Emergency Department

Current Design - An Overview

Dr Mahathar Abd Wahab,
B Sc (Med Sc), MB ChB, M Med (Emerg. Med)
Head, Emergency and Trauma Department
Hospital Kuala Lumpur, Malaysia
JABATAN KECEMASAN DAN TRAUMA
HOSPITAL KUALA LUMPUR, MALAYSIA
Disclosure
• Other Positions:
• Head, Emergency Medicine and Trauma Services, Ministry of Health,
Malaysia
• President, College of Emergency Physicians, Academy of Medicine,
Malaysia (2015-2019)
 • Introduction
• Features of Emergency Department
• Key Services in Emergency Department
Design principles
Outline •
• Overall design
• Acuity area design
• Summary
Introduction – Design of Emergency Dept
• Emergency Department (ED) characteristics;
• ED as part of a whole system approach to emergency care.
• Operate as part of an integrated health system.
• Reflect the importance of acute cares services within the region & their
network
• Services delivery within ED dependable on;
• Patient In Flow & Patient Out Flow
• Need to understand ‘why people come’ as number and type of
patients will influence design
• ‘Service Demand Analysis’
Key Success Factor to New ED /
Refurbishment
• Design
• Process
• Communication
• The ability to change (adaptive)
Conceptual Framework of Health System Integration
CRITICAL PATHWAY

SelfCare Pri.care Rehab.

Community
Wellness Pre Hosp.Care Hosp.Serv. Participation

CALL CENTRE
RESOURCE CENTRE

CARE PLAN

From Womb to Tomb

Emergency Medicine and Trauma Services

EM Clinical
PHC Disposition
Services
Features of Emergency Department
• High levels of activity / High intensity
• High patient turnover
• Varied case mix
• Large multi-disciplinary workforce
• Need for efficiency of process
• Infection control requirements
• Access issues
• Interface with pre-hospital services
• Multiple interactions with in-hospital
specialties / patient transfers
• Communications issues
• Potential for growth
• Teaching activities
• Major Incident capacity
• surge capacity
• Responsiveness to local service demands
/ social issues
• Administrative functions – EM specific
• Possibility of aggression/assault – security
issues
 Emergency Medicine and Trauma Services

Discharge

self

Treat & observation

referral

Diagnostic, Therapeutic
ambulance Resuscitation Treat & admit

PHC
Triage Emergency Medicine Clinical services Disposition
Arrival
Pathways that a patient may follow on arrival to the Emergency Department:

Patient Flow and Model of

Care
• Reduce unnecessary steps
• Unilateral / unidirectional
patient flow
• Adaptive to patient need
Key Services in Emergency Department
• Service provision
• Triage services
• Care of the critically ill
• Resuscitation and stabilization
• Therapeutic intervention and definitive care
• Observational medicine
• Care for the elderly
• Care for the victims of domestic violence
• Care for the paediatric
• Decontamination services
• Supporting Services – Labs, Imaging
• Administrative
• Training
 This conference set out to challenge the way that

Design Outline
we think about the integration of three things:
Advancing ED process design (Processes); Spatial
ED design that is responsive to clinical service
(Space); both of which that contribute to a team

Principle in Design Integration

dialogue (People).

Sp
ss

ace
oce
Pr

People
 Structure Mirror Processes & Structure
Facilitate Care
Dedicated treatment zones

Key Design Patient privacy and confidentiality

Concepts
Internal function relationship – Internal
Network
External function relationship – External
Network
 Service Demand Analysis
Acuity & Pattern of Diseases
• Acuity of Cases
• Critical / semi critical / non
critical
• Infectious diseases / NCDs
• Mental health illness
• Geriatric population / elderly
• Paediatrics

1. Length of Stay
2. Pattern of Arrivals
Internal Function Areas – Internal Network
• An entrance/waiting room/reception area;
• A triage area;
• A resuscitation area;
• A mental health assessment area;
• An acute treatment area – care of semi-critical and critical patients
• A consultation area (also called Fast Track area/sub-acute/minors/ambulatory care);
• Adjunctive areas (x-ray, Short Stay Unit (SSU), allied health, investigations room (point of
care testing));
• Administrative areas;
• Support Areas - Storage areas , staff amenities, drug preparation rooms, Dirty utility and
disposal areas;
• Patient amenities areas e.g. a food storage fridge that meets OH&S standards for patient
sandwiches (for after hours);
• Training and research areas.
External Function Areas – External Network
• Hospital access / egress
• close relationship to the main entrance of the hospital is desirable, for patient
and relative wayfinding, after-hours access and egress, and parking/public
transport.
• Investigative modalities
• Acute services – OT, ICU, HDW, CCU, Angio suite, Helipad
• Definitive wards
• Functional relationships with other aspects of the hospital important
in the event of mass casualty incidents
 Overall Design
Floor Space
1. Attendance numbers and patterns
2. Patient acuity
3. Overall LOS
4. Admission rates and practices
5. Turnaround times for imaging and laboratory investigations,
6. The % of patients; > 65 years, paediatric
7. Academic activities
8. Imaging options : undertaken within the ED (e.g. CT scanning)
9. Requirements for Paediatric Care including playrooms, family areas etc.
10. Case Mix : Mental Health, NCD, Communicable diseases
 Overall Design
Patient Flow
“The key is designing spaces that
respond to the environment and
the available resources”

