Designed to provide the community with treatment for urgent medical care, hospital emergency departments (EDs) have become the front door to healthcare services, accounting for up to 60% of hospital admissions. This, plus problems with security and staffing, have had an impact on the specific decisions that are made in designing a modern ED.

From managed care to the Balanced Budget Act of 1997, a restructuring of healthcare reimbursement has forced individuals to seek care from emergency facilities. EDs must provide access to all who seek care, regardless of their ability to pay, as required by the Emergency Medical Treatment and Active Labor Act (EMTALA). While utilization has increased, financial pressures have resulted in the closures of rural hospitals, increasing pressure on the remaining EDs and requiring rural residents to travel to urban centers for care (Figure 1). Overcrowded urban EDs have become the providers of primary care for the uninsured and those without access to other resources.

During the 1990s, there was a growing number of emergency visits in fewer hospitals

Boomers and an aging population have played a large part in increasing the demand for emergency services. According to a report on ED utilization from the Centers for Disease Control and Prevention and the 1999 National Hospital Ambulatory Medical Care Survey, 14.2% of the general population use an ambulance service, but for those over age 75, ambulance use skyrocketed to 42%.

Meanwhile, ED physicians and nurses are requesting more protection. Both the American Medical Association and the Emergency Nurses Association enacted legislation calling on hospitals to increase security in EDs. Futurist Russell C. Coile, Jr., notes in Futurescan 2002: Healthcare Environmental Outlook (2002-2006):

No longer can the U.S. be complacent that terrorism will not occur within its borders. America's 5,000 community hospitals and 700,000 physicians suddenly find themselves thrust into the front lines in the new war against international terrorism. The dangers of biochemical and anthrax attacks are boosting the visibility and funding for public health organizations at the federal, state and local levels. The events of Sept. 11 have galvanized hospitals to address terror and mass casualties.

In September 2001, the Environment of Care Leaders organization conducted a survey to determine which security measures were being implemented. Ninety-six percent of the hospitals had limited or were seriously considering limiting access points. Eighty-eight percent were looking to install surveillance cameras. Sixty-four percent had already placed or were considering placing guards “24/7” at the emergency entrance. Most facilities had no intention, however, of installing metal detectors either in the ED or throughout the facility.

Overcrowding: More People, Less Staff

Yet another problem faced by EDs is overcrowding: more people, less staff. “Emergency departments in the United States are operating at critical capacity,” says Arthur Kellermann, MD, a member of the American College of Emergency Physicians board of directors and professor and chairman of emergency medicine at Emory University in Atlanta. “Decreasing resources have squeezed the excess capacity out of the nation's healthcare system. Hospitals have fewer staffed inpatient beds, which means that critically ill patients are often waiting in hallways for admittance to the hospital.” (Figure 2)

103,000 staffed beds and 7,800 medical/surgical ICU beds were lost in the 1990s

Patients who cannot be sent home because they are too sick, and yet cannot be moved to an inpatient unit because the hospital is full, are referred to as “boarders.” These patients fill hallways in EDs. It is interesting to hear a perspective of emergency phy-sicians who suggest that if patients can be held as boarders in ED hallways, why couldn't the same practice be used in the nursing units?

Physician call duty in the ED has become a nationwide problem. Recently, orthopedic surgeons at Palomar Medical Center in Escondido, California, forced a two-week closure of the center's trauma services by refusing to take call duty in the ED, casting a spotlight on physicians' growing frustration with ED on-call duty.

Palomar is one of several hospitals that have chosen to increase specialists' pay in order to keep them on call. In fact, according to a January 2001 Office of Inspector General survey of more than 100 hospitals nationwide, 54% of physicians and nurses reported problems filling ED on-call rosters with specialists, with 12% attributing the problem to specialists' refusal to take calls. The respondents said that neurosurgery, cardiovascular surgery and pediatrics were among the top specialties for which on-call was a problem. According to a 2001 Schumaker Group survey of 635 hospital administrators and ED managers, this lack of specialty coverage posed significant health risks to patients. Some hospitals are even exploring the potential of telemedicine programs to limit the frequency of night call; this would have an impact both operationally and on design planning.

Efficiency has become so paramount to hospital EDs that they are benchmarking to improve their processes, particularly turnaround time. From patient tracking to nursing documentation, systems are in use that streamline ED processes. Telemedicine, computerization and digital technology are altering the ED approach to clinical care. Best practices outlined by The Advisory Board Company to address bottlenecks in EDs include strategies such as a dedicated ED communications nurse, emergency-physician charting scribe, short form for triage, bedside registration and preformatted charting documentation.

