ED Design Book First Look PDF

Emergency
Department Design
A Practical Guide to Planning for the Future
SECOND EDITION
WRITTEN BY
JON HUDDY, AIA
EDITED BY
Tracy G. Sanson, MD, FACEP
PART TWO
Twenty-seven case studies written by architecture
and design professionals and emergency physicians
EDITED BY
James Lennon, AIA
Michael Pietrzak, MD
David Vincent, AIA, ACHA, LEED AP
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FIRST PRINTING APRIL 2016
ISBN 978-0-9889973-5-6
Publisher’s Notice
The American College of Emergency Physicians (ACEP) makes every effort to ensure that
contributors to its publications are knowledgeable subject matter experts. Readers are
nevertheless advised that the statements and opinions expressed in this publication are provided
as the contributors’ recommendations at the time of publication and should not be construed
as official College policy. ACEP recognizes the complexity of emergency medicine and makes
no representation that this publication serves as an authoritative resource for the prevention,
diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for
the definition of or standard of care that should be practiced by all health care providers at any
particular time or place. Drugs are generally referred to by generic names. In some instances,
brand names might be added for easier recognition.
To the fullest extent permitted by law, and without limitation, ACEP expressly disclaims all liability
for errors or omissions contained within this publication, and for damages of any kind or nature,
arising out of use, reference to, reliance on, or performance of such information.
Copyright 2016, American College of Emergency Physicians, Dallas, Texas. All rights reserved.
Except as permitted under the US Copyright Act of 1976, no part of this publication may be
reproduced, stored, or transmitted in any form or by any means, electronic or mechanical,
including storage and retrieval systems, without permission in writing from the publisher. Printed
in the USA.
ACEP BOOKSTORE
PO Box 619911, Dallas, TX 75261-9911
800-798-1822, 972-550-0911
bookstore.acep.org acep.org/eddesign
AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

Jessica Hamilton, Assistant Editor
Marta Foster, Senior Editor
Robert Heard, MBA, CAE, Associate Executive Director
COVER DESIGN James Normark, Irving, Texas

INTERIOR DESIGN AND PRODUCTION Susan McReynolds, Carrollton, Texas
PROOFREADING Wendell Anderson, NorthStar Writing & Editing, Eugene, Oregon
INDEXING Sharon Hughes, Hughes Analytics, Goreville, Illinois
PRINTING Modern Litho, Jefferson City, Missouri
ii
Table of Contents
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
In Appreciation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Chapter 1 An Architect’s Retrospective . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 2 Preparing to Lead and Internal Team-Building . . . . . . . . . . . 19
Chapter 3 Project Delivery Options and Selecting Your Consultants,

Designers, and Builders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Chapter 4 Project Justification and Needs Assessment . . . . . . . . . . . . . 61
Chapter 5 Scope Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Chapter 6 The Design Puzzle: Pieces and Parts . . . . . . . . . . . . . . . . . . 133
Chapter 7 Design Components, Configurations, and

Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Chapter 8 Insights for Specialty Emergency Departments . . . . . . . . . . 237
Chapter 9 Wrap-Up – Imagine an Emergency Care Environment

in the Distant Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
PART TWO Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Case Study 1 Anne Arundel Medical Center, Emergency Department . . . 289
Case Study 2 Bayhealth Medical Center, Kent General Pavilion
Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Case Study 3 CGH Medical Center, Emergency Department . . . . . . . . . . 299
Case Study 4 Charleston Area Medical Center, Memorial Hospital
Case Study 5 Concord Hospital, Emergency Department. . . . . . . . . . . . . 309
Case Study 6 CoxHealth South, Emergency Department . . . . . . . . . . . . . 315
Case Study 7 Le Bonheur Children’s Hospital, Emergency Department . . . 321
Case Study 8 Lenox Health Greenwich Village, Freestanding
Case Study 9 Massachusetts General Hospital,
Case Study 10 Massachusetts General Hospital, Lunder Building
iii
Case Study 11 MedStar Washington Hospital Center, Project ER One . . . . 343
Case Study 12 Memorial Hermann Northwest Hospital,
Case Study 13 Methodist Dallas Medical Center,
Case Study 14 Methodist University Hospital, Emergency Department . . . 355
Case Study 15 OhioHealth Westerville, Freestanding
Case Study 16 Penn State Hershey Medical Center,
Case Study 17 Saint Francis Hospital, Trauma Emergency Center . . . . . . . 371
Case Study 18 Southwest General Health Center,
Case Study 19 Stafford Hospital, Mary Washington Healthcare,
Case Study 20 Tampa General Hospital, Emergency and
Trauma Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Case Study 21 United Hospital, Peter J. King Emergency Care Center . . . 391
Case Study 22 University Hospital of Bern, Intensive Care,
Emergency Center, Operational Center . . . . . . . . . . . . . . . 395
Case Study 23 University of Colorado, Emergency Department . . . . . . . . . 397
Case Study 24 University of Colorado Health, Greeley Emergency
and Surgery Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Case Study 25 University of Michigan Hospital and Health Centers,
Emergency Critical Care Center. . . . . . . . . . . . . . . . . . . . . . 405
Case Study 26 University of Pittsburgh Medical Center,
Mercy Hospital Emergency Department . . . . . . . . . . . . . . . 411
Case Study 27 University of Texas MD Anderson Cancer Center,
Emergency Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
iv Emergency Department Design

