The Best ED Design Promotes Flexible, Adaptable Spaces

Published on June 28, 2014
Dr. Manuel Hernandez suggests that mixed-use exam rooms and a re-ordering of the patient intake area are examples of simple and low cost design solutions aimed at increasing efficiency.

EPI: In what countries are you seeing innovative design in emergency medicine? Are certain countries putting a higher emphasis on this than others?

Dr. Manuel Hernandez: One of the often overlooked aspects of designing healthcare spaces is that the design solutions needs to reflect the clinical and cultural realities of the communities being served. For example, what works well in a North American emergency department that sees 150 patients a day is not going to work in a Chinese emergency department that averages over 1,000 patient encounters per day. The operational, staffing, and technology considerations are, and should be, vastly different in these environments.

In North America much of the innovation in emergency department design is being developed in community hospitals that are heavily focused on balancing clinical quality with efficiency and the optimal patient experience. This is where all-private room designs first emerged, as did operational innovations like physicians in triage, the use of advanced technologies for arrival, and new registration processes.

In emergency departments in Asia, the Middle East, and Gulf Cooperative Council countries, the emphasis has been on designing solutions that support parallel patient streaming in an effort to support hundreds of patient arrivals per hour. In this situation, the design solutions are very different than those employed in North America. For example, designing a 200 treatment station emergency department with all-private rooms would be spatially impractical.

EPI: When we talk about the best design in emergency departments, a lot of it can feel like it has to be high tech and expensive. What’s an example of great design being implemented that is lo-tech and easy on the budget?

Hernandez: Great design does not need to be expensive or overly reliant on technology. The greatest solutions I have seen in emergency department stem from proper pre-design planning activities that focus heavily on rethinking the process and patient flows. They are then able to translate these into responsive physical solutions.

A perfect example of this type of design thinking is demonstrated in emergency departments that have placed the x-ray unit closer to the arrival and intake zone with the intention of securing the x-ray prior to physician evaluation. With the proper policies and procedures in place, this model accelerates patient throughput without adding any additional expense to the design solution. Another great example of low-cost innovation is the introduction of the vertical patient model that replaces some expansive exam rooms with trolleys and smaller treatment stations with lounge chairs. This solutions reduces the footprint of the department which translates into lower design and construction fees while maintaining the overall capacity of the department.

Budget-Friendly Design Tips:
1. Place the x-ray unit close to the arrival and intake zone in case x-rays need to be taken prior to physician evaluation.
2. Replace expansive exam rooms with trolleys and smaller treatment stations with lounge chairs.

EPI: A lot of emergency physicians want a better-designed emergency department yet they are a decade away from a full re-design. What is a simple first step that an ED can take towards better design today?

Hernandez: It’s important to remember that design is about more than the physical space. Design is about the sum of all parts that come together to create the entire emergency department experience. It’s about how processes, staffing, models of care, technology, equipment and the physical space interact with one another in ways that deliver results beyond what any solution could provide on its own. Many emergency departments are not in a position today to engage in a full-scale renovation or redesign. For those that are in this situation they can still achieve improvements in efficiency and patient experience from simple, inexpensive solutions.

My experience has been that this process is best achieved by looking comprehensively and objectively at where the department is today with respect to performance and where it realistically aspires to be in the foreseeable future. With a clear picture of the distance between current and future state of the ED, decisions can be made that will help it advance toward creating an optimized structured and a methodical approach. In many instances completely innovative patient flow models can be developed within existing spaces. Innovation in process is simple, inexpensive and offers some of the best design solutions available.

Designing flexible, adaptable spaces that can provide services to a patient with a fracture one minute, a patient with a corneal abrasion the next, followed by a patient enduring chest pain represents the most efficient and effective emergency department design available today.

EPI: What one design fix (big or small) does nearly every emergency department need? Put another way, what is the highest-yield design improvement world wide?

Hernandez: In my experience the most important design innovation that can be incorporated into any emergency department design is flexibility and adaptability to the physical environment.

If you look at the evolution of emergency departments across all countries where emergency medicine as a specialty has grown and evolved, what we do and how we do it has evolved. If our physical environments are not able to respond we risk compromising quality, performance, efficiency and cost. One the worst mistakes I see many new emergency departments make is overspecializing their design solutions. Insisting on specialty treatment spaces such as an eye room, an orthopedic room, a gynecology room and the like result in rigid spaces that are unable to serve multiple functions when demands require. This results in underutilized spaces. Designing spaces that can provide services to a patient with a fracture one minute, a patient with a corneal abrasion the next, followed by a patient enduring chest pain represents the most efficient and effective emergency department design available today.

EPI: What are the global trends that you’re noticing in emergency department design? Differences by region?

Hernandez: Emergency department design varies considerably across regions. In North America and other advanced emergency medicine models we are seeing a number of key trends evolving. The first trend, which began many years ago, is the evolution of the all-private room emergency department design. Additionally, the inclusion of clinical decision (observation) units in emergency department design is gaining momentum, particularly in the United States. Additional emerging trends in design include internal waiting areas that are able to serve as clinical spaces when necessary, evolving patient intake and triage concepts, and a growing number of dedicated behavioral health zones. These include exam and consultation rooms, safe rooms, and patient reception/waiting areas that are separate from the main emergency department.

In other areas of the world the emphasis has been on evolving design to reflect the growing prevalence of emergency medicine, advancing diagnostic capabilities, and evolving patient expectations for their emergency department experience. As I discussed earlier, countries with high-volume emergency departments such as India and China are experimenting with patient streaming designs that focus on receiving a large number of patients simultaneously without the typical queues that result. Advances are also taking place in response to new emergency models of trauma and critical care in which the emergency department often play a prominent role. Another major innovation we are seeing is in response to pandemic situations like the MERS outbreak in the Middle East. In this model, emergency departments are able to respond to a profound surge in patient volumes with potentially communicable conditions while continuing to manage the general emergency department population that continue to seek care during a pandemic.

This article originally appeared in Issue 13 of Emergency Physicians International.

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