Redesigning Your ED for the Threats of Tomorrow
It’s a typical Thursday evening in the emergency department. Treatment stations are fully occupied. Physicians and nurses are busily tending to patients. Families come and go from the department and the waiting room is full of patients waiting for their turn to receive care.
Suddenly, chaos ensues. Maybe a patient under law enforcement custody overpowers an officer, gains access to a firearm and opens fire. Or a psychiatric patient not properly supervised stabs a nurse with a sharp object from her treatment area. Perhaps an individual, seduced by the opportunity for martyrdom, detonates an explosive vest, sending shrapnel and other projectiles in every direction. In another part of the world, a gang member with a gunshot wound is in the trauma resuscitation bay when a rival gang member enters to finish what he started on the street. Or a lone criminal holds the emergency department staff at gunpoint in an effort to steal narcotics from the department’s medication dispensaries. Different emergency departments, different challenges, but the same unfortunate outcome.
Every day in emergency departments around the globe, safety and security play front and center in the minds of hospital staff. With the increasing frequency of terrorism and mass acts of violence, most hospitals are focused on developing systems and plans to respond to the massive influx of patients associated with external disasters, yet few have exerted the same effort to design their emergency department to withstand such an incident with a minimal impact to life, limb and property. Many hospitals focus on preparing for pandemics of influenza, ebola, SARS and the like, yet few consider how to protect their emergency departments from violence. A review of the literature on planning hospitals for safety and security shows that information in this area is limited, with most research focusing on preparedness, not solutions focused on withstanding a direct assault on the emergency department itself.
Planning for Safety and Security Begins at the Beginning
The time to plan for safety and security in a new emergency department is at the inception of a design project. Identifying the types of risks that need to be mitigated, the size and scope of the events and the likelihood of such an event are all important aspects of conducting and initial risk-benefit analysis of what types of safety and security events should be designed into a new emergency department.
Once potential risks have been identified, emergency department staff, hospital leaders, and design professionals should identify safety and security performance expectations. These metrics should then inform the types of solutions that will be required. Some performance and success expectations may require a built environment solution, while others may be best handled through modifications to operations, policies, staffing or technology.
A final, but essential predesign consideration is understanding the budget for an ED design project. While there are a number of beneficial design and technological solutions that will enhance safety and security, each comes at a price that is often a premium over traditional design methods, construction materials and overall equipment. Understanding budgetary constraints will enable emergency department and hospital leadership to make informed decisions regarding the value of each investment made. It is also important to consider how each of the safety and security measures planned for inclusion in a new emergency department design will impact future flexibility and adaptability of the spaces. For example, blast-resistant safe rooms are much harder to move or expand than spaces separated by aluminum framing and sheet rock.
Specific Design Components to Enhance Safety and Security
There are a wide variety of design options and building materials that can assist with mitigating the impact of safety and security issues. Each department should consult with their design and security professionals to consider which materials are right for the new emergency department based on local building code requirements, the design and construction budget, and the desired performance specifications. However, some of the most important design solutions that support safety and security are ones that costs very little.
Every emergency department should be designed with the specific intention of ensuring proper lines of sight from staff work zones and security monitoring posts to all areas of the emergency department. This focus on sight lines will ensure that emergency department staff can maintain situational awareness, which can provide early and life-saving detection of a threat within the department, along with easy notification of others to the situation.
Another simple and low-cost solution to ensuring the safety and security is designing the department with a limited number of access points from the clinical, or sterile zone, to the non-clinical areas (reception, administration, etc.) and the hospital complex. Limiting the number of access points will reduce the number of doors that need to be monitored and, when necessary, secured to facilitate a departmental lock down to ensure the safety and security of those inside the sterile area.
A third and equally important design consideration is considering how emergency department staff are positioned in the department relative to patients, visitors, corridors, areas of refuge and the like.
In many parts of the world, emergency departments and other areas of the hospital are being designed using patient-centric, or customer service approaches. These considerations have led to solutions that include decentralized staff workstations -- including use of conference tables instead of traditional nursing stations -- where the staff may be seated with their backs to the corridors when performing work functions. Going back to the concept of situational awareness and understanding that the emergency department is a chaotic and often somewhat uncontrolled environment, design solutions that limit the ability of the emergency department staff to “duck and cover” or those that position them with backs to corridors or patients, should be considered carefully before implementing.
Learning From Geographically-Specific Design Approaches and Building Codes
Each part of the world is subject to a different set of natural and man-made disasters that, over time, have informed how buildings can be designed to withstand a disaster. While disaster studies may not be the exact safety and security issues an emergency department is attempting to mitigate, the learning principles may be applicable.
When considering how to design environments that can endure the impact of the blast from an explosive event, much can be learned from parts of the world where buildings are designed to withstand a volcanic eruption or the force of a category five tropical cyclone. In the case of the solutions tied to volcanic eruptions, building solutions have been designed to mitigate and absorb the initial blast and the aftermath, including fire which can spread rapidly, as well as falling ash which can add thousands of tons of weight to a roof. Buildings designed to survive hurricanes are intended to withstand massive winds, epic flooding and shrapnel flying at a building in excess of 300 kilometers per hour.
Hospitals and emergency departments designed in some of the most rural areas of the world can teach us about how to design spaces to function “off of the grid” for hours, days or even weeks. Thinking about adequate storage space to function without replenishment for extended periods of time, as well as access to clean or filterable water and even energy reserves to power emergency generators for extended periods of time, can be an important consideration in areas where a safety or security event can mean functioning for extended periods before help arrives.
Medical units designed inside high security prisons can provide vital lessons in how to ensure patient and staff security in the event of a safety or security issue within the hospital or emergency department where it becomes necessary to completely secure and isolate the emergency department from the rest of the hospital complex and the exterior environments. While it is not suggested to design an emergency department to resemble a “prison ward,” there are critical lessons to be learned about access strategies, situational awareness, creating safe spaces, and the speed at which environments can be secured if conditions warrant.
Leveraging the New Emergency Department for Mass Casualty Training Exercises
In addition to designing the new or expanded emergency department with safety and security in mind, another valuable opportunity is to leverage the newly designed space to engage in pre-occupancy training exercises relevant to the types of safety and security incidents that could potentially occur in the new ED.
Training exercises that are of value prior to opening a new or expanded emergency department to the community should focus on potential safety and security issues relevant to the local environment. Around the globe, the focus may be different, and can range widely from active shooter, use of improvised explosive device, to use of high velocity vehicle or hostage condition. In each situation, the use of the vacant emergency department allows leadership to assess the ability of the emergency department to respond to a number of different “what if” scenarios, advancing learning to the next training exercises.
The design of hospitals and emergency departments has continued to evolve as clinical technologies and patient expectations have advanced. The unfortunate reality is that design must also adapt to reflect the dangers of a world where violence is a common occurrence and, in some cases, the emergency department is ground zero for the violence. However, with proper planning and smart operational, technological and physical design solutions, the emergency department can be better prepared with withstand the threat.