Syracuse University

SURFACE
Architecture Thesis Prep School of Architecture Dissertations and Theses

Spring 2013

Waiting as Remedy: The Architecture of Emergent

Care
Jack McCarrick
Syracuse University

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McCarrick, Jack, "Waiting as Remedy: The Architecture of Emergent Care" (2013). Architecture Thesis Prep. Paper 224.
http://surface.syr.edu/architecture_tpreps/224

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WAITING AS REMEDY
THE ARCHITECTURE OF EMERGENT CARE

Jack McCarrick
M.Arch I Candidate
Robert Svetz
Primary Advisor
Brian Lonsway
Secondary Advisor

School of Architecture, Syracuse University, Spring 2013

TABLE OF CONTENTS 2

I INTRODUCTION 3

II THE EMERGENCY DEPARTMENT: 5

TOWARD A NEW LEVEL OF CRISES
Waiting Room vs. Emergency Room
Diversity of the Waiting Room
III WAITING AS REMEDY 25

IV THE CLINIC REVISITED 33

Herzog & de Meuron: Rehab Basel
OMA: Maggies Centre
V SPACES OF WAITING 37
The Retail Store
VI WAITING AS REMEDY REVISITED 45

VII SITE 53
The Urban Hospital
The Suburban Hospital
VIII DOCUMENTATION 62
Bibliography
Figure Credits
INTRODUCTION
Following the final phases of the Patient Protection and Affordable Care Act, an estimated
thirty-two million additional Americans will have access to health insurance in 2019. Despite theoreti-
cally having a greater opportunity for access to primary care under the new policy, many of the newly
insured will seek medical attention from emergency departments, regardless of the severity of their
issues. Without consideration for this impending influx of patients, emergency departments have seen
a rise in the volume of incoming patients, becoming overcrowded and leading to a deficiency in patient
care. The current protocol for sorting patients upon their arrival to an emergency department stratifies
patients into a range of acuities with respective wait times based on the urgency or appropriateness of
their visits. With a considerable number of visits not receiving immediate attention or care, many
patients are displaced to the waiting room, where they potentially spend a greater portion of time than
they do receiving treatment once administered to an emergency room.
Considering the discrepancy between the time spent waiting and the time spent receiving care,
the waiting room potentially has a greater impact on patient satisfaction, and in turn patient treatment,
than the emergency rooms themselves. How can the spaces of medical waiting provide care for a
range of urgencies with varying wait times? While the stark sobriety of examination and treatment
rooms has come to represent an expected level of clinical expertise, the waiting room has the potential
to operate with multiple formal and programmatic expressions to administer care accordingly to the
range of incoming cases with various biological needs and psychological desires -- from medical
education and self diagnosis to emergent care to implied care.
Between the years of 1997 and 2007, the number of emergency department visits increased by
twenty-three percent. This increase in visits has led to the congestion of emergency departments, with
over ninety percent of hospitals reporting overcrowding (zero available beds, holding patients in
hallways, long waits). Recent investigations have already considered operational improvements and
changes to emergency department layouts in order to better accommodate and fast track the different
levels of severity for incoming cases, however the role of the waiting room has fallen to the wayside.
Contemporary investigations of high-end architecture into healthcare, such as Herzog & de Meurons
Rehab Basel, have primarily focused on isolated care and treatment centers, considering the role that
landscape and materiality play in the healing process. However, these projects are typically detached
from an urban context with little or no sense of urgency to the care provided.
In order to research the potential of the waiting room, the current condition of the emergency
4
department must first be examined. Patient volumes of different acuities and their respective waiting
times will be researched to determine the necessary space allocation for areas of waiting and areas of
care.
Next, past examples of waiting spaces must be examined. These spaces should not be strictly
limited to medical programs, but rather they should come from other fields where the act of waiting has
been thoroughly considered or exploited to enhance or alter the desires of the users. The various
waiting experiences of commercial spaces will be primarily researched.
Finally, the range of programs necessary for fulfilling the biological needs and psychological
desires of the various patient acuities will be determined.
While the Patient Protection and Affordable Care Act provides insured care to a much larger
group of Americans, it has the potential to reduce the quality of care provided to patients, particularly in
emergency departments. This research will argue for a reimagining of the emergency department in
which there is a definitive split between the architectural implications of spaces where technical care is
administered for biological needs (the emergency room) and spaces where primary and implied care
can satisfy the psychological desires of inappropriate patients (the waiting room) in order to better
serve appropriate patients.
Notes
1. Congressional Budget Office, Updated Estimates for the Insurance Coverage Provisions of the
Affordable Care Act, (March 2012): 3.
2. Richard Niska, Farida Bhuiya, and Jianmin Xu, National Hospital Ambulatory Medical Care Survey:
2007 Emergency Department Summary, National Health Statistics Reports 26 (August 2010): 3.
3. Shari J. Welch, Using Data to Drive Emergency Department Design: A Metasynthesis. HERD :
Health Environments Research & Design Journal 5, no. 3 (2012): 26-45.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 6

