A New Standard
Faced with a growing population and an Emergency Department already taxed to its limits, CoxHealth in Springfield, Missouri, knew that it desperately needed to expand its emergency services on its south campus. CoxHealth and the design team from The Beck Group set out to rethink the Emergency Department for maximum flexibility and efficiency.
The new ED grew the operation from 24 rooms to 62, also incorporating a 26-bed CDU with a stat lab, satellite pharmacy, embedded radiology with two CTs, one MRI, ultrasound, and radiology, and in the process created a new “front door” for the entire facility. HEALTHCARE DESIGN Editor-in-Chief Todd Hutlock spoke with The Beck Group’s Director of Healthcare Architecture Sean Wilson and Associate Principal Michael Kaiser, CoxHealth’s Director of the Emergency Department John Archer, RN, CEN, and Interior Designer Celeste Pratt of Cannon Design (formerly with The Beck Group) about the project.
John Archer, RN, CEN: In 2003, CoxHealth started exploring the concept of a new Emergency Department for the South campus. Initially, we thought to simply build it in the same section of the facility where the existing ED was, but for a number of reasons, the project faded and there wasn’t much momentum behind it. Then, in October 2006, the CoxHealth Board of Directors resurrected the project and decided we needed to move forward with the new ED; we had simply outgrown the old one. The national average is to turn an ED bed about 3.5 times a day; we were turning ours over seven times per day. The space was equipped to handle around 35,000 patients per year, and we handled around 67,000, with another 4,000 walking out the door without being treated. We had a 24-bed ED and we were simply out of room—there were days when we had patients in the hall. It was unacceptable from patient privacy, satisfaction, and safety standpoints.
We met with The Beck Group in early 2007, and the project was realized from there. We built the ED to accommodate 10-to-15-year growth; we wanted to do it right the first time. We spent a lot of time with the architectural design team, and we all collaborated to assess what our long-term growth needs were. The modular design that Beck came in with proved to be the ideal solution. We are currently operating two pods around the clock and two other pods that we flex open during peak hours, with a fifth pod that we haven’t even touched yet, set aside for future growth.
Development and planning
Sean Wilson: This project was a collaborative effort made possible by Rod Schaffer, CoxHealth VP of Facilities. He had the vision and foresight that allowed us to deliver the project in a fully integrated fashion. Michael Kaiser was responsible for the development of the aesthetic and the creativity behind the design elements, and I was responsible for the departmental planning with John Archer and his clinical team. Celeste Pratt and Brandi Barnes handled the interior design. Additionally, because it was an integrated project, we had our construction team involved in the design meetings from Day One. This allowed us to stay on budget and ensure there were no delays in schedule.
Michael Kaiser: We also utilized BIM software to allow interactive virtual walkthroughs, and this allowed us to really visualize how the project would look very early on and tweak things as needed, quickly and easily. This modeling really helped to serve the collaborative process we were going for on this project. We put as much as we could into those models so all the team members could see all of the elements of the project, and to provide a more realistic view. This was one of our first fully realized BIM projects, and it has now become standard operating procedure for us.
Wilson: The location of the ED was determined by the comprehensive campus master plan that we produced. It sits on the southern side of the hospital, which now serves as the new “front door” of the facility; the majority of the pedestrian and vehicular traffic, and the major area of the city’s growth, comes from that direction. It also was the only place on the campus that would allow the size footprint we needed to realize the project.
Kaiser: As with any campus with multiple buildings that were built over time, there were several different materials used that we had to work with. We were also looking at how to pull elements from more recent buildings into our project. For example, many of the newer buildings on campus have arched roofs on them, so that was an element we wanted to pull in. The height of that arched roof allowed us to design to let lots of natural light into the entrance and the pods, as well. Visitors and patients sometimes will be in the ED for a long time, so making that connection to the outside is important.
Wilson: We had several unique features we were able to incorporate into the design. One of the most significant was the use of clerestory windows in all the exam pods. Seventeen-foot ceilings allowed us to ensure that natural light was introduced into all exam rooms and clinician work areas.
Kaiser: We always try to design our buildings to be as intuitive as possible. We tried to make circulation and wayfinding as clear as possible, starting with the airport-style drop-off area. We also made the large sign wall that faces the nearby highway to make it very clear to those driving up.
