Here, they summarise the most up-to-date evidence, and share details of some new research
There are numerous factors to consider when deciding on the best flooring type for use in healthcare facilities, not least matters of endurance, sustainability, and environmental credentials, cleaning and maintenance, infection control, aesthetics, and cost. Safety considerations will commonly focus on the suitability of the material for areas which may become wet or contaminated, with slip resistance being a key concern. But what if flooring could play a bigger role in patient and staff safety?
The problem of falls
Slips, trips, and falls make up the majority of safety incidents in the healthcare sector. Aside from the common consequences of pain and bruising following a fall, patients are vulnerable to serious injuries such as hip fracture and head injuries, and even death as a result. Longer-term disability can result from a fall, with loss of independence, ongoing care needs, and increased risk of moving into a care home. Falls can also have a psychological impact, leading to fear of falling, anxiety, depression, and avoidance of activity, which can be counter-productive, and may actually increase a person’s risk of falling further. A person’s risk of falling is over three times higher if they have fallen before.
Many factors can lead to a fall and contribute to related injuries (not just a slippery floor), with factors such as cognition, medications, footwear, clothing, bone strength, eyesight, health conditions, mobility problems, activity levels, the presence of others, and being in a disorientating environment (such as a hospital), all having a part to play (see Figure 2). There is therefore no panacea when it comes to falls and injury prevention, but flooring does have a part to play. The flooring choice in a hospital is going to impact upon a person’s injuries – whether this has been considered in the decision-making or not; landing on a hard, concrete sub-floor, with a 2 mm overlay, will be a contributing factor to any injuries sustained.
Means of protection
In the quest to improve outcomes for patients, one approach is to look for ways to prevent serious falls from occurring, by protecting patients from life-limiting injuries. Hip protectors have been explored, but they can be uncomfortable to wear, are not always worn at the time of a fall, and only protect one part of the body. Shock-absorbing flooring seeks to prevent fall-related injuries by reducing the impact forces that someone experiences when they land on the floor. Flooring is part of the ambient environment, so – unlike hip protectors – requires no user conformity, and it has the potential to protect any part of the body coming into contact with it, so could have more of a role to play in fall-related injury prevention
Shock-absorbing floors – some considerations
Different floors will offer different degrees of shock absorbency. A high-pile carpet with a thick underlay on a wooden subfloor is going to be more shock-absorbing than a 2 mm layer of PVC or vinyl laid on concrete, but will likely raise concerns around cleaning and infection control. Some manufacturers make floors with impact-absorbing properties that have been designed for use in sports facilities, which have been repurposed for use in healthcare settings, while some are targeting health and care settings with more purposefully designed underlays and overlays specifically aiming to prevent fall-related injuries in vulnerable people. An increased shock absorbency may also provide other benefits in the form of sound attenuation and comfort underfoot. However, like any design decision, there are trade-offs to consider. Might something that feels softer underfoot have the potential to make people who are vulnerable to falls more unstable, and – counter-productively – increase their risk of falling in the first place?
Increased rolling resistance
A softer floor surface will also increase the rolling resistance for moving wheeled objects – so might this lead to an increased safety risk of musculoskeletal injuries in staff who need to move beds, hoists, trolleys, portable scanners, and the like? How will a thicker floor transition to an area with regular flooring, and will this create a trip hazard? How compliant (shock-absorbing) does a floor surface actually need to be to protect against injuries? The issue of moving towards shock-absorbing flooring is therefore not straightforward, even before considering all the other attributes we look for in healthcare floors around sustainability, hygiene, aesthetics, and cost. A more compliant surface to land on may become a safety concern for staff manoeuvring wheeled equipment, or for patients with instability – so we need to look at the research evidence.
What is the evidence for shock-absorbing floors?
We have undertaken a Health Technology Assessment comprising a review of 22 studies exploring novel floors, sports floors, carpet, and wooden sub-floors in health and care settings; this is available in full and in an abridged format.1,2 The research was led by Dr. Amy Drahota, University of Portsmouth, in collaboration with colleagues at University of Southampton, Cardiff University, the Health & Safety Executive in the UK, Simon Fraser University, and University of Waterloo in Canada. Further advisors from the NHS, Estates and Facilities personnel, members of the public, and the National Care Association, helped ensure the relevance of the research. The research was funded by the National Institute for Health Research (Award ID: 17/148/11).