WAITING ROOM VS. EMERGENCY ROOM

From the time a patient is taken to the emergency department to when they first receive medical atten-
tion, there is a drop in the level of care received as he/she experiences the waiting room. Due to a lack
of primary care providers, which is expected to only get worse, and an obligation to accept any incom-
ing patient, emergency departments receive a large number of inappropriate cases daily, causing
congestion and increased waiting times for urgent and non-urgent cases alike. While both groups
(appropriate and inappropriate) seek clinical care in the emergency room, they are, more often than
not, first confined to the waiting room -- an area of medical limbo where care ceases to exist. Despite
this distinct separation between the emergency room and the waiting room, the two receive the same
formal expression of clinical sobriety. Furthermore, the waiting room provides a single waiting experi-
ence for all patients regardless of the severity of each case. It would seem that the spaces of waiting
could take a more involved role in the administration of care through various programmatic and formal
operations that address the wellness of both urgent and non-urgent cases.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 8

<5% of all Physicians

22.9% Private Insurance

50% Other Source of Care4
28% Emergency Departments

51.9% Public Insurance

30%

354 Million
Annual Visits 50% No Other Source of Care4
29.4% Uninsured
for Acute Care
42% Personal Physicians

Deficit of Primary Care Physicians

65%
Current Condition 2013 209,000 16,000

20% Specialists Future Condition 2025 52,000

7% Outpatient Departments
Notes
1. Pitts, Stephen R; Carrier, Emily R; Rich, Eugene C; Kellermann, Arthur L.
Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's Office.
Health Affairs 29: 9. 2010. 1620-1629.
2. Sanders, Bernard.
Primary Care Access: 30 Million New Patients and 11 Months to Go:Who Will
Provide Their Primary Care? Subcommittee on Primary Health and Aging.
January 29, 2013.
3. Garcia, Tamyra Carroll; Bernstein, Amy B; Bush, Mary Ann.
Emergency Department Visitors and Visits: Who Used the Emergency Room in
2007? NCHS Data Brief 38. 2010.
4. Gindi, Renee M; Cohen, Robin A; Kirzinger, Whitney K.
Emergency Room Use Among Adults Aged 1864: Early Release of Estimates
From the National Health Interview Survey, January June 2011. Center for
Disease Control. 2012.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 10