Archer: We gained many valuable insights through making full-scale mock-up rooms, as well, such as what type of doors to install in the rooms and what type of headwall we would use. The goal of our project was not just patient throughput and efficiency, but also staff efficiency—we want staff to walk less, make fewer trips over shorter distances to get supplies—and this approach allowed us to significantly increase our patient load without significantly increasing staff.
Pod system and room standardization
Wilson: We incorporated same-handed universal exam rooms and standardized all elements within. For a department like an ICU or ED, standardization makes a lot of sense. We took this concept one step further and made the primary clinician space for each pod identical. No matter what pod a staff member is in, everything is in the same place. Because of the standardization and same-handed elements, we were able to fabricate a substantial amount of the millwork and other components more economically.
Each pod is comprised of nine to 15 rooms, and is designed to function as a stand-alone emergency department that can treat any acuity level. They have the ability to flex up and down based on census. Each pod is connected to the primary clinical corridor, which houses multipurpose rooms and support space, and allows staff and patients to efficiently navigate the department. In an effort to enhance wayfinding, we color-coded the pods. This has made the space much more family-friendly, and visitors are less likely to ask staff members for direction.
Wilson: We separated the public circulation from the clinical circulation by using two separate corridors to connect to the existing hospital. The public spine runs parallel to the clinical one, and visitors can access it freely regardless of which part of the hospital they are trying to reach. Rather than have a long, mo
notonous 400-foot corridor, we broke it out and segmented it into decentralized waiting areas where we have small alcoves in which people can wait without getting into the clinical area, much like the idea of a concourse at an airport. The corridor is only 11 feet wide, but we took advantage of glass and clerestory, and these alcoves to help open up the space.
The ED waiting room is a very dynamic design, as well. Shapes, materials, and the space itself are set up so people can sit without having to stare at each other. There are positive distractions set up, such as a children’s area and televisions, and also curvilinear benches for more comfortable rest than one might get from a typical chair.
The three triage rooms look out onto the waiting room so that the nurses within can see out through perforated screens, but none of the patients can see into the triage space.
Celeste Pratt: This also keeps the area's sophisticated feeling, enhancing the waiting area while keeping it from having a clinical feel. The furnishings further reinforce this point, but also had to withstand the abuse that a 24/7 facility, such as an ED, goes through. There are also a variety of seating options throughout the waiting spaces.
Wilson: We were also able to incorporate a healing garden into the space that remains accessible from the main waiting space, but also from the clinical space once visitors have entered that area. Not only is there still access, but the garden also provides positive views from the waiting room.
Interior design elements
Wilson: One of the big opportunities on this project was the chance to create a signature space in the main lobby. Despite the fact that this is an ED, it is also the new front door for the facility. The inspiration came from the natural resources—the environment of the Ozarks—and Celeste and her team were able to incorporate those into the main entry and, ultimately, into the rest of the facility. We wanted to make sure that “wow” factor was there when visitors first entered.
Pratt: There were facility guidelines already in place that the Beck Group design team had established with CoxHealth South. One of those guidelines was to include patient and family spaces, eliminate confusion, and help them feel a sense of belonging in the space. So we wanted to include that Ozark aesthetic of natural materials to create something that would look regional. This also extended to the artwork concept, which features photography of local areas included not just in the walkthroughs and waiting areas, but also throughout the clinical spine and care areas.
Wilson: This started out as a LEED project, and while the decision was made not to pursue certification, we followed the sustainable guidelines established by Norma Rosowski at Beck and Rod Schaffer at CoxHealth. So there are terrazzo floors from a regional supplier in the main entry, natural stone quarried from the Ozarks, woods and laminates that reflect the lumber of the area—we tried to incorporate as much natural material as possible throughout the entire space. HCD
Completion Date: September 2010
Architecture, Interior Design, and Program Management: The Beck Group
MEP Engineering: TELIOS Corporation
Structural Engineering: Armstrong-Douglass Partners
Construction: Beck/Walton, a Joint Venture
Equipment Planning: Strategic Hospital Resources, Inc.
Photography: Wade Griffith Photography
Total Building Area (sq. ft.): 89,400
Total Construction Cost: $26,843,000
Cost/Sq. Ft.: 300