Ten studies, carried out in the UK, Canada, the US, Sweden, and New Zealand, have explored the difference that shock-absorbing flooring can make to the number of falls and injuries; six of these studies were carried out in hospitals, and four were based in care homes. In total, the studies analysed 11,857 falls and 163 staff injuries; four explored the use of carpet, three looked at re-purposed sports floors, five studies explored novel health floors, and one compared wooden and concrete sub-floors.
What impact do shock-absorbing floors have on patient and staff injuries?
One type of novel shock-absorbing floor may not be effective in care homes, compared with rigid flooring;3 however, gaps still exist in knowledge. Here, we focus more on the hospital-based data. In summary, there is very low-quality evidence that shock-absorbing floors may be more beneficial than standard rigid floors for reducing fall-related injuries. Let us assume that if hospital wards (specialising in older people’s medicine) have standard rigid floors, three injurious falls will occur every day for every 1,000 inpatients on the wards. Research suggests that on average, one fewer injurious fall would occur each day if shock-absorbing floors were laid instead. Research data always contains some uncertainty, however, and so it is estimated that shock-absorbing flooring could result in between two fewer injuries per day, to about the same number of injuries per day, for every 1,000 patients. Another way to look at the data is according to the number of falls that result in injury. On a standard rigid floor in an older people’s medicine ward, we can estimate that 424 out of 1,000 falls will result in an injury. However, if we were to replace the rigid floor with a novel or sports floor, then the data suggests that on average 153 fewer falls would result in injury (or somewhere between 237 fewer and 30 fewer injuries per 1,000 falls). One care home-based study also indicated that wooden sub-floors may result in fewer hip fractures than concrete subfloors. The fact that the evidence is of very low quality is important, as it means we should question its trustworthiness. We also found very low-quality evidence that shock-absorbing floors may make no difference to the number of falls, indicating that patients would be no more unstable on a shock-absorbing floor than on a regular rigid floor. For staff, there is no strong evidence to suggest that their risk of musculoskeletal injuries is increased on more shock-absorbing floors, but we do not know if this is actually attributable to how well staff adapt to shock-absorbing floors, as these floors do increase staff concerns.
What are people’s experiences of using shock-absorbing floors?
Five studies have explored people’s experiences of using shock-absorbing flooring in practice. These studies related to 147 people, including 12 inpatients, eight hospital visitors, 84 hospital/hospice staff (across a range of roles), eight care home residents, eight long-term care nurses, and 27 care home managers. These studies indicate that: (1) Shock-absorbing flooring is viewed by many as a potential solution to help protect people from fall-related injuries, with a potential side-effect of improving environmental comfort; (2) Changing a floor has consequences for the wider system (e.g. affecting the ease of moving equipment), potentially leading to further adaptations and adjustments in behaviours, attitudes, equipment, processes, and staffing, and (3), that installation may be an initial concern, but can be effectively managed. However, cost and funding considerations need to extend beyond the initial purchase and installation, to consider potential adaptations in staffing/processes/equipment, and potential cost-savings from fall-related injury prevention (should the floor be effective).
What do the economic evaluations say?
There are five economic studies, which, when taken together, suggest that if shockabsorbing flooring does not increase the number of falls, then it will improve the number of years people live in good health, and will reduce costs in the long-run due to the injuries saved; i.e., it would be a costeffective strategy. These economic studies were all based on different assumptions, and were of varying quality. They did not, however, factor in the costs of any changes to staffing, processes, or equipment, so are somewhat incomplete
Implications of these findings for practice?
There is very low-quality evidence that shock-absorbing flooring may reduce injuries without increasing falls, and that wooden sub-floors may result in fewer hip fractures than concrete sub-floors. If this is true, then shock-absorbing floors would result in lower costs and more years lived in good health. The studies confirmed that shock-absorbing flooring has wider workplace implications – it makes it more challenging for staff to move wheeled equipment. Very low-quality evidence indicates both that adaptations can be made to accommodate these challenges, and that there is no overall increased risk of flooring-related staff injuries. It is important to consider the impacts on staffing, equipment, and processes when installing shock-absorbing floors. The evidence is of very low quality, meaning it is uncertain, and that future research may therefore change our understanding.
