating window to the outside world. CABE (2004) highlights the need for patients to have a ’connection with nature’, and these ceiling ‘windows’ are the ideal opportunity to supplement views to the exterior.

Natural light is a key factor in creating an environment for patient recovery. The occupants of the ward should be considered – paediatric wards are opportunities for playful scenes that will help little patients feel at ease.

In public areas where more emphasis might be placed on an attractive and welcoming interior than other factors, then this factor would be listed as:

   • High aesthetics

=Technical Information - Ceiling Types=

==Paint on seamless plaster==
'''General description and properties'''

Paint is easily applied by roller to a plastered ceiling soffit. The soffit could be constructed from plasterboard sheets, which are then skimmed or from concrete. Note that the structure onto which the plasterboard is fixed would need to be non-combustible if the facility is a hospital. Following a primer and undercoat, usually three coats of paint are applied. Two-coat plaster or skimming is highly recommended prior to painting, as defects will be highlighted with the high-gloss type paints.

Paint types that can be applied to the ceiling soffit will vary between oil-based and water-based types. Enamel paint dries to a hard, glossy, finish. It is usually oil-based. Velvet sheen paints are water-based, but produce a less glossy finish. PVA-paints are also water-based, but produce a matt finish. Paint is fairly inexpensive when compared to other ceiling finishes - excluding the structure.
[[File:Paint on seamless plaster diag.jpg|thumb|none]]

'''Infection prevention'''

The smooth seamless finish produced by painted concrete or plasterboard ceilings, make this finish ideal for areas where infection prevention is paramount. There are no joints or crevices to encourage growth of microbes. Paints with nanotechnology enhancements are also being developed. These paints inhibit the growth of algae and fungus.

'''Cleaning and maintenance'''

The enamel and velvet sheen paints are highly washable, durable and stain-resistant. PVA can also be washed, but is not as stain-resistant. Paint is a low maintenance finish which may require re-application every few years, unless latent defects arise.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Paint on a concrete soffit is considered a non-combustible finish as the thickness of the paint is usually less than

0.5 mm – refer to manufacturers’ specifications, and consult with the SANS Part T (4.13).

'''Indoor air quality: Humidity'''

Generally, paints are not adversely affected by a reasonable amount of moisture being generated by the presence of taps or wet fittings in a room. Enamel paints are most resistant to absorbing moisture, when compared to PVA-type paints.

'''Indoor air quality: Emissions and insulation'''

Paints are notorious for high VOC emissions, although manufacturers are now working on products with reduced or zero VOCs. Refer to product specific literature.

'''Acoustics'''

The hard surface of painted soffits reflects sounds and where acoustics are important, there are certainly better options available.

'''Aesthetics'''

While paint can be used effectively to introduce colour for features or emphasis, generally on ceilings in areas where infection prevention is important, the ceilings should be kept single colours - white or light colours – this ceiling would be used in areas where aesthetics is not the highest priority.

==Cementitious board – nail-up ceilings==
'''General description and properties'''

Plain and textured ceiling boards are available for nail-up applications where joints are not a problem. These boards are manufactured from a combination of cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses, and can be nailed at regular intervals to the overhead structure.

The joints between the ceiling boards can be finished using joiners or cover-strips. The ceiling boards can also be fixed between exposed beams.

Although no paint finish is required, paint can be applied. (Refer to comments on paint on plaster above.)
[[File:Cementitious board – nail-up ceilings diag.png|thumb|none]]

'''Infection prevention'''

The textured boards and the joining strips will create areas where microbes can grow. This ceiling finish is therefore not suitable for areas where infection prevention is critical.

'''Cleaning and maintenance'''

Nail-up cementitious boards are unaffected by moisture and resistant to corrosion. When painted they are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is possible if boards do get damaged, but this would be disruptive to the functioning of the room.

'''Access to services'''

Access panels need to be planned in the structure prior to painting. This leaves little flexibility in terms of access to services, and tricky patching if the ceiling ever needs to be altered. This type of ceiling is not ideal where access to services above is required.

'''Fire safety'''

Nail-up cementitious boards are non-combustible.

'''Indoor air quality: Humidity'''

These painted boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the building from roof spaces where applicable. Fibres are safe and recyclable, and manufacturers claim low embodied energy used for assembly and construction. Refer to product specific literature. Emissions from paints should be considered.

'''Aesthetics'''

This type of ceiling board is aesthetically acceptable, and with paint, can be used to create an interesting functional ceiling.

'''Acoustics'''

The hard surface reflects sound and will not aid in sound absorption in the room it covers.

==Vinyl-clad ceiling tiles in suspended grid==
'''General description and properties'''

Vinyl-clad ceiling tiles are manufactured from cement, silica and organic fibres. They are available in 4 and 6 mm thicknesses and are clad on the exposed surface with vinyl. They are suitable for 1 200 x 600mm or 600 x 600mm exposed ceiling grids. The grids are suspended from the structure above. The ceiling tiles can also be supplied with 25 mm insulation backing. No further painting or finishing is required.

'''Infection prevention'''

The vinyl finish is impervious, and vinyl inhibits the growth of bacteria. The boards are unaffected by moisture, and can be washed regularly. This makes them suitable for infection prevention. There are however joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

As mentioned, the vinyl-clad tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stain-resistant. They are relatively lightweight (compared to a concrete soffit), low maintenance and durable. Replacement is very easy if boards do get damaged, with very little disruption to the room function.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Fire safety'''

Vinyl-clad boards are non-combustible; however, fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are well-suited to areas of high humidity as they are not affected by moisture.