EMERGENCY DEPARTMENT FLOWCHART

Patient arrives by
Patient arrives as
ambulance or
walk-in
helicopter

Triage: the sorting of patients

according to the urgency of
their need for care

DIVERSITY OF THE WAITING ROOM

WAITING IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT
As patients come into the emergency department, they are filtered through triage (the sorting of
patients according to the urgency of their need for care) creating a stratification of patients with respec-
tive waiting times from non-urgent (needing to be seen between 2 and 24 hours) to immediate
(needing to be seen in less than one minute). With 42% of patient acuities categorized as a semi-
Physician urgent or non-urgent, a significant portion of the waiting room becomes occupied by inappropriate
Examination cases with no true need for emergency facilities or the more specialized care they offer. Conversely,
emergent and urgent cases (appropriate cases) comprise 51% of emergency department visits, with
average waiting times of 51.2 minutes and 63.3 minutes respectively. While these appropriate cases
have relatively little time to spare and a true need for the emergency room, inappropriate cases have
Additional time to wait but typically no access primary care, or they lack general medical knowledge.
Examination
(X-Ray, MRI)

Treatment
Received

Discharge

Notes
1. Hing, Esther, M.P.H.; Bhuiya, Farida, M.P.H.
Inpatient
Home Wait Time for Treatment in Hospital Emergency Departments: 2009
Unit
NCHS Data Brief 102. 2010.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 12

PERCENTAGES OF PATIENT ACUITIES: MEAN EMERGENCY DEPARTMENT WAIT TIME BY URGENCY

United States, 2009 + PERCENTAGES OF PATIENT ACUITIES

1 IMMEDIATE: Needing to be seen in less than 1 minute

2 EMERGENT: Needing to be seen within 114 minutes

41%
10%
3 URGENT: Needing to be seen within 1560 minutes
2%
4%
4 SEMIURGENT: Needing to be seen within 12 hours

7%
35%
5 NONURGENT: Needing to be seen between 2 and 24 hours

6 NO TRIAGE: No triage system was used

10 20 30 40 50 60 70 min

MEAN EMERGENCY DEPARTMENT WAIT TIME FOR TREATMENT,

BY URGENCY OF PATIENT CARE:
United States, 2009

IMMEDIATE 28.9 min

EMERGENT 51.2 min

URGENT 63.3 min

SEMIURGENT 58.7 min

NONURGENT 53.5 min

NO TRIAGE 38.2 min Notes

1. Hing, Esther, M.P.H.; Bhuiya, Farida, M.P.H.
10 20 30 40 50 60 70 80 Wait Time for Treatment in Hospital Emergency Departments: 2009
Mean Wait Time in Minutes NCHS Data Brief 102. 2010.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 14

TIME FROM REGISTRATION/TRIAGE TO PHYSICIAN ASSESSMENT UPSTATE MEDICAL UNIVERSITY

vs TIME FROM PHYSICIAN ASSESSMENT TO DISCHARGE: EMERGENCY DEPARTMENT
Canada, 2005

3% 97% Trauma Exam Exam Exam

Treat

Immediate Triage Exam Exam

Scan Psych
Reception

Exam Exam
Waiting
Room
Exam Exam Scan

35% 65% Exam

Exam Exam Exam
Waiting
Room
Exam

Exam Exam Exam Exam

Urgent 2012-960
UP

UP

X-Ray X-Ray

66% 33%

Nonurgent Notes
1. Canadian Institute for Health Information.

Time From Registration/Triage to Physician Assessment Understanding Emergency Department Wait Times: Who is Using Emergency
Departments and how Long are They Waiting.
Time From Physician Assessment to Discharge
2005.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 16

EMERGENCY DEPARTMENT FLOWCHART

Patient arrives by
Patient arrives as
ambulance or
walk-in
helicopter

Triage: the sorting of patients

according to the urgency of Trauma Exam
their need for care

WAITING IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT Exam

Scan

22-yo male involved in a motocycle accident brought to the hospital by ambulance. The patient Scan
has an exposed bone, a potential severed artery, and loss of consciousness. He is rushed
immediately to the trauma room.

After stopping the bleeding, setting the bone and temporarily stabilizing him, the patient
is taken to have a CT-Scan performed to insure there is no unseen internal bleeding or other
bone trauma.
UP
2012-960
UP

The CT-Scan reveals nothing new, and the patient is relocated to the intensive care unit to be
closely monitored in order to prevent further deterioration.