What about new flooring solutions?
Given the uncertainty surrounding current flooring solutions, research and innovation are required to establish the specifications for improved products. Here, we introduce a new two-year project, funded by the Engineering and Physical Sciences Research Council, in which we aim to develop a multi-functional smart floor that will quietly work in the background to prevent falls, detect falls, and protect against injuries, in one integrated solution. In this project we are focusing our attention on passive detection and protection methods, as these are not privacyinvasive approaches, do not require user compliance, and can be easily adopted, even for people that are physically or cognitively impaired. Especially for people who spend the majority of their time in a home environment, the floor has a great potential to be repurposed as a large sensor for device-free positioning, as well as fall detection. As a part of this project, we will introduce an innovative sensing technology to the floors with the potential to predict and monitor for falls. Developing low-cost pressure/ deflection sensing materials for flooring with minimal environmental impact is one of the key objectives of this project. Also, with the help of artificial intelligence, we aim to create design maps to capture the trade-off between different required functionalities by systematic exploration of the whole design space. This design space can then be exploited for multi-functional flooring, and enable designers to provide an optimal solution for a particular care setting
How will shock-absorbency feature in your flooring-related decisions? If this article has helped shape your thinking around selecting healthcare flooring (in any direction), we would be interested to hear from you. Please contact amy.drahota@port.ac.uk to let me know your thoughts.
Dr Amy Drahota
Dr. Amy K. Drahota is a Reader (Associate Professor) in Health & Social Care Evidence & Evaluation at the University of Portsmouth, with a focus on the health and care of older adults, falls and injury prevention, and age-friendly environments. She obtained her PhD on the influence of healthcare environments on patient outcomes in 2007, and has since worked in the field of flooring interventions. Dr Drahota has worked collaboratively to deliver the first and only hospital-based randomised experiment (the HIP-HOP Flooring Study) on shock-absorbing sports flooring (referred to in Health Building Note 00-10: Part A – Flooring). More recently she has led on a Health Technology Assessment of shock-absorbing flooring for fall-related injury prevention in hospitals and care homes (The SAFEST Review), described in this article. Her role at the University of Portsmouth includes undertaking research, supporting postgraduate research students, and delivering learning on undertaking and evaluating research.
Dr Iman Mohagheghian
Dr. Iman Mohagheghian is a senior lecturer in Mechanics of Materials at the School of Mechanical Engineering Sciences at the University of Surrey. His core expertise is around designing, manufacturing, modelling, and testing the performance of novel lightweight energy-absorbing materials and structures. He received his PhD from the University of Cambridge in 2013 in the field of impact mechanics. His PhD was on the application of polymers and polymer nanocomposites as lightweight impact energy-absorbing materials. Prior to joining the University of Surrey in 2017, he was a research associate in the Department of Mechanical Engineering at Imperial College London. The focus of his current research is around design for multifunctionality. He is currently the principal investigator on an EPSRC-funded project, EP/T009306/1, ‘Multifunctional flooring: design for independent living’. The aim of this project is to deliver a holistic design approach in developing novel multi-functional floorings with passive fall prevention, detection, and protection, in one integrated solution.
References
1 Drahota A, Felix LM, Raftery J, Keenan BE, Lachance CC, Mackey DC et al. Shockabsorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review. Health Technol Assess 2022; 26(5). Available from: DOI: 10.3310/ZOWL2323
2 Drahota A, Felix LM, Raftery J, Keenan BE, Lachance CC, Mackey DC et al. The SAFEST review: a mixed methods systematic review of shockabsorbing flooring for fall-related injury prevention. BMC Geriatr 2022; 22(32). Available from: https://doi.org/10.1186/ s12877-021-02670-4
3 Mackey DC, Lachance CC, Wang PWT, Feldman F, Laing AC, Leung PM et al. The flooring for injury prevention (FLIP) study of compliant flooring for the prevention of fall-related injuries in longterm care: a randomized trial. PLoS Med. 2019;16:e1002843.