'''Indoor air quality: Emissions and insulation'''

These boards can be supplied with thermal insulation backing, which will reduce the heat load on the room. Fibres are safe and recyclable, (no asbestos fibres) and manufacturers claim low embodied energy used for assembly and construction. However, the vinyl has low VOC emissions, when compared to some paints. Refer to product specific literature.

'''Aesthetics'''

This type of ceiling board gives a hygienic impression and is aesthetically acceptable. Tiles can also be printed with designs where budgets allow.

'''Acoustics'''

The surface is relatively hard, and does not assist with acoustic control or absorb sounds.
[[File:Vinyl-clad ceiling tiles in suspended grid.jpg|thumb|none]]

==Acoustic ceiling tiles in suspended grid==
'''General description and properties'''

These mineral fibre acoustic ceiling tiles – nominally 20 mm thick - have a pre-painted textured and perforated finish. The boards can be supplied with various edge finishes suitable for an exposed grid, or recessed grid with regular or chamfered edges. They are suitable for 1200 x 600mm or 600 x 600mm ceiling grids. The grids are suspended from the structure above. No further painting or finishing is required.

'''Infection prevention'''

The fissured surface may harbour dust and bacteria, making this type of ceiling board unsuitable for areas where infection prevention is critical – such as theatres. Some manufacturers do produce an ‘anti-microbial’ tile. Refer to the section on Selection Criteria- Infection Prevention for more discussion on this aspect. The boards cannot be washed as they will absorb moisture. Dirty or stained panels can be replaced easily. There are also joints, so the ceiling is not seamless.

'''Cleaning and maintenance'''

Since the boards are adversely affected by moisture, they can only be brush-cleaned and must be kept dry. Dirt often gathers where air-conditioning ducts blow across these tiles, and these then are difficult to clean. They are lightweight and fairly low maintenance. Replacement is very easy if boards do get damaged, with very little disruption to the room function, although batch colours and textures may vary.

'''Access to services'''

Access panels are easily allocated in a suspended grid ceiling, and the removable tiles allow for maximum flexibility for access to services in the ceiling void.

'''Indoor air quality: Humidity'''

These boards are unsuited to areas of high humidity as they absorb moisture and will swell and droop over time when exposed to moist conditions.

'''Indoor air quality: Emissions and insulation'''

These boards provide some thermal insulation which will reduces the heat load of the building. The tiles do have low VOC emissions which will vary according to the manufacturer. Refer to product specific literature.

'''Aesthetics'''

The patterns of the fissures on this type of ceiling tile can create an interesting ceiling which is aesthetically acceptable.

'''Acoustics'''

The perforated surface is excellent for sound absorption and this product is well-suited to areas where noise reduction is prioritised.
[[File:Acoustic ceiling tiles in suspended grid.png|thumb|none]]

==Pressed metal ceiling tiles in suspended grid==
'''General description and properties'''

Pressed metal tiles are manufactured from galvanised steel, and are then epoxy-coated for a durable finish. The ceiling tiles are made to a variety of sizes. Stainless steel tiles are also available. Perforations are made in the surface – in different patterns and diameter to reduce the weight and improve acoustic performance. They are laid in a suspended ceiling grid, or can be hinged to the grid to open downwards. No further painting or finishing is required.

'''Infection prevention'''

The perforated surface may harbour dust and bacteria, and the joints mean the ceiling is not seamless. This type of ceiling is not suitable for areas where infection prevention is critical. The tiles are however washable.

'''Access to services'''

The hinged access tiles are purpose-made for access to services in the ceiling void as they are hinged to swing down leaving the void clear of grid transoms. The lay-in type of panel is also removable in a suspended grid ceiling, allowing for maximum flexibility for access to services in the ceiling void.

'''Cleaning and maintenance'''

The epoxy-coated tiles are unaffected by moisture and resistant to corrosion. They are easy to clean and stainresistant. They are robust and unlikely to be damaged easily, making them very low maintenance and durable. Replacement is easy if tiles do need replacing, with very little disruption to the room function.

'''Fire safety'''

Metal is listed as non-combustible in the SANS Part T as tested under 10177-5, however fire load of the ceiling grid should be ratified with the manufacturer.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The metal tiles are generally made from recycled material and can also be recycled. Refer to product specific literature. The tile itself does not provide any insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically-pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics'''

The perforated surface contributes to sound absorption and compensates somewhat for the hard, reflective metal surface.
[[File:Pressed metal ceiling tiles in suspended grid.jpg|thumb|none]]

==Rigid extruded polystyrene panels (XPS)==
'''General description and properties'''

Polystyrene ceiling panels combine the aesthetic of a ceiling panel with the insulation properties of closed-cell insulation board. These panels are manufactured from high-density rigid extruded polystyrene. These can be supplied smooth for a flush appearance, bevelled to pronounce the 600 mm joint, or grooved at 100 mm intervals to resemble tongue and groove timber planks. Although neatly finished, painting with PVA is recommended. The boards can be fitted over-purlin, nailed-up to brandering, or between exposed trusses, and should be ordered in long lengths to avoid butt-joints on ends. The panels are available in thicknesses of 25, 30 or 40 mm.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the polystyrene itself is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. In certified tests, (by SANAS accredited laboratory) the rigid polystyrene showed no microbial growth and was declared suitable for use in the food industry. Since the surface is jointed, however, its use will be limited.