About the Author
Jon Huddy, AIA, as of the publishing of this book, has participated in the analysis,
planning, and design of more than 325 emergency departments … and counting. His
emergency department design experience includes projects across the United States,
Canada, South America, and Europe. While an architect by training, his emergency
department design experience includes a deep understanding of strategic planning,
technology integration and how the physical environment can be shaped to support
lean operations; allow for efficient staffing and provider coverage; keep the staff and
patients safe; and help deliver successful outcomes that result in elevated patient and
staff satisfaction scores. His designs have accommodated emergency departments
as small as 6,000 annual visits in rural areas and complex medical center emergency
departments as large as 200,000 visits. One of his greatest attributes is the ability to
bring alternative operational and physical design solutions to his clients by drawing on
his international emergency department design experience.
As president of Huddy HealthCare Solutions, LLC, a firm focused on the specialty of emergency
department consulting and design, he personally leads each emergency department engagement,
whether it be for emergency department strategic planning, operational assessment, master
planning, and/or architectural design services. Mr. Huddy has been designing health care facilities
since earning a Master of Architecture degree from the Clemson University Architecture for
Health Studio in the mid-1980s. He also completed the American Institute of Architects/American
Hospital Association Graduate Fellowship in Health Facility Design. Since the early 1990s, Mr.
Huddy has focused on the specialty of emergency department consulting and design and has
teamed with hundreds of hospitals, physician groups, architects, and builders to deliver successful
emergency department design solutions.
Mr. Huddy is a member of the American Institute of Architects and is licensed by the National
Council of Architectural Registration Boards. He has written several articles and delivered
numerous international presentations and educational sessions on a wide range of topics,
including “ED Vision 2030,” “Designing More (ED) with Less (Capital),” and “Designing Safe and
Secure Emergency Departments.” Many of the items and issues from these presentations are
presented in this book. His audiences have included the:
• American College of Emergency Physicians (ACEP, US)

• American Organization of Nurse Executives (AONE, US)
• American Society for Healthcare Engineering (ASHE, US)
• Center for Health Design (CHD, US)
• Emergency Nurses Association (ENA, US)
• European Society of Emergency Nurses (EuSEN)
• Health Estates & Facilities Management Association (HefmA, UK)
• Institute of Healthcare Engineering and Estate Management (IHEEM, UK)
• National Ergonomics Conference (US)
• Scottish Health Conference (UK)
• Health and Care Infrastructure Research and Innovation Centre (HaCIRIC, UK)
• International Emergency Department Leadership Institute (IEDLI)
“Huddy,” as he has been known since grade school, brings a passion for emergency department
design, a commitment to including caregivers throughout the design process, and a humorous,
energetic presentation style that has allowed him to develop close and lasting relationships with
emergency department caregivers around the world. His unique insights, depth of experience,
and impressive track record of successful emergency department design projects are the building
blocks from which he has written this text.
Huddy is very interested in hearing about your unique design solutions to the challenges you
face in creating your emergency department of the future. He can be reached at 803-517-7522
or j.huddy@huddyhealthcare.com.
v
In Appreciation
I would like to express my sincere appreciation to the following people for their support,
encouragement, and guidance during the development of this book:
To the American College of Emergency Physicians for inviting me to write the second
edition of this book.
To ACEP’s senior editor, Marta Foster, for actually signing up to work with me again!
She has taken the “wandering text” of this architect and fine-tuned it into an easy-to-
read, easy-to-use reference tool.
Special thanks to my friends Jessica Baker, Jim Jepson, Kathy Clarke, David White,
Freda Lyon, Mary Jagim, Susan Sheehy, Rich Simone, and Liz Jones for their unique
insights that I have incorporated into this book.
Special thanks to my international friends who have consistently given me insights to

health care around the world: the Canadian health care system: Joanne McFadden
and Jerald Peters; insights to the UK’s National Health Service: Liz Smith and Duncan
Sissons; support during travel across UK and Europe: Melanie Grahame and Nicolle
Czternastek; and a tour of the UK pubs: Bob Taylor.
To my father, Al, and to the memory of my mother, Barbara, for their eternal love and
support.
And finally, to my wife, Suzanne, and to my children: Tyler, Austin, and Marissa, for their
love and support (and cutting sarcasm that seems to be a large part of Huddy heredity).
— Jon Huddy
vii
About the Editor
Tracy G. Sanson, MD, FACEP, is an emergency physician with more than 20 years of
experience in emergency medicine education, emergency department management,
and leadership. She was the director of the Division of Global Emergency Medical
Sciences (GEMS) at the University of South Florida and is Co-Chief Editor of GEMS
Journal of Emergencies, Trauma, and Shock.
Dr. Sanson has served in several and varied leadership positions with the Society for
Academic Emergency Medicine (SAEM), the Council of Residency Directors (CORD),
and the American College of Emergency Physicians (ACEP). She chairs the College’s
Educational Meetings Subcommittee and is a member of the ACEP Speaker’s Bureau
and the 911 network. She has been a member of the ACEP faculty for many years,
including the ACEP Teaching Fellowship and the Emergency Department Directors
Academy. Dr. Sanson received the National Emergency Medicine Faculty Teaching
Award in 2006.
Tracy has held director positions with the US Air Force, the University of South Florida, and
TeamHealth for the past 20 years. She completed her medical degree and residency training at
the University of Illinois at Chicago. She has served on TeamHealth’s Medical Advisory Board,
Patient Safety Office Division, and as faculty in their leadership courses. Dr. Sanson heads her
own consulting firm, specializing in emergency department team and satisfaction assessments,
leadership training, personal development/coaching, and branding. She has consulted and
lectured nationally and internationally on administrative and management issues, leadership,
professionalism, communication, patient safety, brand development, personal development,
women’s issues, and emergency medical clinical topics for a wide range of health care
organizations.
ix
Contributors
The author gratefully acknowledges the contributors to this new edition.
Brian Aldred, MD
Jessica Baker
Kathy Clarke, RN, BSN, CEN
Marysol Imler, RN
Jim Jepson, AIA
Liz Jones, AIA
Abel Longoria
Ted Mallin, AIA
Joanne McFadden, BID, PIDIM, IDA, IDC, LEED AP
Carlos Moreno, AIA
Jerald Peters, Architect, AAA, AIBC, MAA, SAA, OAA, FRAIC, LEED AP
Rich Simone
Susan Sheehy, PhD, RN, FAEN, FAAN
Duncan Sissons, BSc, MRICS, Dip Proj Man, MAPM, MIOD
Liz Smith, RGN
Ahmad Wazzan, MD
David White, MBA
Jim Zaza
The American College of Emergency Physicians gratefully acknowledges the

