Architectural Record | Rethinking the E.R.

Rethinking the E.R.

April 2007 Download PDF

Evidence-based design makes the crowded, chaotic emergency room a thing of the past.

Most everyone, at some point in life, experiences an emergency room. For me, it was a gash on my forehead in the ninth grade that required stitches. By the time my mother and I navigated our way through the parking garage, past baffling signage and the triage station, and finally landed in the waiting area, we had decided that the confusion was a way for the hospital to weed out patients—if you expired before reaching the doctors, they probably couldn't have helped you anyway.

Today, all of that is changing. As construction and renovation in the U.S. health care sector booms—it was a $41 billion industry in 2006—hospitals, and the architects who design them, must keep up with the latest research and technology if they want to stay competitive. From the mounting needs of aging baby boomers to the replacement of old infrastructure with all-digital facilities, market demands could push yearly health care construction to $60.1 billion by 2010.

Evidence-based design

Many of the advances in health care design today can be found in the emergency and trauma departments, where fast, effective service is paramount. Jim Crispino, president of Philadelphia-based firm Francis Cauffman, believes that the emergency department, or E.D. (the proper name for the E.R.), is a critical component of a hospital's overall success. Increasingly, the E.D. is the point of entry for patients, constituting their first experience in the hospital environment.

Crispino, who has been designing health care facilities for 20 years, says that the emergency department is fast becoming the hospital's new front door. “Usually for a regional medical center or a community hospital, 25 to 30 percent of people go to the emergency department first,” he says. “Of the people admitted to the hospital, over 50 percent are generally coming in from the emergency department.” As a result, notes Crispino, “clients are rethinking the relationship of the emergency department to the rest of the hospital.”

Francis Cauffman (which does 65 percent of its work in the health care sector) employs research staff to conduct independent studies on how the physical environment impacts patient outcomes and staff efficiency, from minimizing medical errors to improving patient well-being. This research-intensive approach, known as evidence-based design, is gaining momentum: At the International Conference and Exhibition on Health Facility Planning, Design, and Construction held in San Antonio in February, much of the program was dedicated to educating professionals on the uses and benefits of evidence-based strategies.

“For many clients, evidence-based design is becoming an expectation,” says Debra Levin, president of the Center for Health Design. In her 18 years at the nonprofit organization, which funds research, education, and advocacy on how the built environment affects health care outcomes, Levin has watched evidence-based design go from a small discipline at the fringes to a client necessity. “Clients don't always know exactly what it is or what it looks like, they just know they need it,” she says.


For the emergency department at F.F. Thompson Hospital in Canandaigua, N.Y., Francis Cauffman employed a number of research-based design strategies. Some focus on staff and patient well-being: Natural light, a rarity in an E.D., is admitted to all public spaces, treatment rooms, and staff work spaces. The patient treatment areas are private, and each has an individual thermostat that can be controlled by the patient or a family member. Gone are the cavernous waiting areas, replaced by more intimate spaces scattered throughout the department, where family members can wait, eat, or consult with physicians.

Decentralization is the new norm for staff areas as well. For instance, equipment is now stored in or outside of patient rooms, which cuts down on the time that staff spend looking for supplies. “Integration is the overriding theme influencing medical technologies,” says Crispino. “Traditional boundaries between imaging, surgical, and related patient care technologies are breaking down.”


Isolation is also on the rise: At F.F. Thompson, the E.D. has an HVAC system separate from the rest of the hospital to prevent highly infectious diseases from spreading. Within the E.D., some individual rooms have an independent air-control system.

For the emergency department at Health Alliance's West Chester Medical Center in Cincinnati, currently under construction, RTKL proposed a design strategy based on the hospital's own advances in E.D. protocols. The hospital wanted to cut down on the time it took for patients to receive a diagnosis and treatment, so staff members devised a set of rules for responding to patient symptoms. If, for example, the patient comes in with chest pain, this kicks off a series of protocols that dictate tests and imaging before the doctor even arrives.

“The minute the hospital said it was protocol-driven, that led me to think of isolated pods, so that they could cohort specific patient profiles within those pods,” says John Castorina, vice president and partner at RTKL.

Castorina and his team designed a main corridor, or “spine,” to which three separate pods attach. Each pod houses eight private beds and all the supplies that physicians and nurses need to treat patients there. Each one has the capacity to function independently—shutting itself off from the rest of the E.D. in case of infectious-disease emergencies or dangerous psych patients—or to work in tandem with another pod.

Meanwhile, the main nursing and staff stations along the spine serve as the air traffic control, monitoring each of the pods and communicating patient needs as they develop. “Everything plugs into the spine,” Castorina says. “[The pods] can work independently of each other but still see each other.”

RTKL developed this concept after intensive consultations with medical staff. “Emergency-room physicians have to react instantaneously, and their whole job is to stabilize and transport,” Castorina says. “The most that we as architects can do is listen to what they have to say, interpret it for them, and show it to them.”

Same-handed rooms

Understanding the needs of medical staff is crucial for health care architects. For HDR, based in Omaha, Neb., that means hiring employees with medical training, such as Cyndi McCullough, a vice president who was a practicing nurse before joining the firm 12 years ago.

When Metropolitan Health Hospital asked HDR to build a new facility in Wyoming, Mich., the client wanted to employ the latest in evidence-based design. “We used information from the Institute of Medicine on patient safety,” McCullough says. “One of the things that came out of that was the same-handedness of the inpatient areas.” Traditionally, hospital rooms mirror one another, as they do in a hotel. Same-handedness makes the layout of every room identical so that doctors and nurses can move through the space more intuitively, which makes errors less likely.

Nearly all of the E.D. rooms in the new Metro Health Village hospital will be same-handed, according to project architect Jim Ulrich of HDR. It's an expensive design proposition, since it requires individual plumbing for each unit. “There is significant research that shows same-handedness cuts down on mistakes,” Ulrich says, “so that was a very large criterion from the client.”

Going green

Another major goal was to become one of the few LEED-certified hospitals in the country. Metro Health Village—which is scheduled for completion in late 2007, at a cost of $120.7 million—will be the first hospital in Wyoming built around an entirely green master plan and will feature a green roof and water-efficient landscaping. The E.D. will be outfitted with a sustainable line of furnishings and recyclable carpeting. Even the products used to clean the hospital will be green.

Marrying evidence-based research with the latest in green technologies is no small task in an emergency department. Sometimes, the two can be at odds: samehanded rooms, for example, require more infrastructure and plumbing than traditional patient rooms. Meeting green-certification standards and hospital regulations can be a headache for architects. HDR used both LEED and the Green Guide for Health Care (a voluntary, self-certifying metric tool kit) as a guide.

“It's extremely hard to comply with all of the criteria for green building and still comply with health care regulations,” Ulrich says. “But it's a stand-alone, brandnew hospital, so that made it worthwhile to try.” And the client was willing to foot the expense. “The owner was very intent on going green,” Ulrich adds.

With clients and patients demanding more, the boom in health care promises to be a rich, and challenging, marketplace for architects. “Many people say that the only way for a great architect to have a great project is to have a great client,” says Levin. “These days, it's a very educated group out there.”

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