Designing an Adaptive Emergency Department
Emergency Departments - Designing for Chaos
Recently, while programming a new emergency department, I was working with the nurse manager to chart out the weekly average number of patient visits and acuity levels of each visit in the ED. The variation in the type and number of cases was startling. It was not uncommon to have weeks where the patient volume varied by 200%-300%. After trying to make sense out of the math, we adopted the mantra that "there is no average week in the ED".
By nature an ED is a highly volatile environment and prone to massive fluctuations in patient volume and case types. More so than any other department in the hospital, the demands made on an ED are dynamic and unpredictable. As an architect, I am trained to design a space based on a program of the client's needs. So how do you design a space when the needs are so variable? I believe the solution is to create a design that is adaptive, flexible, and organized. Other spaces and departments in a hospital like imaging suites, therapy rooms, and operating rooms are designed to do one thing and to do it very well. These are highly engineered spaces that are designed with Swiss watch precision. That approach works fine if the space your programming has predictable patient volumes and consistent turnaround times. Most ED's aren't that fortunate. So how do you accommodate chaos? You keep the design simple, flexible, and robust.
A well designed ED should be simple and flexible enough to accommodate the variety of case mixes encountered in the "average" day. The standard ED design utilizes specialty treatment rooms such as Orthopedic, Ob/gyn and bariatric treatment rooms. This design only works for just the right mix of patients and is too rigid to be functional for most ED's. A universal room design is substantially more flexible since every treatment room is set up the same and is designed to function as a general treatment room and is stocked only with the basic par level of supplies. These rooms can be instantly turned into a specialty treatment room by utilizing centrally located specialty carts. These carts are stocked with specialty supplies such as sutures, OB/GYN, orthopedic, and cardiac supplies.
Another feature of the universal room design is referred to as "same handed design". Unlike the standard practice of mirroring the treatment rooms to take advantage of sharing a wet wall, universal design keeps the room orientation exactly the same. This means the door into the treatment room is always on the same side of the room (usually the left side) the family chairs, the computer, medical supplies and the hand wash sink are always in the same location. This universal design allows the staff to develop a type of reflexive muscle memory when working in these rooms.
Visual and acoustical clutter is another impediment to a well run emergency department. Simply put, clutter is a distraction and organization promotes focus, especially in a crisis environment. The trick is to keep the ED organized without decreasing its flexibility. Technology such as mobile phones integrated into the nurse call system have helped greatly reduce the acoustical clutter such as overhead paging, alarms and nurse call signals. To help reduce the visual clutter, keep supply carts, crash carts, imaging equipment and stretchers in recessed alcoves adjacent to the corridors. These alcoves keep circulation corridors clear while keeping the equipment organized and easily accessible.
Signage is often haphazardly added as an afterthought to the design. Often layers of miscellaneous, uncoordinated signs, post-it-notes, and paper taped to glass litter the ED and create a sensory overload similar to that of the local fast food strip. But well coordinated signage can contribute to an organized appearance and significantly increase the efficiency of the ED. Good signage uses colors, font sizes and shapes to subtly convey information in a similar way highway signs use this same information to help the freeway driver quickly categorize and prioritize information.
All of these elements contribute to creating a more orderly, less chaotic, atmosphere without decreasing the flexibility of the space. The way to deal with chaos isn't to try to tame it but to plan for it. Don't design a Swiss watch, design a Swiss army knife, adaptive, flexible and organized.