'''Access to services'''

Access panels need to be planned in the ceiling prior to installation. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They can however be mechanically damaged, and should preferably be fitted at high levels. Replacement of damaged panels would create a fair amount of disruption.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ’healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 – noncombustible materials only.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The insulation properties of the rigid polystyrene will reduce the heat load and act as a bulk insulator. The Rvalues increase with the thickness from 0.833 (for 25 mm thick board) to 2.667 for 80 mm thickness – double layer). Rigid polystyrene panels have no obvious odour, but under high heat conditions (near heat-generating light fitting , for example), some aromatic hydrocarbons are released. The manufacture of rigid polystyrene panels requires the use of HCFC-gasses, however, the measure of these gasses is at levels less than 150 ppm even where large quantities are stored. The VOC emissions of adhesives used to install the product should also be considered.

'''Aesthetics'''

The tongue and groove pattern creates interest in the surface of the ceiling, and can evoke a homely residential feel to the room/area. This can be used to good effect in healthcare facilities.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.
[[File:Rigid extruded polystyrene panels (XPS).jpg|thumb|none]]

==Expanded polystyrene panels (EPS)==
'''General description and properties'''

These laminated expanded polystyrene panels are made up of low-density fire-retardant board finished with a fire retardant PVC-foil, the surface of which can be embossed or smooth. The layers are bonded under high temperatures. The panels can be supplied full size in 4.8 x1.2 m boards for over-purlin fixing, or cut to suit a suspended ceiling grid (1 200 x 600mm). It can also be installed under purlin or between rafters. PVC H-joiners are used at junctions. Because the panels are very light, wire-hung suspended grids are not recommended, as these could result in drafts lifting the ceiling. Rigid steel battens are required. No further painting or finishing is required. The panels are generally available in 40 mm thickness.

'''Infection prevention'''

The rigid polystyrene neither absorbs moisture, nor is it affected by moisture. This prevents the growth of mould or bacteria on the product, and the PVC-foil surface finish is not a nutrient source for bacteria. However, if substantial soiling/dust is allowed to build-up on the surface, the soiling could provide reservoirs for bacterial growth - as with any product. Since the surface is jointed, however, its use will be limited to areas where ‘seamless’ ceiling surfaces are not required.

'''Access to services'''

Access panels are easily accommodated where the suspended grid system is utilised. Where nail-up systems are installed, access panels need to be planned in the ceiling prior to installation.

'''Cleaning and maintenance'''

The panels are unaffected by moisture, resistant to corrosion and easy to clean. They do not require repainting or maintenance apart from occasional cleaning. Replacement of damaged panels in the suspended grid is not disruptive.

'''Fire safety'''

Although polystyrene is combustible, it has no flame-spread characteristics, and will not add to a fire load. It is classified as B/B1/2/HV S and USP in terms of SANS 428/SANS 10177, which means that it is combustible (B), but has no flame-spread (B1), can be used where combustible materials are permitted in various building types (Class 2 of occupancy) and it can be used in horizontal and vertical applications (H and V) with or without sprinklers. Note that ‘healthcare’ falls into Class 2 of occupancy, but ‘hospital’ falls into Class 1 - noncombustible materials only. Fire-rating of the suspended grid should also be considered.

'''Indoor air quality: Humidity'''

These boards are unaffected by humidity and are suitable for use in humid, moist conditions.

'''Indoor air quality: Emissions and insulation'''

The excellent insulation properties of the polystyrene will reduce the heat load and act as a bulk insulator. The manufacture of expanded polystyrene panel does not require the use of CFCs and no adhesives are used to install the product.

'''Aesthetics'''

The wood-grain or random textured embossing creates interest in the surface of the ceiling. The board has a slightly shiny finish.

'''Acoustics'''

The rigid polystyrene boards do not absorb sound and should not be used for acoustically-sensitive areas.

==Timber and timber composites==
'''General description and properties'''

Timber products have been used in ceilings for many generations. The most common locally available timber is maranti and pine - in various standards and quality. The versatility of the timber products provides almost unlimited options in terms of fitting ceilings - from standard tongue and groove planks, to slatted battens. The timber is usually varnished or treated with a preservative. Engineered timber products are also available with melamine or veneer finishes.

'''Infection prevention'''

Timber is a source of nutrient to bacteria, and good maintenance and cleaning will be needed to ensure that mould and other bacteria are prevented from establishing. Timber would not be suitable for areas where a seamless finish is required due to the jointing. Acrylic resin-based antibacterial varnish containing silver has superior microbial and chemical resistance, and will extend the life span of the timber. Medium-density fibreboards (MDFs) with melamine/veneer finishes could be installed in suspended grids.

'''Access to services'''

Access panels in a timber ceiling would need to be planned before the installation, and a purpose-made hinged or removable door created. This leaves little flexibility in terms of access to services, and patching is difficult if the service access ever needs to be altered. This type of ceiling is not ideal where access to services above the ceiling is required. Where suspended grids are installed, this provides easy access to services.

'''Cleaning and maintenance'''

The timber slats or planks are washable, but access to narrow grooves may limit the effectiveness of cleaning. Occasional re-varnishing would be required, which could be disruptive to the activities in such areas. Engineered MDF ceiling panels do not require repainting and should not be put in contact with water, but cleaned by dry brushing/vacuuming. These panels can easily be replaced however, where installed in a suspended grid.

'''Fire safety'''

In terms of SANS 10400, timber is combustible and not permitted for use in ceilings for the Occupancy E2 (hospitals). It is however permitted under certain conditions for E3 and E4 occupancies.

'''Indoor air quality: Humidity'''

Well-varnished timber will be protected from the effects of moisture, but generally, timber should not be used in rooms where humid, moist conditions persist. MDF ceiling panels are not suitable for humid or wet areas.