Understanding these “behind the scenes” problems of EDs and their conceptual solutions will enhance the design of these spaces. An in-depth assessment of reception (ambulance and walk-in), triage, diagnostics (especially radiology and pathology service access), treatment and consults, and discharge (transfer or home) is critical in designing the most efficient flow of activity within the ED.

Patient Experience

More people are seen in the ED than in the hospital lobby. This is leading hospitals to build customer loyalty by making the emergency experience as convenient and pleasant as possible. Recently, architects D. Kirk Hamilton and A. Ray Pentecost III interviewed the production designer for television's ER program, Ivo Cristante, to compare the “icons” used in the media versus those needed to create a soothing patient-centered environment. Highlights of the interview:

“We bend the rules of architecture to a real extent, but it works for drama,” Cristante noted. Everything on the set is exaggerated for effect. The huge stacks of paper and charts on the nurse's station imply the complexity of the work being done and lend to the confusion. The main corridor has too many supply carts, lending to the visual impression of overcrowding.

Cristante illustrates the point with the location of the waiting room and the bleak uncomfortable seats across from the nursing station. To create intentional disharmony, Cristante uses a space with “too many lines and sharp angles,” adding to the emotional effect of the scene.

“There are many ways to create an effect,” Cristante added. “Color is a great way to add emotion for a scene, for example.” He describes the selection of a “happy” green, and only a few shades away is a “sad” green.

Hamilton and Pentecost note in their commentary on this interview:

The real hospital is clearly a backdrop for real-life dramas. As such, architects and designers should be thinking of ways to eliminate many of Cristante's symbols designed to contribute to an upward spiral of anxiety and stress. There is a growing movement among healthcare architects and designers to make the emergency department a place sensitive to the plight of patients and families. Attention is paid to the visual and auditory environment, as well as the provision of amenities. Unlike the ER set, the real emergency waiting room has a very real need for plants, a view to nature, artwork and positive distractions of several kinds.

As we enter these complex times of greater demands on the country's emergency care system, design professionals need to look deeper into the real problems EDs face. They cannot always be solved with bricks, mortar and glass. As designers and planners, we need to understand the operational factors that drive each facility. A successful architectural solution is greatly influenced by numerous operational factors. In AIA's The Academy Journal (April 2002), Hamilton describes the impact of organizational theory:

Intangible social systems range across aspects like leadership, governance, teamwork, incentives, norms and culture. Tangible technical systems can include architecture, technology, information systems and logistics. The ability to “jointly optimize” both could offer the client more robust interventions that have a higher probability of success.

Without a complete understanding of current ED operations, functional responsibilities and liabilities, any new facility is doomed. The days of meeting every problem with “more square footage” are gone. HD

Anthony J. Haas, AIA, ACHA, a principal with Watkins Hamilton Ross Architects in Houston, has more than 20 years' experience in medical planning and design, focusing particularly on emergency department design. Pamela S. Jones, RN, MSN, an associate with Watkins Hamilton Ross Architects, has almost 20 years' experience in healthcare and another 10 in design engineering and the customer service industry. For more information, call (713) 665-5665 or e-mail


Level 1 Trauma Center Design Suggestions

The following are operational and design suggestions from the director of a recently completed level 1 trauma center (illustrating the concerns for which design must make allowances):

  • Add a privacy curtain and valet rope in front of the triage area.

  • Place stretcher area behind triage to allow patients a place to lie down rather than having to sit in the waiting room while others are seen in triage. Patient care should not be provided in this area, however, because it would become impossible to staff.

  • When expanding the waiting area, consider the need for additional nonclinical and volunteer staff to serve in reception and as patient liaisons.

  • Operate in the new space for six months with no changes. Have staff write down suggestions over this period and then review them.

  • Consider flexibility in staffing hours. If staff is working seven 12-hour shifts in a two-week period and overtime needs to be reduced, use six 12-hour shifts and one 8-hour shift. Schedule the 8-hour shift from 7 p.m. to 3 a.m. to cover the peak hours.

  • Be sure to build enough counter space for technology such as computers and printers.

  • Consider hiring a forensic nurse to handle sexual assault cases. This would allow these patients to be seen directly when they arrive rather than sitting and waiting for triage.