June 25, 2015
By David Vincent, AIA, ACHA, LEED AP, Designer and Director; Jim Lennon, AIA, Vice President; and Michael P. Pietrzak, MD, Chief Medical Advisor, HKS Team ED

The Emergency Department (ED) is the 24/7 front door for U.S. healthcare. Despite a 7 percent decrease in ED capacity nationwide, visits are up 32 percent over the last decade. Universal care coverage will likely continue the increase in demand for ED services, because it will take several years for primary care capacity to grow accordingly.

There are numerous innovations and trends in ED design and operations. Among them are the emergence of freestanding EDs, advanced concepts for highly infectious diseases, linear ED design and recliner-centric, patient-focused pods.

Freestanding EDs

Freestanding EDs can be affiliated with hospitals or nonaffiliated. Nonaffiliated freestanding EDs are generally operated by private-practice physician groups. These are becoming very popular, particularly in the state of Texas, where legislation has made this a favorable business model.

These are not “watered-down” EDs or urgent care centers. They offer full emergency services, usually by board-certified emergency physicians. These facilities almost always have on-site imaging — including CT, general radiography and ultrasound. They additionally and often have on-site lab and pharmacy services as well. Unlike a hospital setting, technology is generally on display in a freestanding ED. This is intentional to emphasize to patients that they’re in an advanced care environment. 

Freestanding EDs are designed to be convenient and easily accessible. They are often located in the suburbs, sometimes alongside ambulatory care facilities, as part of a hub-and-spoke approach to extending a provider’s services into suburban areas. These facilities follow a budget-driven, competitive model. 

They are often designed with consumer-oriented, hospitality-like features. We’ve developed a concept featuring smooth, clean finishes, very much like a high-end contemporary hotel. 

There are some ongoing challenges across the country, mostly related to cost reimbursement, as to whether or not this business model will continue to be viable. We’ll be watching to see what happens. 

Unidirectional Workflow for Infection Control

In the United States, infection-control areas have traditionally included an anteroom for both gowning (donning) and degowning (doffing). This model works well to protect immune-suppressed cancer patients from getting outside infection. But if the patient is contaminated, this could be the wrong model. 

We’ve developed a concept design for unidirectional flow of staff members. Instead of an anteroom, this design features an exit room where caregivers can decontaminate or dispose of personal protection equipment (PPE) and other items. Caregivers can exit, decontaminate, shower, get dressed and get back to the staff work area, greatly reducing the risk of unwanted contamination. Further, this allows others to enter the patient room without risk of contamination. 

This design can be used to retrofit an inpatient setting by using the middle of three sleeping rooms to absorb the exit room functions of the two rooms on either side. 

There may be several different solutions, but one common principle is recommended: unidirectional flow. 

Linear Design

Over the last 20 years, EDs have been thought of as basically circular, with a nurse station in the middle and beds around the perimeter. If there are more than 15 beds, you have to add a separate circle, or pod. In a linear ED, patients enter from the left, and they flow around a peripheral circulation system that’s intuitive in terms of wayfinding. The staff works in the middle. Every room has two doors: one for the staff, one for the patients. 

The linear ED fills from left to right, scaling up and down according to the patient census. There’s never a need to staff an entirely separate pod just to accommodate one additional patient. 

We’ve discovered there’s an underlying pattern to the arrival of patients at all EDs: It’s low in the morning, and it comes up. So, unlike most departments, the emergency department has to be able to breathe — to go from small to big and back down again, every single day. If you can’t easily and simply demonstrate in a floor plan how the ED does that, it’s likely to have significant operational difficulties. 

This design demonstrates an advanced way of providing staff flexibility and scalability. This protects the hospital’s capital investment. 

Recliner-Centric Pods

In studying the flow of patients in the ED, we’ve also learned that approximately 50 percent of incoming patients need to be in a bed. The other 50 percent could very well tolerate being in a chair or a recliner. So we have created what we call pods. 

These pods wrap around the individual patient with space for two family members. Each pod has a pullout table and other accommodations similar to those found in first-class airline seating. An electronic tablet connected directly into the pod can be used to control several functions, such as communicating with caregivers, listening to music, or changing the color or intensity of individual lights. Parametric focused sound speakers create a tight cone of sound around each pod. This technology is mature, readily available and inexpensive. 

The pods can be arranged in a pinwheel fashion in the center of a room. Or they can be used to turn two ED bays into space to care for four patients, separated by sound-absorbing curtains with magnetic closures. The pods can be integrated into a linear ED design to allow one caregiver to attend to patients using the pods and patients in beds, in traditional patient bays, without disrupting workflow. 

Leading Edge

Our team has been developing these ideas for nearly 14 years. It takes that long to see innovations of this type implemented. We’re continuing to work on other new ideas and believe we’re on the leading edge. We’re going to continue to be there.

Want more information:

Join Us: Rethinking the ED Experience Video: https://www.youtube.com/watch?v=zgXlZ_kqu4M 

An Improved Approach to Infection Control: http://www.hksinc.com/insight/an-improved-approach-to-infection-control/

HKS Unveils the ER of the Future at ACEP 2014 Video: https://www.youtube.com/watch?v=C9HttKhKEr4

7 New Factors Shaping Hospital Emergency Departments (BD+C): http://www.bdcnetwork.com/7-new-factors-shaping-hospital-emergency-departments

Bridging the Gap – Trends in Freestanding ED’s (MC&D): http://mcdmag.epubxp.com/i/479185-mar-apr-2015/39

Hospitals Test Out New Design Concepts (HFM): http://www.hfmmagazine.com/display/HFM-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HFM/Magazine/2015/Apr/hfm-hospital-innovation-centers


Posted in Health
Tagged emergency department design