'''Indoor air quality: Emissions and insulation'''

Timber is a natural product that does not emit VOCs. However, engineered timber products such as mediumdensity fibre-board contains a higher resin to wood ratio than any other urea-formaldehyde pressed wood product, and is recognized as being the highest formaldehyde emitting pressed wood product. (source: US Environmental Protection Agency). These VOCs are fairly quickly dissipated. Refer to product specific literature. The timber planks or engineered panels do not provide much insulation value.

'''Aesthetics'''

The patterns of the perforations create an interesting effect which is aesthetically pleasing, and used together with bulkheads for lighting creates an interesting ceiling.

'''Acoustics''' <br />The perforated surface of the slatted ceiling or MDF tiles aid in reducing the re-transmission of sound. MDF acoustic tiles are specifically manufactured for their superior performance in absorbing sound.
[[File:Timber and timber composites.jpg|thumb|none]]

=Performance=

==Performance categories==
The properties described in the selection criteria in Section C above have been listed in the table below, and then grouped into five performance categories that would satisfy the requirements in various areas within a healthcare facility
[[File:Performance category.png|thumb|none]]

*Skimmed or plastered and painted – seamless ceiling

Examples of ceiling materials or finishes for Class 2 (typical room – general ward):

*Vinyl-clad or pressed metal tiles in grid, etc.

Examples of ceiling materials or finishes for Class 3 (typical area – dirty utility):

*Skimmed or plastered and painted – jointed, vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Examples of ceiling materials or finishes for Class 4 (typical area – office or waiting room):

*Acoustic ceiling tiles in grid; timber and composite panels, etc.

Examples of ceiling materials or finishes for Class 5 (typical area – plant room):

*Expanded or extruded polystyrene; skimmed or plastered and painted – jointed; vinyl-clad or pressed metal tiles in grid; expanded or extruded polystyrene panels, etc.

Refer to Table 2 – Matrix of recommended performance categories to establish what performance category the ceiling of the room in question will require – this could be a number of options in some cases.

==Performance categories recommended per room==
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" |'''1 2 3 4'''
|'''5'''
|-
| rowspan="22" |'''Acute In-patient Wards (Adults)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Day Lounge (patients)'''
|
|
|
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurse Station '''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Administration Department'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Offices/Interview Rooms'''
|
|*
|*
|*
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Boardroom'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Print room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Casualty and Trauma'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Hazmat Shower'''
|*
|
|
|
|
|-
|'''Minor Theatre/Suture Room'''
|*
|
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="12" |
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-assisted Ablution'''
|
|
|*
|
|
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs'''
|
|
|*
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Scrub area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Central Sterilising and Supply Department (CSSD)'''
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Packing'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''Staff Change Room'''
|
|*
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Sterile Storage'''
|
|*
|
|
|
|-
|'''Sterilisation (autoclaves)'''
|
|*
|
|
|
|-
|'''Trolley Wash'''
|
|*
|
|
|
|-
|'''Washing and Disinfecting Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Community Health Centre'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dental Surgery'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Isolation/Separate Nursing Ward'''
|*
|
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|
|
|-
|'''Offloading or Holding Area for Pharmacy'''
|
|
|
|
|*
|-
|'''PABX/Server Rooms'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient-Assisted Ablution'''
|
|
|*
|
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Public WCs and Change Rooms'''
|
|
|*
|
|
|-
|'''Reception/Nurses’ Station '''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="14" |

|'''Records Room'''
|
|
|*
|
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Rehydration Area'''
|
|*
|
|
|
|-
|'''Resuscitation Area'''
|
|*
|
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|*
|
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|*
|
|
|
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Ward'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''X-Ray Room'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="23" |'''Day Clinic (Department)'''
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Patient Waiting '''
|
|
|
|*
|
|-
|'''Recovery Area'''
|*
|
|
|
|
|-
|'''Scrub Area'''
|*
|
|
|
|
|-
|'''Setting Area'''
|*
|
|
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area (public)'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Ward Nurses’ Station '''
|
|
|
|*
|
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''High Care or Cardiac Care Unit (HC/CCU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|}

{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
|
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="15" |'''Intensive Care Unit (ICU)'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Nurses’ Station'''
|
|*
|*
|
|
|-
|'''Open Ward Area'''
|
|*
|
|
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Kitchen – (Main Hospital)'''
|'''Bulk Dry Goods Store'''
|
|*
|
|
|
|-
|'''Chemical Store'''
|
|
|
|
|*
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Cold Room/Freezer'''
| colspan="4" |specialised
|
|-
|'''Cooking Area '''
|
|*
|
|
|
|-
|'''Cutlery/Crockery Store'''
|
|*
|
|
|
|-
|'''Dishwashing and Potwashing Area'''
|
|*
|
|
|
|-
|'''Food Preparation Area'''
|
|*
|
|
|
|-
|'''Office'''
|
|
|*
|
|
|-
|'''Plating/Serving Area'''
|
|*
|
|
|
|-
|'''Receiving Area'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|*
|*
|
|-
|'''Trolley Wash Area'''
|
|*
|
|
|
|-
|
|
|
|
|
|
|
|-
| rowspan="17" |'''Laboratory'''

'''(Pathology/Cytology/Haemato logy/Chemistry) '''

'''(Biosafety Level 2)'''

''' '''

