This is a continuing series from Huddy HealthCare Solution’s ED Design Team that covers “issues to consider” in support of making your next ED design project a success.         © 2014 Huddy HealthCare Solutions

Not Always 100% Full

I know it feels like it, but your ED is not always 100% full. And, if it is, you REALLY do need an ED expansion project!  There will be times over the course of a day, week, month or year, that your ED will need to “accordion down” from 100% capacity (and staffing coverage) to 75% or 50% capacity based on lower patient volumes.  The key to designing an efficient ED is to consider a design that supports efficient staffing and safe use of the environment when you are at 100% capacity and when you may be at 50% capacity, such as in the middle of the night.  The consideration of an efficient and safe operation of an ED at full capacity and half capacity is also very important to those EDs that see large seasonal fluctuations in patient volumes.  University area EDs, or tourist area , may see a 50% increase in ED volume during some peak periods of the year.  In this case, the design team needs to design an ED that can operate efficiently and safely when the ED is at both its highest and lowest patient volumes.

Separation of Entrances

The separation of Walk-In Vestibules and EMS Vestibules should be considered in every ED project.  No one walking into an ED should be able to see the EMS crew unloading a patient and moving them into the ED on a stretcher.  When designing a new, or expanded, ED your first consideration may be to put the Walk-In Vestibule at one end of the ED and the EMS Vestibule at the far, opposite end of the ED.  While this complete separation from one end of the ED to the other may seem appropriate, you need to consider the impact on 24 hour operations.

Pic1Resuscitation/Trauma Rooms, serving your most critical patients, are usually designed very close to the EMS Vestibule to limit travel distances when EMS personnel are accessing the ED with a patient.  However, if you put the EMS Vestibule (and Resuscitation Rooms) at the opposite end of the department as the Walk-In Entrance (and Triage area) it means that in the middle of the night when a resuscitation patient arrives you will have to move staff away from the “front care zone” to the “back resuscitation zone” at the opposite end of the department.   Diagram A shows a Walk-In Entrance in Zone A and the Resuscitation Rooms in Zone D.  Think of Zones A, B, C, and D as areas for teams of staffing and providers covering rooms in their “zone.”  If your ED is not at 100% capacity this means you will have vacant exam rooms (and no staff members) between the two opposite ends of the department.   The middle-of-the-night separation and isolation of the resuscitation team from the front end (i.e. staffed zone) of the department is operationally inefficient.  And, this isolation of the resuscitation team does not support safe clinical care.   The trauma team’s inability to rapidly access additional team members as needed in support of a resuscitation case is not supported with the isolated resuscitation rooms.

Centralize Resuscitation Rooms

Pic2To make sure you don’t design an ED where your most critical rooms are isolated in the middle of the night, you should consider centralizing the Resuscitation Rooms.  Centralizing the Resuscitation Rooms allows the rooms to be accessed by available staff any time over a 24 hour period, no matter how “full” the ED is at any time of day.  As shown in Diagram B, the centralized Resuscitation Rooms can be covered by any clinical team that is staffed in Zone A, B, C or D.  If in the middle of the night (or in a very slow season) you are only staffing Zones A or B, the Resuscitation Rooms can still be immediately accessed from these staffed areas.  As the ED starts to fill with patients (or in a very busy season), you may “accordion up” and staff Zones C and D.  So, in a slow period, the Resuscitation Rooms can be covered by teams in Zones A or B, and in a busy period the Resuscitation Rooms can be covered by any of the four Zones A, B, C or D.

Back Door Access

Some centralized resuscitation rooms actually have “backdoor access” for arriving EMS teams with stretcher patients.  This backdoor access allows EMS teams to deliver patients to these critical rooms in the middle of the department without any other patient in the ED knowing of their arrival.  EMS enters from the backside of the room and the clinical team accesses the patient from the front side of the room.  This is an excellent way of centralizing trauma rooms without disrupting the department when these most critical patients arrive in the ED.

Next Week: Behavioral Health

Next week’s article will be on the placement of behavioral health to support the flow of these unique patients, safety of the staff, and appropriate design considerations.  So, check back in next week for “Behavioral Health: Location Can Support A Safe Environment.”

If you would like more insights on ED design please contact Jon Huddy at