architectural firms and hospitals that contributed to the case studies section.
James Lennon, AIA Charleston Area Medical Center, Memorial

Michael Pietrzak, MD Hospital Emergency Department
David Vincent, AIA, ACHA, LEED AP Charleston, West Virginia
HKS Inc. BSA LifeStructures
Editors Indianapolis, Indiana
Don Altemeyer, AIA, ACHA
Anne Arundel Medical Center, Emergency Jeff Cowsert, NCARB
Department
Annapolis, Maryland Concord Hospital, Emergency Department
The MS2 Group Concord, New Hampshire
Providence, Rhode Island Shepley Bulfinch
Emilio S. Belaval, MD, FAAEM, President Boston, Massachusetts
Joseph Twanmoh, MD, MBA, FACEP, David Meek, Associate AIA, LEED AP
Vice President
CoxHealth South, Emergency Department
Bayhealth Medical Center, Kent General Springfield, Missouri
Pavilion Emergency Department The Beck Group
Dover, Delaware Dallas, Texas
EwingCole Sean Wilson, Director of Healthcare Design
Philadelphia, Pennsylvania
Mary Frazier, AIA, LEED AP, Principal Le Bonheur Children’s Hospital,
Emergency Department
CGH Medical Center, Emergency Department Memphis, Tennessee
Sterling, Illinois FKP Architects, Inc.
CannonDesign Dallas, Texas
Chicago, Illinois Gary S. Owens, FAIA, ACHA, LEED AP
Manuel Hernandez, MD, MBA, FACEP,
Principal, CannonDesign
Cynthia Zander, Chief Operating Officer,
CGH Medical Center
xi
Lenox Health Greenwich Village, Methodist University Hospital, Emergency
Freestanding Emergency Department Department
New York, New York Memphis, Tennessee
Perkins Eastman Frank Zilm & Associates, Inc.
New York, New York Kansas City, Missouri
Jeffrey Brand, AIA, Principal, Executive Frank Zilm, DArch, FAIA, FACHA, President
Director, and National Healthcare Practice Jon R. Summers, Principal, brg3s
Area Leader
OhioHealth Westerville, Freestanding
Massachusetts General Hospital, Emergency Department
Emergency Department Westerville, Ohio
Boston, Massachusetts DesignGroup
NBBJ Columbus, Ohio
Boston, Massachusetts Elliot Bonnie, Principal, Healthcare Designer
Benjamin A. White, MD, Director of Clinical
Operations Penn State Hershey Medical Center,
Michael Noll Emergency Department
Hershey, Pennsylvania
Massachusetts General Hospital, Lunder EwingCole
Building Emergency Department Philadelphia, Pennsylvania
Boston, Massachusetts Thaddeus J. Przybylowski, Jr., RA, LEED AP,
NBBJ Principal
New York, New York
Joan Saba, Global Healthcare Practice Leader/ Saint Francis Hospital, Trauma Emergency
Partner Center
Tulsa, Oklahoma
MedStar Washington Hospital Center, Page
Project ER One Dallas, Texas
Washington, DC James Augustine, MD, FACEP, Director of
HKS Inc. Clinical Operations, Emergency Medicine
Dallas, Texas Physicians
Michael P. Pietrzak, MD, Healthcare Strategic Joshua Theodore, ACHE, EDAC, Principal
Initiatives, HKS Inc., and Project ER One Health Industries Design, Page
Managing Director
James Lennon, AIA, HKS Inc. Southwest General Health Center,
David Vincent, AIA, ACHA, LEED AP, Principal Emergency Department
and Senior Vice President, HKS Inc. Middleburg Heights, Ohio
Mark Smith, MD, Chief Innovation Officer, CannonDesign
MedStar Health Chicago, Illinois
Scott Thomas, Senior Vice President,
Memorial Hermann Northwest Hospital, CannonDesign
Emergency Department Terri Rini Barber, Vice President of Support
Houston, Texas Services and Chief Information Officer,
PhiloWilke Partnership Southwest General Health Center
Houston, Texas
Jennifer Young, AIA, Associate Partner Stafford Hospital, Mary Washington Healthcare,
Methodist Dallas Medical Center, Emergency Stafford, Virginia
Department X32 Healthcare
Dallas, Texas Fredericksburg, Virginia
Perkins+Will Jody Crane, MD, MBA, Principal
Dallas, Texas Kelly McDonough, DPN, RN,
David Collins, AIA, LEED AP, Regional Administrative Director, Nursing Practice
Healthcare Practice Leader/Design Principal and Nursing Operations
Cary Garner, AIA, LEED AP, Managing Principal
xii
Tampa General Hospital, Emergency University of Pittsburgh Medical Center,
and Trauma Center Mercy Hospital Emergency Department
Tampa, Florida Pittsburgh, Pennsylvania
Gresham, Smith and Partners GBBN Architects, Inc.
Nashville, Tennessee Cincinnati, Ohio
Robert A. Berry, AIA, NCARB, EDAC Todd Dunaway, AIA, EDAC, Principal
United Hospital, Peter J. King Emergency University of Texas MD Anderson Cancer