''' '''
|'''Blood and Blood Products Store'''
|
|*
|
|
|
|-
|'''Cell and Tissue Laboratory'''
|
|*
|
|
|
|-
|'''Cytopathology Sample Storage'''
|
|*
|
|
|
|-
|'''Clinical Material Store'''
|
|*
|
|
|
|-
|'''Disposal Area (dangerous materials)'''
|
|
|
|
|*
|-
|'''Drug and Vaccines Store'''
|
|*
|
|
|
|-
|'''Flammable Goods Store (external)'''
|
|
|
|
|*
|-
|'''Gas Cylinder and Pressure Vessel Store'''
|
|
|
|
|*
|-
|'''Hazardous Substances Store'''
|
|
|
|
|*
|-
|'''Histopathology Laboratory'''
|
|*
|
|
|
|-
|'''Microbiology Laboratory'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POCT consulting room'''
|
|
|*
|
|
|-
|'''Reagents/Chemical Stores'''
|
|
|
|
|*
|-
|'''Records Rooms'''
|
|
|*
|
|
|-
|'''Sample Collection Laboratory'''
|
|*
|
|
|
|-
|'''Specimen Reception and Sorting Rooms'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="4" |
|'''Stores (protective clothing/equipment)'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room (including lockers)'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Laundry – (Main Hospital)'''
|'''Assembly, Packing and Dispatch'''
|
|
|*
|
|
|-
|'''Chemical Store'''
|
|
|*
|
|*
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pressing '''
|
|
|*
|
|
|-
|'''Sorting'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Washing Room'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="21" |'''Maternity/Delivery Department'''
|'''Baby Bathing Area'''
|
|
|*
|
|
|-
|'''Circulation '''
|
|
|
|*
|
|-
|'''Delivery Suite'''
|*
|
|
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''First Stage Room'''
|
|*
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Nurse Station'''
|
|
|
|*
|
|-
|'''Nursery'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Viewing Area'''
|
|
|
|*
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="12" |'''Mental Health Facility'''
|'''Body Room'''
|
|*
|
|
|
|-
|'''Children's Play Area'''
|
|
|
|*
|
|-
|'''Clean Utility'''
|
|
|*
|
|
|-
|'''Cleaners’ Room/Station'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Counselling Room'''
|
|
|
|*
|
|-
|'''Dirty Linen'''
|
|
|*
|
|
|-
|'''Dirty Utility (Sluice)'''
|
|
|*
|
|
|-
|'''ECT Procedure Room'''
|
|*
|
|
|
|-
|'''En Suite Bath/Shower Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Group Therapy Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="24" |
|'''Gymnasium (OT and physio)'''
|
|*
|
|
|
|-
|'''IT Room'''
|
|
|*
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Medicine Store'''
|
|*
|
|
|
|-
|'''Multi-Purpose Hall'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient-Assisted Bathroom/Shower'''
|
|
|*
|
|
|-
|'''Patient Dining Room'''
|
|
|
|*
|
|-
|'''Patient Laundry'''
|
|*
|
|
|
|-
|'''Patient Lounge'''
|
|
|
|*
|
|-
|'''Pharmacy'''
|
|*
|
|
|
|-
|'''Quiet Room'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Seclusion Room'''
|*
|
|
|
|
|-
|'''Security Control Room'''
|
|
|*
|
|
|-
|'''Security Search Room'''
|
|
|*
|
|
|-
|'''Staff Change Room and WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Wards'''
|
|*
|
|
|
|-
|'''Ward Kitchen'''
|
|
|*
|
|
|-
|'''Waste Disposal Room'''
|
|
|
|
|*
|-
|
|
| colspan="5" |
|-
| rowspan="14" |'''Mortuary'''
|'''Blue Room'''
|
|*
|
|
|
|-
|'''Circulation Space'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Instruments Room'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Medical Observation Room'''
|
|*
|
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Pathologist Change Room'''
|
|
|*
|
|
|-
|'''Post-Mortem Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Viewing Room'''
|
|
|
|*
|
|-
|'''Visitors’ Waiting Room'''
|
|
|
|*
|
|-
|
|
|
|
|
|
|
|-
| rowspan="13" |'''Neonatal Intensive Care Unit'''

