Emergency department design pdf

This work reports and analyzes the results of a large survey of the requirements of ED stakeholders. It then compares these requirements with existing designs on the one hand and international standards on the other. Further, we propose a new hybrid design which combines the requirements of both the stakeholders and international standards using quality function deployment QFD , also known as the House of Quality, method.

The proposed method was used to assess two existing EDs located in two countries. The analysis of the survey responses showed certain discrepancies between stakeholder requirements and the existing designs such as the absence of an initial admission unit and insufficient space of the treatment unit. The emergency department ED plays an important role in providing patients with prompt and effective clinical care [ 1 ].

It is the healthcare entry point responsible for receiving, sorting, assessing, stabilizing, and managing patients arriving at its door with different degrees of urgency and complexity. Conditions of patients requiring an emergency care vary from major trauma and stroke to intoxication and mental disorders [ 2 , 3 ]. Therefore, ED is considered to be an extremely complex system [ 4 ]. Yet, its design has witnessed little, even if no progress in recent years, to cope with these complexities efficiently and cost-effectively.

Improper facility design can lead to numerous problems. In the ED in particular, crowding is a prominent problem [ 5 — 7 ]. As addressed by Carter et al.

In addition to crowding, many healthcare professionals find current EDs incapable of meeting the expectations of patients, their families, and the medical staff. To alleviate these ED problems, Welch [ 9 ] listed a number of factors that could improve the quality of ED service. Some of these factors involved human resources such as the incorporation of medical teams , administrational controls such as creating express admission units , and architectural design issues such as the creation of intake pods zones, and discharge kiosks.

Chan et al. Kolb et al. Tawfik et al. Results showed a reduction in patient crowding and an improvement in patient flow. One of the most popular methods known for involving stakeholder requirements is the quality function deployment QFD method, also known as the House of Quality HoQ [ 13 , 14 ].

This method, developed by Toyota in the early Sixties, translates the customer requirements into appropriate technical specifications. It is one of the total quality management TQM tools [ 15 ]. The ultimate goal of QFD is to translate the subjective design criteria into objective ones to complete the design process in a systematic manner.

Implementation of QFD takes four steps or phases, namely, 1 product planning, 2 parts design, 3 process planning, and 4 production planning [ 16 ]. The objective of this paper is twofold. Firstly, we seek to take the quality function deployment QFD methodology one step further and apply it to propose a stakeholder-based design for the healthcare facilities.

We have started with the ED not only because of its importance but also for its complexity which makes it a challenging quest. Towards this objective, we have collected the requirements of a large sample of ED stakeholders in two countries in the Middle East. We have then implemented the HoQ methodology in order to obtain an improved design over the existing ones. In doing so, we have made use of some of the most commonly used international standards IS. Other design aspects such as environmental considerations, operational models, and architectural requirements are outside the scope of this work.

First of all, a focus group of ED stakeholders in Egypt and Saudi Arabia, including patients, was asked to mention those needs that they believe are important to improve the ED design, efficiency, and patient satisfaction. In addition, other concepts on ED design were collected from the guidelines of the Australasian College for Emergency Medicine [ 1 ], the Australasian Health Facility Guidelines [ 2 ], ED patient flow guidelines [ 5 , 9 ] , and ED overcrowding reduction concepts [ 11 ].

These concepts were used along with the inputs of the focus group to build a questionnaire of 84 items. Then, we classified the survey items into eight groups, namely, 1 basic services, 2 requirements to streamline the material flow, 3 requirements to streamline the patient flow, 4 clinical support services, 5 consultation services, 6 areas to support the diagnostic services, 7 patient holding areas, and 8 areas for staff support and teaching.

The survey was then conducted for two months among ED stakeholders, all of whom at the time of the survey were working in either Egypt or Saudi Arabia.

The stakeholders can be roughly divided into two main groups. The first one includes strongly-affiliated ED staff e. Out of subjects, completed the questionnaire with a response rate of Then, the average importance value of each item was calculated and converted into a percent score.

This step is to translate the SR into relevant design specifications DS based on 1 brainstorming among experienced healthcare planners, 2 international guidelines, and 3 review of the literature.

Table 1 shows the proposed design specifications with their functions. The relationship matrix is the core of the QFD methodology. This matrix maps the correlation between SR and DS. According to Franceschini et al. The first series is derived from a logarithmic interval scale with 3 as a basis, while the second is derived from a linear interval scale. If the ratings derived from a linear interval scale are interpreted as being derived from a proportional scale, this can lead to a wrong priority rank of design specifications [ 20 ].