Care Center Center, Emergency Center
Saint Paul, Minnesota Houston, Texas
Michaud Cooley Erickson PhiloWilke Partnership
Minneapolis, Minnesota Houston, Texas
Jeff Clark, LEED AP, Principal Cathryn Horan, Partner
University Hospital of Bern, Intensive Care,

Emergency Center, Operational Center
Bern, Switzerland
Itten+Brechbühl Inc., and Lead Consultants
Inc.
Bern, Switzerland
Hugo Erni, Lead Consultants Inc.
Jost Kutter, Itten+Brechbühl Inc.
University of Colorado,
Aurora, Colorado
HDR, Inc.
Omaha, Nebraska
Jennifer L. Wiler, MD, MBA, FACEP
J. Stephen Bohan, MS, MD, FACEP
Richard Zane, MD
University of Colorado Health,

Greeley Emergency and Surgery Center
Greeley, Colorado
H+L Architecture
Denver, Colorado
Steve Carr, Principal-In-Charge
Barrett Koczkur, Project Architect
Cherie Dice, Interior Design
University of Michigan Hospital and Health

Centers, Emergency Critical Care Center
Ann Arbor, Michigan
Niagara Murano
Birmingham, Michigan
Benjamin Bassin, MD, FACEP
Jennifer Gegenheimer-Holmes, RN, BSN,
MHSA
Cemal Sozener, MD, MEng, FACEP
xiii
Foreword
“It is difficult
to get the news from poems
yet men die miserably every day
for lack of what is found there.”
Physician and poet William Carlos Williams held deeply to the belief that poetry was not an
enigmatic endeavor reserved for mystics and shamans, but that it could impart a true and
corporeal impact on those exposed to it. In both good design and good caregiving there is
poetry, there is empathy, there is a desire to best aid those who find themselves at our door.
In few places is the importance of careful and conscientious design so evident as the
unpredictable environment of an emergency department; a place in which meetings are dire
and contingency is one of the few constants, a place where every possibility is one that must
be prepared for. This is a space where the unexpected lives, a doorway, a place where quick
responses will dictate how we are to emerge. In a space where infinite possibility and uncertainty
reign, careful architecture is of the utmost importance — because where there lives the possibility
of chaos, so too lives the sister possibility of comfort. It is our job to do everything we can to tip
the scale in comfort’s favor. That is the aim of this book.
The history of the emergency medicine winds back past Clara Barton and Napoleon’s early
ambulance service, even further back toward the Knights Hospitaller, bringing relief to injured
pilgrims during the Crusades. We find ourselves here, thousands of years later, with the future of
our practice winding in new directions still.
Even in the brief years since this book’s last publication, the needs of emergency departments
have changed rapidly. As an example, the danger to health care providers in professional settings
escalates as violence moves off the streets and into the medical setting. Optimal patient care is
achieved only when patients, visitors, and health care workers are protected against violent acts
occurring within the health care setting. A safe working environment is conducive to improved staff
morale and enhanced productivity and has been addressed in this edition. Managing the changing
expectations of emergency care can be one of the most stressful and challenging tasks we face.
Working with these rapidly evolving expectations of the care we provide will require flexibility,
durability, and an attitude of optimism. This requires adaptable environments. This publication
presents the tools to appropriately and, at times, innovatively respond to the needs of both the
patient and staff. Case in point, this edition resisted the trend toward increasing patient evaluation
space at the expense of staff needs, instead recommending adequate break rooms and staff restr
ooms and even addressing the concerns for breastfeeding employees requiring a private space
in which to pump. This edition works to positively and creatively channel your time and energy
commitment in developing a “Great place to heal and Great place to work” department.
At the heart of this book is a question: what would an emergency department designed with
efficiency, effectiveness, and care at the heart of it look like? This book is intended to fasten
together the worlds of all those involved in the design process, allowing each to navigate the
other. In designing effective emergency departments, we are called to be both physician and
architect, both scientist and poet. To achieve this, we must ask the right questions. This book is an
excellent place to begin.
There is power in excellent caregiving as there is power in excellent design. When the two meet,
that’s where poetry and comfort will live.
—Tracy G. Sanson, MD, FACEP
xv
CHAPTER
An Architect’s Retrospective
An Emergency Department Architect

Looks Back: What a Long Journey!
W
ow, what a wild ride it’s been since I wrote and ACEP published the last
emergency department design book more than 14 years ago. At the time
of the last edition (referred herein as the 2002 edition), I had to date been
involved in approximately 60 emergency department design projects. Now, as I re-
flect back on how emergency department design has changed since the turn of the
century, I have the opportunity to draw from experiences of being involved in more
than 325 emergency department design projects. This experience includes emer-
gency departments of all sizes, shapes, and configurations and has taken me from
Alaska to Hawaii to Florida in the United States, across Canada, down to Colombia,
South America, and over to the Netherlands, Scotland, and England. While every
location has unique emergency department design goals, it’s amazing how much
the challenges of each emergency department project are similar: having to shape
operations and an environment to treat rising patient volumes and escalating acu-
ities with less capital to spend on new facilities. Everyone in the world is focused on
developing high-performance facilities in less space with smaller project budgets.
The variables shaping future emergency department designs are multiplying