CASES 1. Major trauma such as a motorcycle wreck with exposed bone and loss of consciousness
2. Respiratory failure from drug overdose or overwhelming pneumonia
3. Cardiopulmonary arrest - typically an elderly patient
4. Major bleeding from a severed artery
5. Active seizure in an epileptic
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 18

EMERGENCY DEPARTMENT FLOWCHART

Patient arrives by
Patient arrives as
ambulance or
walk-in
helicopter

Triage: the sorting of patients

according to the urgency of Trauma Exam
their need for care

WAITING IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT Triage Exam

Scan

55-yo female is driven by a relative to the hospital and checks in with the reception desk, Exam Exam
complaining of chest pain, sweating and nausea.
Waiting
Room Scan
Exam Exam

The patient is taken to triage for clarification of symptoms and a check of vital signs. Following Exam
the check, the patient is directed to the first waiting room, where she can be monitored by the
Exam Exam Exam
receptionist.

Exam Exam

Exam Exam Exam Exam

After waiting for 20 minutes, the patient is admitted to an examination room with a high level of
visibility. Following a physician consultation, an EKG-Test is administered to check for a
heart attack UP
2012-960
UP

The EKG-Test comes back negative, and the physician suspects a possible pulmonary
embolism. The patient is given a CT-Scan to check for a blood clot.

The CT-Scan reveals a clot and the patient is taken to the intensive care unit to be monitored
and treated for the clot.

CASES 1. Chest pain, sweating and nausea

2. Known heart attack that needs a cardiac procedure
3. Stroke - patient suddenly loses speech or strength and needs emergent procedure
4. High fever and shakes in elderly patient
5. Floppy child who is minimally responsive and with fever
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 20

EMERGENCY DEPARTMENT FLOWCHART

Patient arrives by
Patient arrives as
ambulance or
walk-in
helicopter

Triage: the sorting of patients

according to the urgency of Trauma Exam
their need for care

WAITING IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT Triage Exam

Scan

34-yo male arrives by car and reports to the receptionist. The patient suffered from a deep cut Exam Exam
to his arm from an accident at a construction site. The patient is taken into triage.
Waiting
Room Scan
Exam Exam

The triage nurse determines that there is no arterial bleeding. The patients arm is bandaged, Exam
he is given pain medication, and he is directed to the waiting room and ordered not to wander
Exam Exam Exam
off.

Exam Exam

Exam Exam Exam Exam

Following a 1-hour wait, the patient is taken into an examination room, where his arm is further
examined by a physician. After noticing no significant complications, the arm is sutured.
UP
2012-960
UP

The patient is sent home with a prescription for pain medication and antibiotics. He is to see
a physician after two weeks to have the sutures removed, or sooner if the cut becomes
infected.

CASES 1. Deep cut without arterial bleeding

2. Abdominal pain with nausea and vomiting
3. Migraine headache with severe head pain
4. Altered mental status from drug overdose but no current need to be on respirator
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 22

EMERGENCY DEPARTMENT FLOWCHART

Patient arrives by
Patient arrives as
ambulance or
walk-in
helicopter

Triage: the sorting of patients

according to the urgency of Trauma Exam Exam Exam
their need for care

WAITING IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT Triage Exam Exam

Scan

18-yo female is taken to the emergency department by car and checks in with the receptionist, Exam Exam
Waiting
thinking that her ankle is broken from an accident in a soccer game. She is sent to triage. Room
Exam Exam Scan

The triage nurse determines that the ankle could have a minor fracture. The patient is sent Exam
Exam Exam Exam
to the waiting room until an examination space opens up. Waiting
Room
Exam Exam

After waiting for 2 hours, the patient is brought back to a larger examination space with curtain
Exam Exam Exam Exam
partitions. The ankle is checked by a physician who suspects a simple sprain but calls for an
X-Ray to make sure.
UP
2012-960
UP

The patient is taken to the X-Ray room to have her ankle imaged.

