This is one of a series of articles by Jon Huddy, ED architect and author of ACEP’s ED design book, offering insights to you as an ED physician leader on how to position your emergency department for architectural design success.  This article focuses on the components to analyze, prioritize and consider for your ED design project to assist you in prioritizing future needs.

Never Enough Money

Almost every one of the 300 ED design projects that I have completed has started with a discussion regarding “what is working and what is not working in your current ED?”   Almost every time the response from the doctors is “nothing works!”  And that response is fine if you have the budget to completely relocate your ED and design an entirely new emergency department.  However, in today’s economy many hospitals have limited capital resources to provide for an entirely new ED so the emphasis is on prioritizing needs to apply the available money for expansion or renovations in a way that will have the greatest impact to safety, security, increased capacity and elevated satisfaction scores (among many other goals and objectives).

The following is a small sample of the hundreds of  various components that I review with my clients (hospitals, physicians, local architects, etc.) when establishing future needs.   The components listed below are also a small sample of the items that can also be used to review a proposed design to make sure that certain issues have been considered in the design.  So, whether you are on a tight budget, large budget (lucky you!), renovating, expanding, relocating your ED, or building an ED as part of a new hospital, the following list will be beneficial for you to consider as you venture into your emergency department design project.

Start from the Outside In

I’m assuming that your first, or one of your first, concerns is “number of exam rooms” and that you want to make sure that you increase capacity with your design project.   And while that issue is at the heart of most ED design projects, my recommendation is to start with the actual site where your current or future ED is (or will be) placed and review important components for automobile, ambulance, and heliport access and parking.   Following are just a few of the many issues that I consider as I evaluate an emergency department site design:

  • Auto and EMS drive(s) separation: How quickly are automobiles and ambulances separated from each other when accessing hospital site?
  • Do ambulances mix with service vehicles/trucks when driving on the campus to gain access to the ED EMS drop-off area?
  • Is there direct visibility to ED entrance from major roads/streets where the majority of patients will be traveling to the hospital for emergency services?
  • Once patients/families drive on the hospital site, is the driveway path to the ED clear, straight and easy to navigate?
  • Is there space for multiple automobiles to be covered by a canopy when unloading patients?
  • If ED patients are required to park in a parking garage:
    • Is garage adjacent to ED?
    • Are there designated ED spaces or levels in the garage?
    • Do security cameras cover the garage?
  • Can ambulances drop-off and “pull-through” vs backing up to unload patients?
  • Additional parking spaces for EMS vehicles after unloading?
  • Additional parking spaces for police vehicles close to EMS entrance?
  • Is there an area for disaster staging that can be secured from vehicular traffic in the event of a disaster?
  • Is there storage in the building or in portable storage containers for disaster supplies?
  • Heli-stop Pad:  Level of security to control access to heliport (ground based with fence, elevated, or roof top?)
  • Heli-port – Helicopter Base: ability to refuel, stage additonal helicopters, etc.

Walk-In Access

The next component you evaluate should be the public/patient entry point into the ED.   Components to evaluate include:

  • Space for wheelchairs, including “large” style, near entrance?
  • Clear and direct path for Walk-In patients without traveling through waiting room chairs?
  • Is reception desk/window designed as a pleasant entry space, welcoming?
  • Quality of public seating: Is public seating comfortably placed with adequate area around each chair, space for wheelchairs, etc?
  • Easy access to public toilets, quantity of toilets
  • Family Consult/Grieving Room with separate doors from ED and waiting?
  • Daylight into public area?