exponentially as the complexities of health care continue to evolve. The design
responses for each client’s set of unique operational goals include innovative
responses for flexibility, efficiency, surge capacity, safety, technology integration,
patient satisfaction, and staff satisfaction. And all of these variables need to be met
within dwindling project budgets due to a tight worldwide economy and unknown
future with regard to (in the United States) health care reform. Back at the turn of
the century, the chief concern for most emergency department clients was, “How
do we get away from curtained cubicles to all private rooms?” A few years later, the
emphasis on lean operations added the focus of, “How do we make everything and
everyone as efficient as possible?”
1
At the publishing of this book, early evidence suggests similar results as to what was
recently found in The Wall Street Journal, that “American emergency departments have
become busier since the Affordable Care Act expanded insurance coverage … despite the
law’s goal of reducing unnecessary care in ‘ER.’”1 In Louisville, Kentucky, The Courier-
Journal reported that, nationally, nearly half of emergency physicians responding to a
recent poll by the American College of Emergency Physicians said they’ve seen more visits
since January 1, 2014, and nearly nine in 10 expect the number of visits to rise in the next
3 years.2
So, in the United States, with rising acuities, continued integration of technology, and
growing competition (from competitor hospitals, freestanding emergency departments,
urgent care centers, and commercial store-based convenience care clinics), the future of
emergency care is headed for unforeseen horizons. Similar struggles are being felt with
rising volumes in Canada and nearly all areas of Europe. And the design considerations to
apply to your physical emergency department design to balance against the uncertain future
are nearly overwhelming. However, I worked hard to develop this book in a way that will
help you to define the key variables unique to your facility and services and to set the key
architectural design drivers that will deliver success, no matter what country or region
you’re serving. This book will also present multiple options for design responses based on
lean operational patient flow, rising acuities, volume surges, safety concerns, upgrading the
patient experience, and the ability to treat the right patient in the right place by the right
person.
The 2002 edition of this book was beneficial for the many physician leaders, nursing
leaders, health care organizational leaders, and design professionals as they ventured into
the process of redesigning, expanding, or relocating an emergency department for the
first time. However, times have changed, and I know that developing a new edition for
this book meant reviewing the information in the last edition, identifying what may still
be applicable in the future, jettisoning the now-irrelevant information, and developing
a new set of strategic emergency department design drivers based on the complexities
of today’s health care environment, including an eye to the future. I believe this edition
will be a valuable asset to any emergency physician, nursing director, facilities director,
administrator, architect, or contractor who is facing the specter of shaping an emergency
department that will need to function for the next 15 to 20 years.
Whom This Book Can Help

This book is intended to help two types of professionals facing emergency department
design projects:
x The first-timer. You’re facing an emergency department project for the first time,
and you need to understand the basics of initial planning methods, architectural
design processes, various design concepts, alternative construction delivery
methods, and the basic building blocks for sizing and shaping a successful
emergency department design.
x The grizzled veteran. You’re headed into another emergency department design
project, and you might have read the last book, and now you want to explore new,
updated design delivery methods, design concepts, and features to support future
lean operations.
Please note that, throughout this book, I use the terms new or future, as in “your
new emergency department” or “your future emergency department.” These references
are for any emergency department project—whether it be a completely new emergency
2 Emergency Department Design

department, large (or small) renovation, or expansion of your current department. The
terms new and future referred to within this text apply to any project you might be
considering, no matter what size, scale, or cost.
Also, when I refer to the design team, I mean all participants: physicians, nurses, staff,
your facilities department, ancillary department representatives, your architect, and maybe
even your contractor (builder). Please don’t relate the term design team only to the outside
professional architectural and engineering designers with whom you are working. You’ll
see throughout this book that design team means everyone involved in the process … you
included! And while architects, design students, contractors, and others from the design
world might be reading this book, keep in mind that I wrote it primarily for clinical leaders.
New Points of Emphasis