X-Ray X-Ray
The X-Ray reveals no fracture, and the patient is sent home after being told to keep weight off
of her ankle.

CASES 1. Sprained ankle or simple fracture

2. Simple cut that needs suturing
3. Pregnant patient with gynecological complaints
4. Kidney stones
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES 24

EMERGENCY DEPARTMENT FLOWCHART

Patient arrives by
Patient arrives as
ambulance or
walk-in
helicopter

Triage: the sorting of patients

according to the urgency of Trauma Exam Exam Exam
their need for care

Treat

WAITING IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT Triage Exam Exam

Scan Psych
Reception

6-yo female is brought in by her father, who tells the receptionist that his daughter has strep Exam Exam
throat. The daughter is quickly checked in triage and then told to have a seat in the waiting
Waiting
room. Room Scan
Exam Exam

Exam
Exam Exam Exam
After waiting for 4 hours, the patient is brought to a larger examination space, divided by Waiting
curtains. A physician checks the patient and determines that the sore throat is most likely Room
due to allergies. Exam Exam

Exam Exam Exam Exam

The patient is sent home and told to get rest.

UP
2012-960
UP

X-Ray X-Ray

CASES 1. Child with "strep throat" or ear infection

2. Anyone who just feels bad
3. Dental problems such as infection or broken tooth
4. Psych case threatening something
WAITING AS REMEDY 26

Trauma Exam Exam Exam

Treat Despite having a relatvely large amount of square footage devoted to a relatively small portion of
patients in the emergency department who are categorized as either immediate or urgent, these groups
Triage Exam Exam still experience longer wait times than the Center for Disease Control deems appropriate, putting them
Scan Psych
at great risk. Conversely, semiurgent and nonurgent patients are seemingly better-served than more-
emergent cases in the emergency department, experiencing average wait times that are less than their
Exam Exam appropraite wait times. Considering the lack of need for emergency facilities by such a significant
Waiting portion of the waiting population, it would seem that the waiting room could be expanded to facilitate
Room Scan
Exam Exam needs for primary care or general medical education (promoting self diagnosis). While inappropriate
cases seek a waiting space that would make them more aware or knowledgeable of their current
Exam medical condition, truly emergent cases desire a space that could imply care and assurance in the
Exam Exam Exam
Waiting absence of the emergent treatment they need.
Room
Exam Exam

Exam Exam Exam Exam

X-Ray X-Ray
WAITING AS REMEDY 28

MEAN EMERGENCY DEPARTMENT WAIT TIME FOR TREATMENT, Trauma Exam Scan
BY URGENCY OF PATIENT CARE:
United States, 2009 831 sq ft 11.7%
Exam Scan
IMMEDIATE 27.9 min 28.9 min

664 sq ft 9.4%
EMERGENT 37.2 min 51.2 min Exam Exam

URGENT 3.3 min 63.3 min Exam

Waiting
Exam Room
SEMIURGENT 58.7 min

NONURGENT 53.5 min 468 sq ft 6.6%

Waiting
Exam
Room
10 20 30 40 50 60 70 80
Exam Exam Exam
Mean Wait Time in Minutes 740 sq ft 10.4%
Exam Exam

Exam Exam Exam Exam

PERCENTAGES OF PATIENT ACUITIES: X-Ray X-Ray
United States, 2009 1398 sq ft 19.7%

809 sq ft 11.4%
Exam Exam
1 IMMEDIATE: Needing to be seen in less than 1 minute

Treat

41% 2 EMERGENT: Needing to be seen within 114 minutes

10%
(24.9%) Psych
(40.2%) Exam
2% 3 URGENT: Needing to be seen within 1560 minutes
294 sq ft 4.1%
(21.1%)
4%
4 SEMIURGENT: Needing to be seen within 12 hours

