Designing the perfect emergency department

Designing Emergency Departments is challenging. This is purely because emergency medicine is a young specialty and still in a state of flux. We are trying new things all the time to improve performance and efficiency. We add paediatric waiting rooms and short stay units and ‘fast track’ areas and streaming. When all is said and done, is there such a thing as the perfect emergency department? Probably not, but we can get very close.

I’ve had the privilege of designing emergency departments now for some 15 years and in more than one country. You can’t keep doing something for that long and not notice what works. There are patterns. As they say ‘success leaves clues’. I’ve noticed that there are some essential aspects of emergency department design, that when done right, make a huge difference.

Here is a short list of departments I’ve been involvement in:
-Royal Melbourne Hospital- Melbourne Australia
-St Vincents Hospital – Melbourne Australia
-John Fawkner Hospital – Melbourne Australia
-Hobart Private Hospital – Tasmania
-Alice Springs Base Hospital – Alice Springs
-Waverley Private Hospital – Victoria, Australia
-Shanghai No6 Hospital – Shanghai China
-Oncology Hospital Shanghai – Shanghai China
-The Delhi Trauma Centre – Delhi India
…and the list goes on.

I don’t give you this list to impress you, but to impress upon you, that when you do this often enough, you will notice what works.

Does good design contribute to well being of both patients and staff? Definitely!
Does good design affect efficiency and the bottom dollar? Definitely!
Then let’s make every effort, to make every department as close as possible to perfect.

Below is a conceptual diagram that gives you a glimpse of the potential complexity of the design. This only deals with the reception of patients and the relationship of other design needs. This complexity can only be dealt with by a team that understands the whole project. That team has to be made up of design and medical and nursing and executive people.

How to get a good design?

PIt’s about getting the right team together. This means the leadership team from your hospital and the architect. You see, the architect is great at designing, but knows nothing about how emergency medicine works. The architect can design magnificent spaces and give you amazing experiences, but uses a different side of the brain to the one the doctor and nurse uses. There needs to be a mixture of skills. On some projects, architects get into the job. If they’re designing a fast food outlet, they might flip burgers to understand what is happening. They can’t quite get into it in emergency medicine in the same way. They need the guidance of those that work in the space. Just like those in the space need the guidance in terms of what will make their ‘flow’ even better.

REMEMBER that in the case of emergency departments, these are functional spaces, where ‘form follows function‘. There are only some things that the architect can add. A staircase can be so much more than just a series of steps, but its primary function has to be maintained.

Winston Churchill once said, “We shape our buildings thereafter they shape us.” This is always true. So we had better get it right.

My favourite architect, Frank Lloyd Wright, once said of buildings not designed well, “…a doctor can bury his mistakes, but an architect…can only plant vines”. A design flaw will be there always and we will have to live with it, always. Below is one of his famous works ‘Falling Water’.

My colleagues, if the architect you are using says to you, “you go about your business and leave the architecture to me“, go Donald Trump on them and FIRE that architect because they don’t deserve your department. You will end up with a ‘white elephant’, pretty, white, but perhaps less than usable. The unfortunate part of it all is that emergency departments will always work, no matter how poorly they are designed. Why? Because the people working in them make them work. The efforts of the doctors and nurses and clerks, keep those departments functioning.

A properly designed department is all about relationships. The relationships of the department to the hospital, and the individual relationships of each area of the department. It is this ability to manage the juxtaposition between these spaces that makes a department successful or otherwise.

Let’s look at a simple area such as the reception/waiting room area. Waiting rooms should be well lit and well ventilated spaces. They provide the entrance for ambulant patients to the department. There has to be care taken that the ambulance and ambulant entries are distinct and separated such that patients do not walk into the ambulance triage areas. This is both tedious and a security risk. The waiting room should be an area with comfortable seating and preferably be linked to security. There should be a separate paediatric waiting area. The old ‘firing squad’ arrangement of seating (where everyone is seated in a straight line of chairs along a wall) should be avoided and seats arranged in configurations that allow a more interesting and even potentially interactive environment.

The reception and triage areas should be as open as security allows. There are multiple arguments for an open triage. This is based on works done in courts, however it is questionable if this translates to the emergency department. In studies in court buildings, it was found that communication was enhanced and there was a greater satisfaction rating if the reception areas were open to the waiting areas. The differences between these two environments may make the results less than extrapolatable. Security and safety of staff is paramount.

The triage area would ideally serve the emergency waiting room patients and have the ability to also deal with the ambulance. This however would depend on the size of the department. It is appropriate that the ambulance entrance is close to resuscitation areas, so that patients can be directly taken to them.

Isolation rooms can open into the ambulance bay so that patients delivered by ambulance can enter directly into the isolation area, not needing to pass through the rest of the department to get to these rooms, with the associated contamination risks. This is especially important when hazardous material are involved. Decontamination can start in the showers externally and those patients taken directly to the isolation rooms.

The next relationships that are important to the waiting room are those to ‘fast track’ and to ‘paediatrics’.

To those of you working in the emergency department, these relationships are a no brainer. You might explain this to the architect, but they will still struggle with the concepts. This is why you need a good leadership team made up of major players which should include the Director of the department, the NUM, a select group of others including another doctor and nurse and someone from the executive of the hospital.

I’ve seen many a design at sketch design stage and savaged many of them. I’ve recommended and argued and reported and made huge changes to them. This is because this is the stage to do it at. Right at the beginning, at the sketch design stage. Once the design is set, it’s set. Make all the changes you need and get it right before those drawings get sorted.

I get a call, on average, once a week, to assist with a design and am happy to do so, because I’ve worked in departments that have been poorly designed and know how difficult it is to make them work. I’ll get the call to review that 40 million dollar emergency department after it’s completed because it doesn’t work. It’s too late then.

So take control of your designs and make your department one you are proud to work in and one that works for you.

Peter Kas

MBBS MArch BArch FACEM
Healthcare Architect

To look at some of the other projects, go to https://resus.com.au/designing-the-perfect-emergency-department/.