'''(NICU)'''
|'''Circulation'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Incubator Ward Area'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk Kitchen'''
|
|*
|
|
|
|-
|'''Mothers’ Rest Area'''
|
|
|
|*
|
|-
|'''Nurses’ Station'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="5" |'''Ceiling Performance'''
|-
| colspan="5" | '''1    2    3    4    5'''
|-
| rowspan="2" |
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="15" |'''Operating Theatre (Department)'''
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|*
|
|
|
|-
|'''Dirty Utility'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|*
|
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Nurses’ Station'''
|
|
|*
|
|
|-
|'''Operating Theatre'''
|*
|
|
|
|
|-
|'''Post-Operative Recovery Area'''
|
|*
|
|
|
|-
|'''Pre-Operative Holding Area'''
|
|*
|
|
|
|-
|'''Scrub-up Area/Room'''
|
|*
|
|
|
|-
|'''Setting Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="22" |'''Outpatients Department '''
|'''Reception/Nurses’ Station'''
|
|
|
|*
|
|-
|'''Admissions Room'''
|
|*
|*
|*
|
|-
|'''Baby Changing Area '''
|
|
|
|*
|
|-
|'''Children’s Play/Waiting Area'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|
|
|-
|'''Dirty Utility Room'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Offices'''
|
|*
|*
|*
|
|-
|'''POPS Room'''
|
|*
|
|
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions'''
|
|
|*
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|'''Wheelchair Storage Area'''
|
|
|*
|
|
|-
|
|
| colspan="5" |
|-
| rowspan="11" |'''Paediatric Ward'''
|'''Child-Assist Ablution'''
|
|
|*
|
|
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Dirty Utility (isolation)'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''General Ward (single or multi-bed)'''
|
|*
|
|
|
|-
|'''Isolation Ward'''
|*
|
|
|
|
|-
|'''Kit Room'''
|
|
|*
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="11" |
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Milk/Ward Kitchen'''
|
|*
|
|
|
|-
|'''Nurses’ Station '''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Parent Ablutions'''
|
|
|*
|
|
|-
|'''Play Area (patients)'''
|
|
|
|*
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Pharmacy/Dispensary'''
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Bulk Stores'''
|
|
|
|
|*
|-
|'''Circulation Space'''
|
|
|
|*
|
|-
|'''Counselling Cubicle'''
|
|
|
|*
|
|-
|'''Dispensary'''
|
|*
|
|
|
|-
|'''Liquid Filling Room'''
|
|
|*
|
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Offloading Bay'''
|
|
|
|
|*
|-
|'''Patient Waiting Room'''
|
|
|*
|
|
|-
|'''Schedule Drugs Strong Room'''
|
|*
|
|
|
|-
|'''Staff Change Room'''
|
|
|*
|
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Tablet Packing Room'''
|
|*
|
|
|
|-
|'''Vacolitre Stores'''
|
|
|
|
|*
|-
|
|
| colspan="4" |
|
|-
| rowspan="14" |'''Physiotherapy Department'''
|'''Audiology Testing'''
|
|
|
|*
|
|-
|'''Circulation'''
|
|
|
|*
|
|-
|'''Consulting Room'''
|
|*
|*
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Gymnasium'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|
|*
|
|
|-
|'''Occupational Therapy Room'''
|
|
|
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Speech Therapy'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Waiting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="11" |'''Primary Health Clinic'''
|'''Circulation'''
|
|
|*
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''Consulting Room'''
|
|
|*
|
|
|-
|'''Delivery Room'''
|*
|
|
|
|
|-
|'''Dirty Utility Room (Sluice)'''
|
|
|*
|
|
|-
|'''Dispensary and Pharmacy'''
|
|*
|
|
|
|-
|'''Duty Room'''
|
|
|
|*
|
|-
|'''Equipment Store'''
|
|
|*
|
|
|-
|'''Guard House or Security Kiosk'''
|
|
|*
|
|
|-
|'''Linen Store'''
|
|*
|
|
|
|-
|'''Observation/Rehydration Area'''
|
|*
|
|
|
|}
{| class="wikitable"
| rowspan="2" |'''Department'''
| rowspan="2" |'''Room Name'''
| colspan="4" |'''Ceiling Performance'''
|
|-
| colspan="4" | '''1    2    3    4'''
|'''5'''
|-
| rowspan="12" |
|'''Office'''
|
|*
|*
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Plant Room'''
|
|
|
|
|*
|-
|'''POPS Suite'''
|
|*
|
|
|
|-
|'''Reception/Nurse Station '''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Staff Ablutions and Change Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Surgical Sundries Store'''
|
|*
|
|
|
|-
|'''Treatment Room'''
|
|*
|
|
|
|-
|'''Trolley Bay (entrances)'''
|
|
|
|
|*
|-
|'''Waiting Area (public)'''
|
|
|*
|
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="25" |'''Radiology (Diagnostic)'''
|'''Bucky Room (general X-ray Room)'''
|
|*
|
|
|
|-
|'''Change Cubicles'''
|
|*
|
|
|
|-
|'''Circulation'''
|
|*
|
|
|
|-
|'''Cleaners’ Room'''
|
|
|*
|
|
|-
|'''CT/MRI Scan Room'''
|*
|
|
|
|
|-
|'''Dirty Utility/Sluice'''
|
|
|*
|
|
|-
|'''Fluoroscopy Room'''
|
|*
|
|
|
|-
|'''Fluoroscopy Control Room'''
|
|*
|
|
|
|-
|'''Inpatient Waiting Area'''
|
|*
|
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Linen Room'''
|
|*
|
|
|
|-
|'''Mammogram Room'''
|
|
|
|*
|
|-
|'''Office'''
|
|*
|*
|*
|
|-
|'''Patient Ablutions'''
|
|
|*
|
|
|-
|'''Public Waiting Area'''
|
|*
|*
|
|
|-
|'''Porters and Wheelchair/Trolley Parking'''
|
|*
|*
|
|
|-
|'''Reception'''
|
|
|
|*
|
|-
|'''Records Room'''
|
|
|*
|
|
|-
|'''Server Room'''
|
|
|*
|
|
|-
|'''Staff Rest Room'''
|
|
|
|*
|
|-
|'''Staff WCs'''
|
|
|*
|
|
|-
|'''Stores (Equipment/General)'''
|
|
|
|
|*
|-
|'''Ultrasound Room'''
|
|
|
|*
|
|-
|'''Telemedicine Room'''
|
|
|
|*
|
|-
|'''Viewing Room/CR Room/Reporting Area'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|-
| rowspan="10" |'''Residences (e.g., Nurses)'''
|'''Ablutions'''
|
|
|*
|
|
|-
|'''Bedrooms'''
|*
|*
|*
|*
|
|-
|'''Circulation'''
|
|
|*
|
|
|-
|'''Kitchenette'''
|
|*
|
|
|
|-
|'''Lounge'''
|
|
|
|*
|
|-
|'''Offices'''
|
|
|
|*
|
|-
|'''Public Ablutions'''
|
|
|*
|
|
|-
|'''Reception '''
|
|
|
|*
|
|-
|'''Stores'''
|
|
|
|
|*
|-
|'''Waiting Areas (public)'''
|
|
|
|*
|
|-
|
|
| colspan="4" |
|
|}

=Definitions=

==Terminology==
''Aggregation    Collected together from different sources and considered a whole.''