35% 1881 sq ft 26.5%

7% Total = 7088 sq ft
(43.1%) 5 NONURGENT: Needing to be seen between 2 and 24 hours Notes
(35.8%) 1. Hing, Esther, M.P.H.; Bhuiya, Farida, M.P.H.
Wait Time for Treatment in Hospital Emergency Departments: 2009
6 NO TRIAGE: No triage system was used NCHS Data Brief 102. 2010.
WAITING AS REMEDY 30

Scan Scan
Trauma Exam Trauma Exam

Scan Scan

Exam Exam

Exam Exam Exam Exam

Exam Waiting Exam Waiting

Room Room
Exam EMERGENT Exam EMERGENT
CARE CARE

Exam Exam

Exam Exam Exam Exam Exam Exam

Exam Exam Exam Exam

Exam Exam Exam Exam Exam Exam Exam Exam

Exam Exam Exam Exam

Treat
Waiting
Exam X-Ray
Exam Room X-Ray X-Ray
NON-EMERGENT WAITING NON-EMERGENT
Psych ROOM
CARE CARE
Treat Psych
WAITING AS REMEDY 32

IMMEDIATE EMERGENT URGENT SEMIURGENT NONURGENT

PSYCHOLOGICAL
DESIRE
BIOLOGICAL
NEED
THE CLINIC REVISITED 34

HERZOG & de MEURON: REHAB BASEL

Clinic Type: Center for Spinal Cord and Brain Injury
Location: Basel, Switzerland
Year: 2002

The rehabilitation center aims to create a distinct split between spaces where clinical, more technical
care is administered and those where sensorial treatment is provided. Shifts in materiality and form
distinguish between these two zones, allowing for patients to escape the clinical feel typical of
rehabilitation centers. Wood in the patient rooms is contrasted with zones of greenery interspersed in
plan and a concrete pyramid, celebrating the rehabilitation pool -- where freedom of movement is given
back to the patients.
SENSORIAL TREATMENT

CLINICAL TREATMENT
THE CLINIC REVISITED 36

OMA: MAGGIES CENTRE

Clinic Type: Cancer Care Center
Location: Glasgow, Scotland
Year: 2008

The cancer care center acknowledges the various needs and social desires of patients coping with
cancer by creating a series of continuous spaces ringed around a central garden. Each space is
kinked off access from the next to create distinct zones for the different desires of the patients while
preserving continuity. Furthermore, material (concrete and glass to wood) and formal changes
(rectilinear to curvilinear) create a distinct space of isolation that offers a phenomenological escape.
SPACES OF WAITING 38

THE RETAIL STORE

The act of waiting is manifested in various spatial layouts dependent on a particular retail stores target
audience and their respective desires. Ranging from the generic big box store to the apple store,
waiting can be seen as an opportunity to increase desire and consumption, or it is eliminated
altogether, viewed as a suppressant to desire. Big box retail creates a distinct zone for acquiring
particular items of desire separate from the zone of waiting, the checkout. Alternatively, IKEA combines
waiting with desire, forcing the customer to walk through all mock-up rooms before finally being able to
select their item of choice, constantly driving desire up through the act of waiting to leave. Apple
replaces zones of waiting with mobile employees, filling a single space with overlapping nodes of
desire, increasing consumer interest until they leave, never allowing for a drop in desire.

CONSTRUCTED FACTORS CONSUMER DESIRE

TIME SPENT SHOPPING

INTERCEPTION

SIGNAGE

PHYSICAL INTERACTION WITH PRODUCT

Notes
TIME SPENT WAITING 1. Underhill, Paco
Why We Buy: The Science of Shopping. 36-39, 58-59.
Simon & Schuster. New York: 1999.
SPACES OF WAITING 40

BIG BOX STORE:

Consumers enter the big box store with desire at its maximum level, already aware of the items they
will purchase. Signage distributes these items of desire in space, determing the path of the customer.
Initial consumer desire decreases incrementally as each item is acquired, while the aisles of the store
create constructed zones of desire for the consumer to pass through, creating a new list of desires.
The process ends in the checkout line, a distinct zone of waiting where desire drops.