A correlation value reflects how a design specification supports the purpose of a particular SR. For example, as shown in Figure 2 , the wounded patients who do not need additional treatment in the arrival unit fast track can be managed by allocating a temporary buffer and discharge unit to hold those patients until discharge. This matrix shows how the design specifications support each other to identify the bottlenecks and trade-off.

This means that if the space of the first zone increased, the space of the second zone should be fairly increased as well.

In the QFD literature [ 17 , 21 ], the planning matrix includes the assessment of features of existing products against those of competitors. We modified this matrix to make the QFD methodolgy more suitable for healthcare facility design. Here are the steps to create the planning matrix: 1 Calculate the average importance of each requirement from the questionnaire responses 2 Calculate the existing space of each requirement using the schematic diagram 3 Find the space of each requirement according to AusHFG, NHS, and DoD 4 Compare with for each requirement 5 Set the target area for each requirement as the average value of the three IS 6 Calculate the improvement ratio as where and are the target and the existing spaces for the th requirement 7 Calculate the absolute weight as where , and are the improvement ratio and importance score of the i th requirement, respectively 8 Calculate the relative weight RW i as where is the number of SR.

For the final step of HoQ, the technical target matrix contains the technical priority TP and weight W of each functional unit. The technical priority is calculated as where is the correlation value between requirement and specification , is the relative weight, and and represent the numbers of SR and design specifications, respectively.

The weight is given by where is the technical priority of design specification and is the number of the design specifications. Ventilation schemes can also create isolation capacity for airborne pathogens, including tuberculosis. Isolation rooms have higher cost-per-bed than general ED beds, but they can be affordably constructed utilizing a mechanical ventilation system to create negative pressure Figure 2.

Negative pressure is achieved in an isolation room using mechanical ventilation and unidirectional airflow. The appropriate isolation capacity should be determined according to local burden of disease and availability of other designated treatment facilities tuberculosis, cholera, Ebola, etc. Patient monitoring in airborne isolation rooms can be ensured with strategically-placed windows. Several other easy design choices can improve infection control.

Throughout the ED, well-positioned sinks can promote handwashing. Additionally, adequate bed spacing mitigates the spread of infection [ 13 ] and improves care delivery.

We have found one meter between beds reasonably balances cost, clinical care and infection control needs. Upper-room ultraviolet lights provide effective, low-cost, germicidal irradiation to reduce transmission of airborne diseases [ 14 ]. Lastly, throughout the ED, choose easily sanitized finishings; we recommend sealed floors not tile , non-cloth furniture, and removable, easy-to-clean curtains or patient dividers.

Staff and patient safety and well-being are essential to delivering quality emergency care. EDs face unique security risks, including increased risk of violence against healthcare workers [ 15 ].

In any design, local context should inform the necessary level of security, and ED accessibility and routes of egress in an emergency should be balanced with controlled access. The initial HUM design prioritized accessibility but had multiple unsecured access points. Since opening, we have enhanced security with select locked doors, one-way glass, and security personnel. As needed, consider designs that allow for ED lockdown with safe spaces for staff in high-risk situations.

Often overlooked, privacy is paramount to patients and a priority for quality care delivery. Privacy can be enhanced in an open ward by including limited private exam rooms in addition to curtains and screens.

To promote dignity, sufficient bathroom facilities and dedicated space for waiting families should be included. Staff wellness can be promoted through staff restrooms, break rooms, and secure storage for personal belongings.

Additionally, dedicated workspace for doctors and nurses within the main ED facilitates documentation and allows staff to perform their activities in comfort without compromising patient monitoring. Lastly, planning purposeful space for a patient tracking white board improves ED management and offers space for on-shift education.

Lastly, the location of the ED is key to its function both within the hospital and the surrounding community. By design, the ED is close to radiology and lab services, operating theatres and the intensive care unit. We recommend these adjacencies given the importance of these clinical relationships. Additionally, to facilitate patient flow, we recommend covered pathways large enough to accommodate a stretcher between the ED and other wards, radiology, the kitchen, laundry, and morgue.

As efforts to strengthen emergency care in LMICs continue, purpose-built EDs will be key to improving care quality, patient outcomes, and staff safety and well-being. Foresight and consideration in these seven domains will maximize utility within a given construction budget and position EDs for operational and maintenance success.

The new design is larger given the high demand for care and relatively long LOS. Designated subacute and fast track areas promote flexibility to accommodate fluctuations in patient volume. There is an expanded triage area, incorporating triage into patient flow, and improved lines of sight within the ED to all patients. The waiting area can be separated for patient waiting and family waiting.