1. ‘Structure mirror process, structure facilitate

care’ – work process
2. ‘Unidirectional patient flow’ – patient flow
6 Overall Design
Patient Flow 5

“Splitting flows into acuity levels “Acuity adaptable design and the
will increase throughput and seperation of systems into levels can
responsiveness” increase adaptability”

Decision Management for Acuity Adaptability in a single space that can adapt to changing
Phil Astley and Rachel Northfi
Susaneld explored
Robinson, front-
Philip patient
Astley and Grant acuity. It allows the patient to remain in a
Mills : “Design
Lean Design: the Split ED
end decision making andthe Smartest
the need toED: Process,
engage in Spacesingle
and People” conferencereducing medication errors
room, therefore
Jody Crane described Downing
the general application
College of on July 7-9th 2014
in Cambridge
the consideration of acuity adaptable design and and it increases health professional contact time.
lean principles (e.g. value stream mapping, waste
Drop Zone and Primary
Triage Services
• Triage Counter – ‘Fly Eye Concept’
• 180 degree vision
• Open Counter & Safe Distance
• Interactive counter
• Proactive Triage & Surveillance Triage Services
• PRO services
• First Look concept
• Rapid assessment
• The Ambulance Entrance -
close to the ED Resuscitation Room, appropriate
parking slot
• Security - to maintain ‘car free area’
 Secondary Triage

• Trolley & wheel chair accessible

• Access to ECG and diagnostics,
Registration /Administrative
functions, immediate drug
therapy
Emergency Department Entrance
• Sliding door (two layers)
• Air lock
• Body temperature detector /
alarm
• Infectious disease outbreak
• Patient Containment
• Diversion to isolation
assessment cubicle (with air
lock)

Yonsei University Hospital, Seoul, Korea

 Wait Area – Wait Management Concept
1. Client Focus Environment
2. “Smart Building”
3. Ergonomically Design Facility
And Furnitures
4. Air-condition System And Air
Change Management
5. Capacity - Based on Service
demand analysis
6. Lighting System
7. CCTV And Security
8. Alarm & Alert System
9. Computerized System
“Eliminate the negative associations of
waiting rooms”
Wait Area – Smart Management System

Yonsei University Hospital, Seoul, Korea

 Dedicated Treatment Zone & Cubicle
• Color coded & well defined facility (eg. Red / Yellow / Green / Blue)
• Psychological sensitization
• color schemes chosen should be appropriate given the stressful environment
• Each section with definitive function (based on patient need)
• Natural (ambient) light balance with lighthing ( > 30,000 lux)

Nurse Station of Accident and Emergency Department, USM. SFA Wahab, AR

Ismail, R Othman. International Conference on Applied Human Factors and
Ergonomics 2018.
Ergonomics Risk Assessment of Musculoskeletal Disorders (MSD) During
Simulated Endotracheal Intubation in Hospital Universiti Sains Malaysia (HUSM).
SFA Wahab, MH Mohd Noor, R Othman. International Conference on Applied
Human Factors and Ergonomics 2018.

Lighting Assessment at Resuscitation Area of Accident and Emergency

Department, Universiti Sains Malaysia. SFA Wahab, AR Ismail, R Othman.
International Conference on Applied Human Factors and Ergonomics 2018.
Dedicated Treatment Cubicle
Resuscitation Cubicle
Prof Dato’ Sri Abu Hassan
Hospital Kuala Lumpur
1998

Emergency and Trauma Dept,

HKL

‘GOLF SWING ERGONOMIC’ & ‘COCKPIT ARRANGEMENT’

SECOND NATURE RESPONSE
 Dedicated Treatment Cubicle
Features Resuscitation Cubicle

1.Horizontal Task Distribution

2.Ergonomics arrangements
1.‘Golf swing ergonomics’ – within arm reach
2.Wet pendant & dry pendant
3.Clinically & Therapeutically determined
arrangement of staff based upon intervention
required
4.Task is distributed into small manageable package
unit between the Team Members
5.Joint decision making process
Emergency and Trauma Dept, HKL
Dedicated Treatment Area
Trauma Resuscitation