4 3 4 3

5 5

6 6

2 2

8 8

1 1

7 7

DESIRES 1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

SIGNAGE TIME SPENT SHOPPING TIME SPENT WAITING

Initial Consumer Desire

Constructed Desire
Waiting
Service
SPACES OF WAITING 42

IKEA
Upon entering IKEA, customers are directed to the second floor, where they occupy rooms of desire.
Any individual items of desire are showcased with complementary items, creating variations on
complete rooms. Regardless of the customers need to view other rooms, he/she is required to
progress through all rooms, increasing desire through the act of waiting to leave and checkout.

PHYSICAL INTERACTION WITH PRODUCT TIME SPENT SHOPPING

TIME SPENT WAITING

Initial Consumer Desire

Constructed Desire
Waiting
Service
SPACES OF WAITING 44

APPLE STORE
Apples transparent facade forces desire on passersby, drawing them in regardless of their intention to
purchase. Products are distributed across an open space, creating overlapping nodes of desire.
Waiting is replaced by mobile employees, eliminating any space or period of downtime, allowing desire
to never fall.

SIGNAGE SIGNAGE PHYSICAL INTERACTION WITH PRODUCT INTERCEPTION

TIME SPENT SHOPPING Initial Consumer Desire

Constructed Desire
Waiting
Service
WAITING AS REMEDY REVISITED 46

4 3

IMMEDIATE
Biological Need: Emergent Care / Treatment
Psychological Desire: Reassurance in the waiting room

Ability to Wait: Low

EMERGENT

Biological Need: Urgent Care

Psychological Desire: Comfort / Reassurance in the waiting room
URGENT
Ability to Wait: Medium

SEMIURGENT
Biological Need: Primary Care
Psychological Desire: Medical Knowledge + Attention

Ability to Wait: High

NONURGENT
WAITING AS REMEDY REVISITED 48

NONURGENT

SEMIURGENT

URGENT

EMERGENT

DECREASING URGENCY
IMMEDIATE

Biological Need
Psychological Desire
Waiting
WAITING AS REMEDY REVISITED 50

NONURGENT

SEMIURGENT

URGENT

EMERGENT

DECREASING URGENCY
IMMEDIATE

Biological Need
Psychological Desire
Waiting
WAITING AS REMEDY REVISITED 52

WAITING AS PURE DESIRE / DISTRACTION

The emergency department is reimagined as a stratified system that progresses from the highest level
of biological need for immediate and emerg``ent patients to the lowest level of biological need and the
highest level of psychological desire for nonurgent and semiurgent patients. At each level, the act of
waiting is altered to accomodate the desires of the levels corresponding patients. At one level, desire
GALLERY OF MEDICAL KNOWLEDGE + SELF DIAGNOSIS
is manifested in various waiting rooms, providing comfort or reassurance to a range of patients through
differences in materiality or form. At the next level, desire is dispersed into a field of nodes to create a
gallery of medical knowledge and assisted self diagnosis, to assuage the psychological uncertainty of
inappropriate patients who come to the emergency department. At the highest level, waiting is trans-
formed into pure desire or distraction, in an attempt to completely remove a patient from the medical
setting as they wait to be seen by a health professional.