The emphasis on lean operations (an approach that sprang from the process
reengineering ideas at the end of last century) and the innovative approaches to
streamlining patient care and movement continue to shape emergency department
designs across the country and around the world. The focus
on operational redesign as part of emergency department Keeping Vertical Patients
architectural design is part of this edition and is highly Vertical
recommended for any design project you initiate.
The application of wireless technologies, portable charting What does this mean, exactly? To
tablets, and expanded emergency department information systems me, it means identifying patients
have all had impacts on emergency department design and will who don’t need to be positioned
continue to affect new emergency department designs as more and horizontally on a stretcher for
more technology integration is achieved to assist the clinical staff care and, instead, can be treated
in treating patients while addressing the ever-increasing emergency in a vertical position—in a chair
department volumes and acuities. Safety and security are more or recliner. Jody Crane, MD,
heavily stressed in this edition due to the continuing rise of safety MBA, coauthor of The Definitive
concerns and events that occur in emergency departments across Guide to Emergency Department
the globe in both urban and rural settings. Operational Improvement, says
The impact of special patient populations, such as the (and I’m paraphrasing) that the term
ever-expanding health care needs of behavioral health, geriat- vertical patient refers to someone
ric, pediatric, and bariatric patients, is also affecting emergency who walks into the emergency
department designs as people compare the concepts of specialty department and will likely walk
spaces with that of multifunctional, universal patient care areas.
out of the department, that is, be
Although the emphasis on universal rooms is still a driving recom-
discharged. This is a patient who
mendation for most emergency departments, the goal of meeting
doesn’t need a bed for treatment
the needs of special patient populations remains an issue and
or monitoring and could have his or
challenge with regard to defining a flexible design solution.
her workup done as an outpatient
While there has always been an emphasis on “patient-cen-
with a primary care physician or in
tered” design, there is a new focus on staff satisfaction, including
some other medical setting but,
the importance of staff retention. Simple design considerations
for whatever reason, either doesn’t
such as accessible break rooms, locker rooms for the staff’s per-
sonal items, and lactation rooms are taking on greater importance. have access or chose to come to the
Job satisfaction is also being supported with safe, clean, and ap- emergency department.
propriately sized charting and dictation spaces, some of which are
glassed-in to provide auditory privacy for private discussions or visual privacy for comput-
er or PACS screens.
The number of staff and clinicians working in emergency departments has grown over
An Architect’s Retrospective 3
the past few decades. Physicians, nurses, and technicians are being joined by advanced
practice providers, patient navigators, social workers, crisis management personnel, patient
advocates, discharge techs, and increasing numbers of students and residents.
There’s a new emphasis on the use of observation units with the pressures associated
with readmission policies. There’s also more attention being paid to the design of infectious
disease areas: they have to support policies and procedures for treating patients and
keeping staff and clinicians safe, and they have to accommodate the donning and doffing of
personal protective equipment (PPE) with enough space for a trained observer.
There are numerous other clinical, operational, technological, and regulation-based
issues and components that are affecting emergency departments that are either new since
the turn of the century or were in their infancy at the time of the 2002 edition. This new
edition attempts to include alternatives for design that incorporate the numerous issues
affecting efficiency, effectiveness, and sound clinical practice.
Also, the freestanding emergency department was in its infancy at the turn of the
century. We now have nearly 20 years of history to evaluate older freestanding emergency
departments and new information for future freestanding emergency departments that are
currently on the drafting boards.
There are many new design and construction delivery methods as well that might be a
part of your project delivery process. They will affect the way you interact with your design
and construction team(s). Issues like lean design/construction methods, design-build firms,
and integrated project delivery (IPD) will shape the way your project is
Special thanks to Kathy delivered and are defined in more detail in Chapter 3, Project Delivery
Clarke, RN, BSN, CEN, for her Options and Selecting Your Consultants, Designers, and Builders. You
unique clinical insights and don’t have to be an expert on these design and/or construction delivery
information contained herein. methods, but I do believe it’s important to clarify how the different
processes might affect you as an in-house design team clinical leader.
So, what’s new since the last edition?

x Lean process redesign
x Greater scrutiny on clinician coverage (cost and availability)
x Increases in the number of advanced practice providers in emergency departments
x CMS reporting requirements for lengths of stay and “door-to” measures
x More widely integrated emergency department information systems: CPOE,
wireless technology, biometric identification, computerized documentation
x At-home emergency department patient check-in software or apps
x Registration kiosks
x Greater scrutiny and management of frequent utilizers and “superutilizers”
x Combined triage and nonurgent/fast-track modules
x Strategies to “keep vertical patients vertical”
x Volume impacts from closure of emergency departments
x Five-level Emergency Severity Index (ESI) as the standard; the Canadian Triage and
Acuity Scale (CTAS); and England’s Manchester Triage System
x Competition from freestanding emergency departments
x Use of patient navigators
x Geriatric emergency departments
x Bariatric design regulations
x Prescription dispensing kiosks

x Universal use of WOWs (workstations on wheels)
x Highway billboards displaying wait times
x Ancillary standards such as CLIA
x Influence of TJC with national patient safety goals
x Focus and management based on real-time dashboards for length of stay, room
utilization, and so on
x Increased security concerns
x Increased focus on infection control and Ebola-type patient processes
x Pressure of national best practice standards and benchmarks
x Emphasis on “door to study” (ECG, CT) and “time to intervention” (cardiac
catheterization, interventional radiology, revascularization)
x Bedside ultrasonography (portable)
x Noninvasive positive-pressure ventilation (NIPPV) machines
x Conscious sedation procedures in the emergency department
x Thrombolytic therapy for strokes and MIs
x Focus on medication reconciliation
x Capacity plans to include surge volumes
x More implementation of no-diversion policies
x Communication devices with point-to-point (person-to-person) services
x And the things that never seem to change: rising volumes, rising acuities, increase
in behavioral health issues, tight staffing budgets, and more
Have we seen these trends before?