• Roof mounted X-ray

• Lead Barrier Room
• Wall mounted examination lights
• Privacy - frosty door panel
• Alert & alarm
• Service pendant arm
• Specialized resuscitation trolleys

Emergency and Trauma Dept, HKL

Semi Critical / Examination
Cubicles
• Smart patient trolley
• Open cubicle concept
• Centralised monitoring system
 Acute Respiratory Distress Zone
• Dedicated for mild to moderate
Asthma & COPD
• Air Ventilation / Air Exchange
• Infection control measures

Emergency and Trauma Dept, HKL

Isolation Room
Decontamination Services
• Isolation Room
• Negative pressure room
• Air lock
• Infection control
• Decontamination services
• A de-robing area;
• A decontamination area including
water hose;
• A drying off area;
• An entry to the Emergency
Department
Consultation Room
• Ergonomic arrangement
• QMS
• Patient privacy
• Alert button
• Wall mounted diagnostic
set
• Phone & internet access
• +/- Bedside ultrasound

Emergency and Trauma Dept, HKL

 Chair Centric Area
• Short term observation
• In sitting position
• An open room with recliners
separated by cubicle curtains or
partitions.
• This space often is not enclosed.

Yonsei University Hospital,

Seoul, Korea
Observation Ward / Short Stay Ward
• A unit for placing patients who
require additional time in a health
care setting, but no longer require
ED services and do not need to be
admitted.
• “Patient observe with intend to
discharge”
• Static number of beds with O2,
suction and patient ablution
facilities; and
• Are not a temporary ED overflow
area nor used to keep patients
solely awaiting an inpatient bed,
nor awaiting treatment in the ED.
Imaging Area
• CT Scan
• Angio – suite
• X rays
• Diagnostic ultrasound

Emergency and Trauma Dept, HKL

Outpatient Pharmacy

• QMS
• Short term prescription
• close proximity with consultaion and
patient wait area
• ED stocks

Emergency and Trauma Dept, HKL

Training Areas
• dedicated facilities for formal
education, tutorials/mannequin
simulation, and meetings.
• A private, non-clinical area with
noise attenuation, often near
the staff room and offices, and
with access to toilets and
amenities.

Emergency and Trauma Dept, HKL

Special Population
Requirements
Paediatric
Special Population
Requirements
• Bariatric
• physical and emotional needs of patients who are obese &
providing a safe work environment for staff.
• The planning of space and equipment also needs to consider
the needs of patients of up to 400kg. (ACEM 2014)
• Wait Area - 20% wait area chairs integrated into general
wait (avoid stigma)
• Treatment Area – at least 1 area in Resus, general cubicle,
and isolation/negative pressure room (with bariatric
patient trolley)
• Toilet – floor mounted toilet, grab rails, sink capable of
added load,
• Ceiling mounted lifting device
Special Population
Requirements

• Elderly patients (geriatric)

• “IF THE FACILITIES SAFE FOR THE
ELDERLY, IT WILL BE SAFE FOR
ALL PATIENTS”
• Address 3 D’s in elderly
• Dementia
• Depression
• Disability
Special Population Requirements
Geriatrics
• Proximity to the ED entrance so elderly patients do not need to walk
long distances;
• Short term parking for vehicles close to the ED entrance;
• Access to wheel chairs;
• Ease of requesting assistance from patient transfer services;
• Equipment requirements
• High backed and high level chairs
• Mechanical high-low beds to minimize falls risk
• High level adapters for toilet seats
• Appropriate mattresses for pressure care
 Other Supports System / Areas
(Emergency Department Design Guidelines) (G15)

• EMR / Patient tracking system

• Administrative areas
• Family distress areas
• Acute mental health area / behaviors
assessment room

ED Design, ACEM 2014

 Summary

• ED DESIGN – INTERACTION BETWEEN PROCESS, PEOPLE & SPACE

• END TO END SYSTEM SOLUTION – INTERNAL & EXTERNAL NETWORK
• SERVICE DEMAND ANALYSIS AS KEY FUNDAMENTALS
• ADAPTIVE AND ADAPTABILITY TO CHANGE
• SMART BUILDING CONCEPT
Further Reading & References
1. Department of Health. Health Building Note 15-01: Accident & emergency departments.
Planning and design guidance 2013 .www.gov.uk/government/organisations/department-of-
health
2. Emergency department design guidelines. Australasian College for Emergency Medicine (ACEM)
2014
3. Structure mirror process, structure facilitate care – Abu Hassan Asaari Abdullah.