''Ambulant/ambulatory (of a patient) Being able to walk or move around; not being confined to a bed.''

''Bacteriostatic    A word used to describe the property of a material which claims to inhibit the multiplication of bacteria.''

''Bariatric Describing the condition of obesity.''

''Bonded Chemically attached or fused in layers.''

''Guarantee A document setting out a promise of quality made by a manufacturer or the provider of a service, a formal promise that a product will be repaired free of charge if it breaks or fails within a particular period or that substandard work will be redone.''

''Homogenous Consisting of things of similar type throughout.''

''Heterogeneous Consisting of various layers or types throughout.''

''Hygroscopic Readily absorbing moisture from the atmosphere.''

''Hydrophobic Water-repellent.''

''Impervious Not allowing passage through (usually of water/moisture).''

''Interstices Small holes or perforations. ''

''Jointed Junctions which may be open or covered, but not completely sealed and smooth.''

''Jointless Without joints or having joints, which are sealed by materials and methods which make the whole surface imperious and prevent the collection of dirt and bacteria in the joint.''

''Olfactory Relating to the smell or the sense of smell.''

''Perfusion Inject liquid into tissue or organ by circulating through blood vessels in the body.''

''Polyamide A synthetic polymer made by the linkage of an amino group of one molecule and a carboxylic acid group of another, including many synthetic fibres such as nylon.''

''Resilient finish The quality of a material to spring back quickly into shape after being bent, stretched, or squashed,'' '''resilient''' ''flooring'' ''refers to flooring materials which have a relatively firm surface, yet characteristically have ‘give’ and ‘bounce back’ to their original surface profile from the weight of objects that compress its surface.''

''Seamless A surface without open joints or junctions, or where such joints are completely sealed and smooth to create a continuous and whole membrane.''

''Slip-resistant A quality of a finish to prevent wet or dry slipping. This relates to the friction of the material in relation to the pedestrian traffic across it, and also the type of footwear users have when walking across this finish. Wet pendulum and dry floor friction tests indicate comparative results. Refer to section B4.3.3 for more detail. ''

''Smooth surface A flat surface without projections, indentations or perforations such as a brush-painted plastered surface.''

''Textured A surface finish which is not smooth, but has a fissured/embossed or ridged finish.''

''Tufted A group of threads drawn through a fabric and tied securely beneath the surface.''

''Vitrified To change a material into glass, under high heat and other conditions.''

''Washable A term implying that a finish can be repeatedly and regularly cleaned using water and water-diluted cleaners without detrimental effect to the finish.''

''Warranty A written promise to repair or replace a product that has a manufacturing fault. This commonly comes with conditions and is limited to a timeframe given at the time of purchase.'' ''' '''

==Abbreviations==
{| class="wikitable"
|''CFC''
|''Chlorofluorocarbon''
|-
|''CHD''
|''Centre for Health Design''
|-
|''ENT''
|''Ear, nose and throat''
|-
|''HAI ''
|''Healthcare-associated infections ''
|-
|''HCFC''
|''Hydrochlorofluorocarbon''
|-
|''HDF''
|''High-density fibreboard''
|-
|''IEQ''
|''Indoor Environmental Quality''
|-
|''IUSS ''
|''Infrastructure Unit Systems Support''
|-
|''MDF''
|''Medium-density fibreboard''
|-
|''MRSA   ''
|''Methicillin-resistant staphylococcus aureus, (which is a common skin bacterium that is resistant to a range of antibiotics), otherwise referred to as multi-drug resistant bacteria''
|-
|''NDoH ''
|''National Department of Health''
|-
|''OoM ''
|''Order of Magnitude''
|-
|''PMIS ''
|''Project Management Information System''
|-
|''PMSU ''
|''Project Management Support Unit''
|-
|''PuR''
|''Polyurethane-resistant''
|-
|''PVC''
|''Polyvinylchloride''
|-
|''RC ''
|''Recommendation Committee''
|-
|''VOC   ''
|''Volatile organic compound''
|}

=References=

==Bibliography==
Alcorn, A. and Wood, P., 1998. New Zealand building materials embodied energy coefficients database. (Volume II-Coefficients). Wellington, New Zealand: Centre for Building Performance Research.

AASA, the School Suprintendents Association, 2009. ''Improving indoor air quality: Materials selection.'' [online] Alexandria, Egypt: AASA. Available at: <nowiki>http://www.aasa.org/search.aspx?query=Materials+Selection+</nowiki>[Accessed 9 April 2014].

Cement & Concrete Institute (CCI), 2009. ''Sand-cement screeds and concrete toppings for floors.'' [pdf] Midrand, South Africa: CCI. Available at:

<nowiki>http://www.afrisam.co.za/media/13770/Sand_cement_floor_screeds_and_concrete_toppings_for_floors.pdf</nowiki>[Ac cessed 9 April 2014].

Center for Health Assets Australasia, 2009. ''Floor coverings in healthcare buildings.'' (Technical series TS-7 version 1.1). New South Wales:NSW Health.

Dean, Y., 1996. ''Finishes''. 4th ed. Harlow, UK: Addison Wesley Longman Ltd.

Department of Health (DH), 2010. ''Core elements: Health Building Note 00-03: Clinical and clinical support spaces''. UK: DH.

Department of Health (DoH), 1980. ''Regulations governing private hospitals and unattached operating theatres.'' (Government notice No. R.158 of the Health Act, 1971. (C.63). Cape Town South Africa: Government Gazette.

Department of Health Finance and Investment Directorate Estates and Facilities Division, 2006. ''Health''

''Technical Memorandum 61: Building component series flooring.'' [pdf] London: The Stationery Office. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/HTM%2061%202006.pdf</nowiki> [Accessed 9 April 2014].