We will continue to supply oxygen through a piped system but will add additional ports. Since a pop-up roof is difficult to retrofit, we will ameliorate climate control with air conditioning. Infection control will be strengthened with added sinks and mechanically-ventilated negative pressure isolation rooms.

The wellbeing and dignity of patients, family, and staff will be enhanced with expanded bathroom facilities, upgraded security with limited access points, and a staff lounge. The new ED continues to take advantage of our current adjacencies within the hospital.

The dashed box indicates new construction, whereas the remainder of the space reflects redesign within the existing footprint of the HUM ED.

Patients move from the waiting area to dedicated triage space into the appropriate fast-track, acute, sub-acute, or observation areas.

Staff workspace is positioned to prioritize line-of-site to critical patients. These recommendations reflect our best current understanding to immediately improve infrastructure for ED care within health systems in LMICs. Though some recommendations may differ from those in high-resource settings, we believe these represent an important step in providing high quality and equitable emergency care.

As EM develops and health systems improve, these recommendations will require adaptation. Future research should quantify the impact of different ward design options on quality of care, safety and monitoring, and patient privacy and satisfaction in LMICs. Additional studies could consider the best mechanisms for balancing security with accessibility, and future work should include a formal costing analysis of ED design and construction, which will vary by local setting.

Our findings should be considered relative to several limitations. First, our recommendations are drawn from our collaborative experience in a relatively large referral hospital in Haiti. However, our team has implemented aspects of these recommendations in other contexts including smaller hospitals with positive outcomes, and we anticipate many recommendations are generalizable.

Second, our new prototype is slated for construction but not yet in use, so additional considerations could emerge. Third, while we solicited broad input, this represents a quality improvement project rather than a research investigation, so there may be viewpoints not reflected here. As emergency care continues to expand, purposeful ED design can improve care delivery, quality, and efficiency. We hope that these recommendations provide a foundation for ED infrastructure in other LMICs to improve clinical care delivery and patient outcomes.

JKP was the facilities manager for HUM for its first three years of operation and contributed to operationalizing recommendations. JA and RWF provided all figures. All authors revised the manuscript for intellectual content and approved the final version. Health systems and services: The role of acute care. Bulletin of the World Health Organization. Strengthening health systems to provide emergency care. In: Disease control priorities: improving health and reducing poverty.

Washington, DC: World Bank; Strengthening emergency care: experience in central Haiti. The Lancet Global Health. Millard WB. The cost of koi: Evidence-based design in emergency medical facilities. Annals of Emergency Medicine. Physical design correlates of efficiency and safety in emergency departments. Critical care nursing quarterly. Dickinson EE. To browse Academia. Log in with Facebook Log in with Google. Remember me on this computer. Enter the email address you signed up with and we'll email you a reset link.

Need an account? Click here to sign up. Download Free PDF. Davide Oricio. A short summary of this paper. Download Download PDF. Translate PDF. General considerations Built Environment: General Considerations Document Review Whilst the guidelines outline the need to integrate the clinical requirements, functional needs and practical size requirements of an Emergency Department, the document is not intended to be an exhaustive guide to models of care and patient pathways as such information can become outdated quickly.

In the dynamic environment of Emergency Departments, models of care can change rapidly depending on government policies and initiatives, patient needs and demographics, Emergency Department staffing, and other factors. Both documents do not exist in isolation, and should typically be viewed as complementary. ACEM however reserves the right to propose different views on certain elements of Emergency Departments considering Emergency Physicians and other staff spend more time in and use Emergency Department facilities more than any other group.

The peer knowledge and learnings contained in the guidelines are documented elsewhere for Emergency Physicians who are not architects, designers or planners, and who increasingly will be involved in the Emergency Department planning and design process. An Emergency Department is also an important interface to the many inpatient and outpatient services offered by its parent hospital and the health service of which it is a part.

In addition, a large proportion of the total acute admissions to inpatient wards are via Emergency Departments, both in Australia and New Zealand. Design The design of an efficient Emergency Department in which care is coordinated and carried out in an appropriate environment depends on the productive collaboration between a number of key stakeholders involved in the building or redevelopment process.

Consideration that Emergency Department models of care will change over time is needed, as well as consideration of the relationship between the Emergency Department and the greater hospital. The psychosocial wellbeing of staff should be considered through design and space use. This should not be underestimated given that staff will occupy the Emergency Department spaces much longer than any patient, relative or carer.