While “today in the emergency department” feels very different than it did 10 years
ago, I’m shocked at how similar the data being collected at the turn of the century are to
the data being collected today: increasing emergency department use rates, an aging popu-
lation, and in turn, increasing quantity of emergency department visits
in nearly every region of the country. While we know that the new em- Special thanks to David White,
phasis is educating the public and treating the right patient in the right MBA, for assistance, unique
place, whether that is in a primary care, urgent care, emergency care insights, and information
facility, or other location, the current utilization trends (increasing!) are contained in this section.
very similar to emergency department utilization trends that we were all
experiencing 10+ years ago.
In 2002, the American Hospital Association reported that there were more than 110
million emergency department visits in the United States.3 With an estimated 2002 United
States population of more than 288 million people,4 the resulting emergency department
visits per 1,000 population (also known as emergency department use rate) were 381.9
(meaning, for every 1,000 people, there was an average across the United States of just
over 381 emergency department visits). Along with overall population, this emergency
department use rate had been increasing at strong rates since the turn of the century—
see Table 1.1.
The prevailing wisdom at that time was that the continued rapid TABLE 1.1.
growth in the number of emergency department visits was unsustain- Emergency department visits per
1,000 population, 2000–2002.3
able, and that with the increased presence of more urgent care clinics
and the advent of convenience care clinics, the number of emergency 2000 2001 2002
department visits would surely not exhibit such rapid increases or 366.5 371.6 381.9
possibly even start to decline. Flash forward to data from 2012: there were more than 133
million emergency department visits in the United States.5 Combine that with an estimated
2012 US population of almost 314 million6 and you end up with a jump in emergency de-
TABLE 1.2. partment visits per 1,000 population to more than 424. Not only that,
Emergency department visits per over the past 3 years, the growth in use rates was still relatively strong
1,000 population, 2010–2012. 5 (Table 1.2).
When I wrote the 2002 edition of this book, only 19 states and the
2010 2011 2012
District of Columbia had an emergency department use rate over 400,
411.7 415.5 424.4
and only six (including DC) over 500. By 2012, those numbers soared
to more than 32 states with an emergency department use rate higher
than 400, and 12 were higher than 500 (both include DC). There is tremendous disparity in
emergency department use rates across the different geographic regions of our country, with
the Pacific region (Alaska, California, Hawaii, Oregon, Washington) traditionally having
the lowest (only 3,206 emergency department visits per 1,000 population in 2012) and the
East South Central region (Alabama, Kentucky, Mississippi, Tennessee) having the highest
at 524.6 However, when comparing 2002 to 2012 (see Table 1.3), it’s evident that each of
the different regions has experienced strong growth in its respective emergency department
use rates. Back in 2002, only three of the nine regions had an emergency department use
rate over 400, with only one over 500. By 2012, there still was only one region over 500,
but there were seven of the nine with emergency department use rates over 400.
TABLE 1.3.
Increases in emergency department visits per 1,000 population, by region.5
Region States 2002 2012 % Change
New England Connecticut, Maine, Massachusetts, New
Hampshire, Rhode Island, Vermont 441.1 489.7 11.0%
Middle Atlantic New Jersey, New York, Pennsylvania 386.3 444.7 15.1%
South Atlantic Delaware, Florida, Georgia, Maryland, North
Carolina, South Carolina, Virginia, West Virginia 397.6 435.8 9.6%
East North Central Indiana, Illinois, Michigan, Ohio, Wisconsin 397.2 475.9 19.8%
East South Central Alabama, Kentucky, Mississippi, Tennessee 501.6 524.7 4.6%
West North Central Iowa, Kansas, Minnesota, Missouri, Nebraska,
North Dakota, South Dakota 365.0 420.5 15.2%
West South Central Arkansas, Louisiana, Oklahoma, Texas 408.4 434.7 6.4%
Mountain Arizona, Colorado, Idaho, Montana, Nevada,
New Mexico, Utah, Wyoming 321.8 345.8 7.5%
Pacific Alaska, California, Hawaii, Oregon, Washington 295.6 320.7 8.5%
Doing More With Less

All of these data point to the continued need for state-of-the-art emergency
departments. I can’t quantify the exact future upward (increasing) emergency department
volume impacts from health care reform. Nor can I quantify the future downward
(decreasing) impacts, or potential success rate, of educating and diverting the nonurgent
patients away from the emergency department. But I can tell you that the “new” economy
has my emergency department clients rethinking every architectural design project

and focusing tremendous energy on confirming true facility needs for the future. No
construction project dollar can go unjustified! All clients considering an updated or new
emergency department wonder if they can afford the project or if there are more cost-
effective strategic or operational alternatives to alleviate volume impacts and, thus, reduce
new construction needs.
This book will show you how to analyze the need for a new emergency department,
how operational redesign is a key component to not overspending on architecture, and
how to develop economically sound solutions for any emergency department construction
project. In summary, a lot of this book is focused on how to deliver more capacity with less
available capital resources.
Think beyond.
The goal of this book is to push you beyond traditional architectural design concepts
and to help you identify the common threads of what makes a successful emergency
department design. This book identifies various architectural design and construction
processes, planning guidelines, design tools, and numerous issues to consider that will help
you throughout the planning and design process. I’ve placed great emphasis on providing
practical step-by-step information as well as pearls and pitfalls based on actual case
histories—from both my personal experiences and those reported by ACEP and Emergency
Nurses Association (ENA) members.
This book will allow you to confidently take the lead on your design team, use
your energies to make a positive impact on the project, and be successful in developing
an emergency department design that meets the goals of your organization and the
expectations of the patients, families, and communities you serve.
Am I hearing what you’re saying?

And on that note, let’s face it, physicians and architects speak different languages.
As an architect, I have no idea what you mean when you say that a patient has a tension
hemopneumothorax, flail chest, cardiac tamponade, DIC, ARDS, and so on. (I hope I
got that right.) And as a clinician, you probably don’t know how to respond when I ask
you, “What’s your preference on the vertical and horizontal alignment of the contextual
fenestration on the southeast exterior elevation?” You’re talking about a patient in trouble,
and I’m just asking you where you want windows.
To help bridge this communication gap, I’ve attempted to include insights on what
architectural terminology you might hear during a project and what your focus should be
during various phases of the project.
The Design Experience