Department of Health Gateway Review, Estates & Facilities Division, 2011. ''Performance requirements for building elements used in healthcare facilities.'' (Version:0.6:England). [pdf] Leeds: HMSO. Available at: <nowiki>http://www.derbyshirelmc.org.uk/Guidance/8941-England-8941_0.6_England.pdf</nowiki> [Accessed 9 April 2014].

Department of Health, n.d. ''R&D project B(04)02: Developing an integrated system for the optimal selection of hospital finishes.'' Aberdeen, Scotland: Department of Health.

HermanMiller Healthcare, 2006. ''Sound practices: Noise control in the healthcare environment.'' (Research summary/2006). Zeeland, Michigan: Herman Miller.

Joseph, A., Malone, E., Pati, D. and Quan, X., 2011. ''Healthcare environmental terms and outcome measures: An evidence-based design glossary.'' Concord, CA:The Center for Health Design.

Jung, W.K., Koo, H.C., Kim, K.W., Shin, S., Kim, S.H. and Park, Y.H., 2008. Antibacterial activity and mechanism of action of the silver ion in staphylococcus aureus and escherichia coli. ''Applied and Environmental Microbiology'', 74(7), pp.2171-2178.

Lavy, S., 2010. Facility managers’ preferred interior wall finishes in acute-care hospital buildings. In: CIB, ''18th CIB World Building Congress: Facilities management and maintenance''. Salford, United Kingdom, 10-13 May 2010. Salford, United Kingdom: CIB.

Makison, C. and Swan, J., 2005. The effect of humidity on the survival of MRSA on hard surfaces. (R&D report B(03)02). [pdf] London: Estates and Facilities Division of the Department of Health. Available at: <nowiki>http://www.wales.nhs.uk/sites3/Documents/254/B(03)02%20MRSA.pdf</nowiki> [Accessed 9 April 2014].

Nanda, U., Malone, E. and Joseph, A., 2012. ''Achieving EBD goals through flooring selection & design.'' [pdf] Concord, CA:The Center for Health Design. Available at:

<nowiki>http://www.healthdesign.org/sites/default/files/chd_achieving_ebd_goals_through_flooring__design_final_0.pd</nowiki> f [Accessed 9 April 2014].

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 56: Building component series: Partitions.'' UK: TSO.

NHS Estates, 2005. ''Health Technical Memorandum (HTM) 60: Ceilings.'' 2<sup>nd</sup> ed. UK: TSO.

NHS, National Services Scotland, 2006. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2007. ''Scottish Health Facilities Note 30: Infection control in the built environment: Design and planning.'' (Version 3). Scotland:Health Facilities Scotland.

NHS, National Services Scotland, 2009. ''Scottish Health Technical Memorandum (SHTM) 61: Building component series: Flooring.'' Scotland:Health Facilities Scotland.

PricewaterhouseCoopers LLP (PwC) in association with the University of Sheffield and Queen Margaret University College, 2004. ''The role of hospital design in the recruitment, retention and performance of NHS nurses in England.'' (Full report). [pdf] Edinburgh: Commission for Architecture and the Built Environment (CABE). Available at: <nowiki>http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/therole-of-hospital-design.pdf</nowiki> [Accessed 9 April 2014].

Welsh Health Estates, 2009. ''Health Building Note 04-01: Adult in-patient accommodation''. Cardiff, Wales:Welsh Health Estates.

Wolkoff, P., 1999. How to measure and evaluate volatile organic compound emissions from building products. A perspective. ''The Science of the Total Environment,'' 227(1999), pp.197-213

==Websites: Further reading ==
<nowiki>https://www.transparency.perkinswill.com</nowiki>

<nowiki>http://www.gatech.edu</nowiki>

<nowiki>http://www.GreenhealthMagazine.org</nowiki> <nowiki>http://greenhomeguide.com</nowiki>

<nowiki>http://gbcsa.org.za</nowiki>

<nowiki>http://www.green-buildings.com</nowiki>

<nowiki>http://www.healthcaredesignmagazine.com</nowiki>

<nowiki>http://www.isoboard.com</nowiki>

<nowiki>http://www.isolite.co.za</nowiki>

<nowiki>http://www.everite.co.za</nowiki>

<nowiki>http://www.armstrong.com</nowiki>

<nowiki>http://www.owa.co.za</nowiki>

=Photographic and illustration credits=
Cover photo: M. Swinney
{| class="wikitable"
|Fig.1
|M. Swinney
|-
|Fig.2 to 5
|Diagram by C. Hiralal
|-
|Fig.6
|R.Cubbin based on Lifecycle Floor Cost Table – by Nora®, USA
|-
|Fig.7
|G. Abbott- CSIR
|-
|Fig.8
|R.Cubbin
|-
|Fig.9
|M. Swinney
|-
|Fig.10
|R. van Rensburg
|-
|Fig.11
|M. Swinney
|-
|Fig.12
|R. van Rensburg
|-
|Fig.13 to20
|M. Swinney
|-
|Fig.21
|R. van Rensburg
|-
|Fig.22
|M. Swinney
|-
|Fig.23
|R. Cubbin
|-
|Fig.24
|M. Swinney
|-
|Fig.25
|R. Cubbin
|-
|Fig.26 to28
|M. Swinney
|}
<br />{{Expand}}
[[Category:Crosscutting Issues|Materials_and_finishes - Internal Ceiling Finishes]]
{{DEFAULTSORT:Materials_and_finishes }}

File:Selection criteria diag.png

2020-10-22T11:46:09Z