This includes patients requiring resuscitation and those with emergent, urgent, semi-urgent and less- urgent conditions Australasian Triage Scale ATS categories [2]. An Emergency Department also requires the capacity to deal with mass casualty and disaster situations. There are particular patient types seen in the Emergency Department that may have specific psychosocial and treatment needs. Many different solutions have been used successfully to aid patient flow.

It should always be considered that barriers to patient flow and especially access block [3] are symptoms of hospital-wide problems. It is therefore strongly recommended that any work on clinical service redesign and redevelopment extends beyond the Emergency Department to incorporate the entire hospital.

The goal for any model of care should be to reduce unnecessary steps in the patient journey, and to optimise the timeliness of all the essential components of the journey. Each individual Emergency Department presents its own challenges, and no one solution fits all. They may be situated in the waiting room, at the reception desk or within the triage area of the Emergency Department.

They are based in the triage and ambulance assessment area and work as a team to augment the triage process with early disposal decisions and investigation instigation. It is resource intensive. The reception or triage area may stream selected patients to this area.

Alternatively, ambulant and ambulance patients may present in this area and are streamed. These areas should be staffed for a rapid turnover of patients with suitable appropriate outflow areas. Caution should be exercised in physically designing a new Emergency Department around a specific model of care, bearing in mind that best practice approaches in Emergency Medicine may change, and that the lead time from design to completion of an Emergency Department is in the range of years.

Size Size will vary depending on the size of the Emergency Department and the allied health workload. The policy outlines minimum requirements for the delineation of the four levels of Emergency Departments. Benchmarking involves using published data on attendances per annum, review of current operations and visiting other recently built or redeveloped Emergency Departments.

Space planning is carried out by a facility planner using published data, and the layout of the facilities is planned by the architect in consultation with user groups such as clinicians and hospital administrators. It is critically important that Emergency Department administrators and clinicians have major input into the planning from the beginning.

The major decisions on the function and size of the Emergency Department are usually made in the early planning stages, as changing these decisions later in the design process is difficult and expensive. This is documented in the schedule of accommodation.

This document lists the number of each space required and the area allowed for each type of space e. User groups of clinicians and managers will meet with the architects and engineers to review and approve the design proposed.

There may be many changes to the size of the planned Emergency Department prior to final construction, either due to broader spatial constraints, or due to fiscal constraint. Sometimes even seemingly small adjustments can make the function of an area impractical or dysfunctional.

In addition, because size determination is often undertaken far in advance of the capital works being completed, by the time the facilities are operational, the facility can already be too small.

This has implications for formulas that are used to estimate future demand on Emergency Departments. Emerging methods for planning Emergency Department size There is consideration of the use of lean-led design and simulation modelling in the planning process. Lean-led design is a systematic approach to healthcare architecture that focuses on defining, developing and integrating safe, efficient, waste free operational processes in order to create the most supportive and patient focused physical environment possible.

Simulation modelling uses dynamic computer models to analyse the patient flow, staffing, facilities, technology and operational practices, in order to optimise the planning to satisfy the patient needs.

This technology has been widely used in operations research, defence, manufacturing and transport for decades. The methods have been adopted by leading American health care architects. Successful application of these methods requires commitment by hospital management and clinicians working collaboratively with experts in process improvement, simulation modelling and healthcare architecture.

The planning process should include thorough analysis of the current processes and developing optimal future process. These methods use the knowledge available from large data sets, clinicians and managers to develop the optimal solution. This includes the needs and requirements of staff, and the varying demographic of those patients who utilise the Emergency Department. The needs of these varying patient groups can be addressed through, for example, suitably placed furniture and art, adequate access to information and communications technology, and appropriately designed rooms and equipment that are suitable for use by particular patient populations.

Whilst the needs of patients, carers and relatives are highly important, it is also necessary that a healthy working environment for staff is facilitated by the design of the Emergency Department. These needs can be catered to through the use of well-placed staff bases, staff rooms large enough to accommodate the maximum number of possible users, and ensuring that staff facilities are located separately from clinical areas, in order to promote effective breaks from patient care.

A positive patient experience can improve patient satisfaction and can reduce perceived waiting times. Studies also show that patient satisfaction is directly related to greater patient adherence to prescribed medications and medical advice, as well as to greater Emergency Department staff satisfaction, increased morale and greater retention [6]. When designing waiting areas, and other areas and facilities that Emergency Department patients and their relatives, friends or carers will use, it is important to consider that these people will often be afraid, anxious or in pain, and so the physical environment should, where possible, play a role in mitigating these emotions.