After more than three years of renovation and new construction, the new ED at the John Muir Medical Center campus in Walnut Creek, Calif., is nowhere near as noisy as it used to be.

“In our old space we were sort of all in a fishbowl together,” said Julie Stromberg, RN, MS, CEN, CNAA-BC, director for emergency services, noting the ED has more than doubled in size from 11,000 square feet and has added multiple private treatment rooms. “It’s really quiet, and very soothing for patients.”

More space also changed workflow. Staff have divided into pods — which Stromberg points out is a best practice for facilities the size of John Muir-Walnut Creek (572 beds), a Level 2 trauma center. “It’s much more efficient,” she said. “It’s like little emergency departments throughout our ED, which are independent but [the staff] can cross over.”

Set the mood

Given the relentless demands placed on EDs, a soothing ambience and improved efficiency may seem like minor luxuries. But well-designed environments can make an ED safer and healthier for patients and staff. “The good news is patients do better,” said Ella S. Franklin, RN, CRC, EDAC. “Their anxieties are reduced and the amount of pain medicine they need is reduced.”

Positive distractions such as fish tanks, TVs or interactive video walls can ease waiting room tensions. Research has documented that patients presented with such distractions, instead of an uncomfortable waiting area, can better communicate with healthcare providers, said Franklin, managing director of the ER One Center for Building Sciences, part of the MedStar Institute for Innovation, based in Washington, D.C.

Even just having only one waiting room — a melting pot of distressed patients, family members and others who may be near a boiling point — can foster “I-was-here-first” resentments that might endanger patients or others, said Jon Huddy, managing principal and director of ED design at FreemanWhite Inc., an architecture and consulting firm specializing in hospital design. “We’ve got to get away from everyone sitting in one room staring at each other while anxieties rise,” he said.

Multiple sub-waiting rooms behind triage help avert potential conflicts by moving people forward in the process, Huddy said. Sub-waiting areas also can facilitate patient isolation and keep patients vertical when appropriate.

New ED designs also frequently situate a security guard at the reception desk. “People feel more comfortable with the hospital security officer sitting there, no matter what the environment,” said Huddy, author of “Emergency Department Design: A Practical Guide to Planning for the Future” (American College of Emergency Physicians, 2002).

John Muir-Walnut Creek has gone one step further. Besides its security locations, the hospital’s ED includes a police substation — a locked room with a police computer where officers can work comfortably, instead of having to do so from their patrol cars. Through mirrored glass, officers in the substation can see into the main waiting room.
Lockdown capabilities and back-door escape paths from various ED areas are vital for everyone’s safety, Huddy said. Also, security must be able to immediately access the ED’s clinical area without re-opening the main door, in case threats lurk there.

Such flow-through design is important in triage, for patient and nurse safety, said Kathy Clarke, RN, BSN, CEN, senior operations analyst for FreemanWhite. If patients crash, she says, they can be taken directly into clinical space, rather than back out the way they came in, she said.

Park the car

Patient safety can be enhanced before a patient even enters an ED, Clarke said. Some hospitals offer valet parking to ensure that distant or paid parking lots don’t hinder emergency patients. “We’ve had patients drive themselves up, and they are actually having their heart attack … and then what do we do with their car?” said Clarke, who also works as a nurse on a PRN basis at St. Mary Mercy Livonia Hospital in Michigan.

Clarke, who has helped plan EDs with annual patient loads ranging from 8,000 to more than 100,000, notes redesigns don’t always involve big-dollar construction. “Many times we will go in and just look at operations,” she said.

She focuses on developing a process where patients see a nurse first. If a hospital has registration personnel as the first point of contact, Clarke said, “we are asking the registration person to make the decision, is this patient in distress? They don’t have the experience to do that.” Consequently, Huddy said, registration cubicles up front are being eliminated, with triage nurses or others initially gathering just enough data points to identify a patient and his or her chief complaint. (A full registration is completed later, at bedside.)

Provide doors, not curtains

Architects also are eliminating obstructions such as storage rooms to create clean lines-of-sight across the department and into treatment spaces, Huddy said. “New EDs [are] situated so you can maintain visibility of the patient in each room, but … the patient can’t see across the ED.”

Just having actual treatment rooms, and not simply curtains or cubicles, reduces patient anxiety, he said. It also can reduce medical errors by minimizing distractions from outside the room, improving the accuracy of information that healthcare providers get from patients.

FreemanWhite is developing ED treatment rooms with clinical, patient and family zones, so relatives know where to sit without interfering with care, Clarke said. Beds are parallel to the corridor and can accommodate TV viewing, and perhaps access to patient education videos on topics such as how to care for plaster splints.

At John Muir-Walnut Creek, improvements in the rooms’ head walls allow staff to plug in fall alert systems that notify nurses of potential problems, Stromberg said. Also, larger treatment spaces allow relatives to remain on hand and help with patient care, prevent falls and soothe their ill or injured relatives.
Amenities such as warm blankets or food and beverage stations encourage family presence. “It’s a second set of eyes and ears in the room,” Clarke said of relatives who stay with patients. “They participate in the treatment plan; they sometimes ask better questions at discharge.”

New EDs typically are designed with identical exam rooms to promote clinical safety and efficiency, Huddy said. All the drawers even are organized the same so healthcare workers don’t have to hunt for a required supply. “If they need a specialty room,” he said, “there are carts outside the room. You pull in a cart to specialize the room.”

Private treatment spaces also help with infection control, especially if healthcare providers pass a sink for handwashing as they enter or exit, Huddy said. Infection control efforts, Franklin said, also should take into account the supply chain — how exactly masks, gowns and other protective gear are delivered, and removed, in treatment areas. Wider corridors might be needed for robotic delivery, or alcoves to accommodate carts containing protective supplies. “Typically it’s an afterthought,” she said.

ED planners have many other infection control tools available. Surface materials that impede bacterial growth can be used on monitors, upholstered furniture, side tables, bedrails and more. Air flow in the ED can be segregated to prevent cross-contamination from airborne pathogens. Filtration can be improved, including with the use of antibacterial materials.

In summarizing a multitude of hospital innovations, Franklin uses the term “evidence-influenced design,” noting the current body of knowledge can’t be equated with evidence-based medicine yet. With many variables at play in any design, it’s challenging to study whether one particular factor makes a difference, she said. “Nobody’s going to give you a couple million dollars to build a hospital and the only thing you’ll change is the flooring.”

The study of such factors in healthcare, she said, is a fairly new science. “The evidence base is small but growing rapidly.”