IKEA OF WAITING ROOMS + URGENT + PRIMARY CARE

WAITING ROOM + EMERGENCY CARE

Biological Need
Psychological Desire
Waiting
SITE 54

ST. LUKES HOSPITAL

1. 76 Minutes
2. 6% of Patients Left

MOUNT SINAI HOSPITAL

1. 46 Minutes
2. 3% of Patients Left
THE URBAN HOSPITAL
METROPOLITAN
HOSPITAL CENTER The urban hospital provides the possibility for waiting to take place outside of the waiting room if a
1. 44 Minutes patient is in the condition to leave and return at a later time. In Manhattan, individual hospitals can be
LENOX HILL HOSPITAL 2. 5% of Patients Left identified for an intervention based on their average wait times. Hospitals in urban conditions, typically
1. 56 Minutes take the form of towers that occupy an entire block, with a significant portion of the ground floor
2. 0% of Patients Left devoted to the emergency department. A reimagining of an urban emergency department would
require a sectional reorganization of space, in which the ground floor would still be devoted to emer-
NEW YORK
gent cases, while other hospital functions would be shifted upwards to create space for nonemergent,
PRESBYTERIAN HOSPITAL
inappropriate cases.
1. 93 Minutes
BETH ISRAEL
2. 6% of Patients Left
MEDICAL CENTER
1. 76 Minutes
2. 6% of Patients Left
NYU HOSPITALS CENTER
1. 46 Minutes
2. 1% of Patients Left

NEW YORK DOWNTOWN HOSPITAL

1. 32 Minutes
2. 1% of Patients Left

Notes
1. Average time patients spent in the emergency department
before they were seen by a healthcare professional 1. Medicare.gov
Hospital Compare Data: Timely Emergency Department Care
2. Percentage of patients who left the emergency department
2013.
before being seen
SITE 56

ASHEVILLE, NC

THE SUBURBAN HOSPITAL

As suburban hospitals typically develop piecemeal through the addition of appendages, they would
likely be the suitable testing ground for a new type of emergency department. Furthermore, the avail-
ability of neighboring land to the campus allows for the consideration for a reorganization in plan as
well as in section. The suburban hospital typically lacks neighboring attractions, requiring all waiting to
take place within the hospital itself, however, this could motivate the design to more critically engage
the act of waiting within a hospital.

MISSION HEALTH SYSTEM

SITE 58

ST. JOSEPH CAMPUS

CANCER CENTER

MEMORIAL CAMPUS
 60

DEPARTMENT
EMERGENCY
EXISTING

TUBE
G265.03
PLTTS
SHAFT
G265.02
ROOM
PACS
#13
RAD
CT #1
#6
E RM
RESOURC
#5
RAD
#16
RAD
#2 CT #2
RAD
#15
RAD
#1
RAD
CT #3
#3
RAD
#2
NTIONAL
OR.#1 INTERVE
OR.#2
#3 #2 #1
SOUND SOUND NTIONAL
OR.#3 INTERVE
#4
NTIONAL
INTERVE
UP
VE
R EA
MO
LT
BI
ST
LL
WE
DO
Mc
PROPOSED
SITE
SITE
DOCUMENTATION
BIBLIOGRAPHY
Canadian Institute for Health Information. Understanding Emergency Department Wait Times: Who is
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Congressional Budget Office. Updated Estimates for the Insurance Coverage Provisions of the
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Garcia, Tamyra Carroll, Amy B Bernstein, and Mary Ann Bush. Emergency Department Visitors and
Visits: Who Used the Emergency Room in 2007? NCHS Data Brief 38. (2010).
Gindi, Renee M, Robin A Cohen, and Whitney K. Kirzinger. Emergency Room Use Among Adults Aged
1864: Early Release of Estimates From the National Health Interview Survey, January June
2011. Center for Disease Control. (2012).
Hing, Esther and Farida Bhuiya. Wait Time for Treatment in Hospital Emergency Departments: 2009.
NCHS Data Brief 102. (2010).
Medicare. Hospital Compare Data: Timely Emergency Department Care.
http://www.medicare.gov/hospitalcompare/results.aspx#loc=NEW%20YORK%20CITY%2C%
20NY&lat=40.7143528&lng=-74.0059731. 2013.
Niska, Richard, Farida Bhuiya, and Jianmin Xu. National Hospital Ambulatory Medical Care Survey:
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Pitts, Stephen R et al. Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's
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62
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