Triage (Care Initiation)

When assessing the triage/care initiation area you will need to match your evaluation with the operational processes intended for the area.  An old-fashioned triage area, with typical triage processes, will be designed differently from a “care initiation” area that may support a provider-in-triage operational concept.   Match the following selected components for evaluation based on your intended operations:

  • Privacy at initial Reception area?
  • If triage is backed-up is there a separate area to ask pre-triage patients to wait different than the main public waiting room?
  • Post-triage inner waiting:  Is there a place for post-triage patients to wait (if ED is at capacity) rather than sending them back to main public waiting room?
  • Are there any protocol stations, or “rapid care” areas near/adjacent/or part of triage to allow “vertical” patients to receive care immediately after triage?
  • Isolation room immediately adjacent to triage/reception?
  • Is there a discharge inner waiting area for patients awaiting discharge or financial counseling?
  • Are there any Care Management or Medical Home consulting offices as part of the discharge path?
  • Is there a separate path out of the ED for discharged patients instead of walking back through the public waiting room?

Safety and Security

Safe and secure design includes hundreds of considerations.  A few of the key items to consider include:

  • Can vehicular access drive to the ED be controlled or blocked in the event of a disaster?
  • Exterior of building should be well lit for security purposes and to support patient access to the door at night.
  • Is a security presence provided in the ED?  Where?
  • Ability for public to see security and be aware of its presence?
  • Is there an established location for security to be placed in the event that they need to supervise behavioral health patients?
  • Can the location of security view:
    • to parking lot?
    • to auto drop off area?
    • to ambulance dock area?
    • to walk-in entry vestibule?
    • to main public waiting?
    • to reception desk?
    • to glassed-enclosed triage spaces?
  • How quickly can security access behavioral health area?
  • Does security “wand” people at certain times or days?
  • Separate mental health access and control point?
  • Is there an escape path for the receptionist or personnel at the reception desk.
  • Triage escape (flow through rooms)?
  • Is there panic alarms at reception? At triage? In main ED?

Evaluation of General Treatment Area(s)

  • Treatment rooms that don’t meet current minimum size (120 sf or applicable code) or configuration requirements?
  • Quality of private patient care rooms vs. cubicles?
  • Are rooms all configured the same way (universal) vs. various configurations or “mirrored” rooms?
  • Visibility from nurse station / work areas to patients:  Glass-front ICU-type doors?
  • Are in-room stretchers perpendicular or parallel to the corridor?  Perpendicular stretchers with the head of the patient at the far wall forces the patient to look out to the nurse station area instead of focusing on an interior wall or TV with the bed parallel to the corridor.
  • Is there room for staff, patient and family zones within the room?
  • Exterior windows and natural daylighting available?
  • Ability to accordion up and down between “zones,” “modules,” etc?
  • Patient can control lights in room?
  • Areas specific for geriatric care?
  • Bariatric Rooms are larger, special toilet accommodations?
  • Air isolation room: quantity vs. volume; private toilets?
  • Sexual Assault (SANE) capabilities with adjoining toilet/shower, evidence storage, interview/taping room?
  • Convenient access:
    • to CT/Imaging (in ED or outside ED)?
    • to surgery?
    • to cath lab?
    • to ICU?
    • from helipad?

EMS Access Point

Components to evaluate in support of EMS access to the ED include:

  • Upon entering the EMS entry vestibule/door, is there an electronic screen to notify/direct EMS personnel to appropriate care space?
  • Upon entering ED, can clinical personnel visualize arriving EMS personnel and stretcher patient?
  • Is there an EMS staging/holding area other than “in the corridor” for arriving stretcher patients?
  • If there is an EMS staging area, is the patient separation by 3-walled cubicles instead of cubicle curtains to deliver a level of privacy?
  • If EMS staging area, is there access to a pneumatic tube in support of advanced protocol specimen collection and testing?
  • Stretcher storage room/alcoves out of hallway?
  • Ability for EMS to access resuscitation rooms quickly and efficiently?
  • Internal work space for EMS/law enforcement near the ambulance entry vestibule?

Additional Considerations

There is a long list of additional considerations for pediatric patients, psychiatric patients, ancillary support, clinical support spaces, staff support and administrative support spaces.   Huddy HealthCare Solutions has over 300 items we check when either analyzing existing conditions or evaluating future designs.   If interested in understanding the depth of our design analysis components, please contact Jon Huddy directly.

Jon Huddy can be reached at (803) 517-7522 or j.huddy@huddyhealthcare.com