As a clinician or health care executive, you’ll find that designing a new emergency
department will take you out of your comfort zone and put you in a position to lead an
in-house team through what might be a foreign process for you. However, a successful
design project can be extremely rewarding for everyone involved, especially the in-hospital
team leader. The challenge lies in defining the future needs and physical design solutions
for an emergency department that will need to last 15 years or more. The reward will
come when your new department opens and you know that you were a driving force for
its development and ultimate success, especially as you watch your emergency department
design continue to support future operational and technological changes over the coming
years.
Every architectural design project is complex, whether your department is renovating
existing space, expanding into new construction, or building in a completely new location.
No matter how big or small a challenge you think designing your emergency department
will be, I can guarantee that it will be more difficult, more intricate, at times more
frustrating, and more time consuming than you planned. However, by approaching the
project systematically with clear goals, quantifiable objectives, and an ability to delegate to
trusted team members, you can minimize the complexity of the challenge, reduce wasted
time during the process, enjoy the process, and focus all your input on creating a truly
exceptional emergency department. But what is success? That will be the initial question for
you and your team to ponder as you start the process.
Cultural Similarities of Successful Projects

Every project is different, and due to existing facility conditions, challenging sites,
different capital budgets, different design codes based on your jurisdiction, or limited space,
no two projects are the same. However, the most successful emergency department design
projects I’ve been involved with have included the following cultural similarities on which
successful projects have been developed:
x A view to the future. Many times, emergency physicians and nurses create
designs only as a reaction to what they hate about their current physical
environments. Some examples: the current nurses’ station is too cramped, so they
tell the architect to make the new nurses’ station as big as possible. The current
patient care spaces are curtained cubicles, so all they want is as many private
rooms as possible. More space and private rooms might be a part of the future
solution, but defining the future based only on bad history is what I call a view
to the past. A truly successful design team has clinical and organizational leaders
who push the design team to look to the future. What can we do? How can we
design for the future? A true leader will inspire and support originality, innovation,
inventiveness, and creativity. By supporting out-of-the-box thinkers (who I like to
refer to as out-of-the-curtained-cubicle thinkers) and establishing a design team
culture that supports new ideas (operational, technological, and physical), the team
will develop creative solutions that will set a course for a flexible and successful
emergency department design that works well into the future. This brings me to my
next point: leadership needs to come from within the emergency department.
x A defined clinical leader. Yes, your project will most likely be managed or
directed by a vice president, director of engineering, or director of facilities. But
strong leadership from within the emergency department is another key to success.
If you expect your facilities director or architect to make all the right decisions for
you without your input, then don’t be surprised or disappointed when the new
department is finished and it isn’t all you dreamed it to be. No one knows your
business like you and your staff do. As an emergency department leader, you have
to be the champion for your team—and your team includes physicians, nurses,
physician assistants, technicians, ancillary staff, and the architect! I don’t believe
the architect is the main reason a project is or is not successful. The architect is
a major part of a successful team, but not even an architect who has a wealth of

knowledge and experience in emergency department design should be the driver
of an emergency department design project. The drive, direction, and vision of a
design should come from the people who deliver the care. A superior architect is
someone who positions the caregivers to lead the project, inspires the caregivers
to be creative, challenges traditional assumptions, and creates an environment in
response to the caregivers’ future needs.
x Multidisciplinary teams. Your in-house design team needs to be inclusive of
physicians, nurses, physician assistants, technicians, registration support, and other
emergency department staff. And the emergency department is not an island unto
itself, so the most successful teams also include “partner” departments, such as
Information Services, Imaging, Pharmacy, Laboratory, Environmental Services,
Security, and more. The key point is that no physician, physician group, nursing
group, or facilities department group can design a truly effective emergency
department in isolation. Be very inclusive, and when appropriate, ask for input
from volunteers, patients, and families. A great time to do this is at the outset of
a project when you’re defining goals and objectives. Work with your organization
to set up a meeting with people who have used your services, and include their
families. Yes, you should be able to guess the first 10 items your patients will want
in a new emergency department, but you’ll be amazed that you never thought of
their 11th comment!
x Physicians and nurses integrated from the beginning. It’s my experience that
nurses (nursing staff, managers, directors) tend to jump right in and make the
time commitment to be at every emergency department project design meeting.
Physicians, on the other hand, tend to hang back and really want to get involved
with the project only “when there’s something to see.” Meaning, many physicians
want to set aside time for the emergency department project only when some
preliminary drawings are ready to evaluate (OK, I mean criticize!). You’ll see in
this book that there are many key steps before the actual drawing is started that
will shape the project, quantify a budget, define its path to success, and, ultimately,
deliver a facility that will meet your needs. If you’re a physician and wait to join
the team to see the first drawings, you most likely are joining the team too late to
actually affect the scope, budget, configuration, and overall success of the project.
It sounds simple to get involved early, and I know with increasingly busy schedules
it’s very hard for emergency physicians to commit time to a design project.
However, the earlier you’re involved in a project, the more impact you’ll have on
its successful outcome.
x A commitment to focused time. So when you do set aside the time to be a
part or lead the design team, make sure that when you are with the team you
are focused on the emergency department project. I’ve seen many physicians and
nursing leaders jump in and out of meetings, giving 5 minutes here and 5 minutes
there, while they attempt to read e-mails and manage the department at the same
time they’re participating in the design meetings. I know you already have a job
that takes 125% of your available time, but by setting ground rules with yourself
and your staff about focused participation during the design meetings (ie, “for the
next 90 minutes, don’t call me unless it’s an emergency”), the time you spend at the
meetings will be the most impactful.
x Strong support from administration. If you don’t start with support from senior
administration (whether hospital or health system support), you’re doomed to fail.
Or, at best, doomed to a project that will be delayed for multiple years. Convincing
administration you need a new emergency department is addressed in this edition,
but hiding the fact that you’re building a case for a new emergency department can
have severe impacts to project success or project schedule. I was part of a design
team that was working diligently to define the needs, scope, configuration, and
cost of an emergency department project when, after a few meetings, I said to the
vice president over emergency services (who was a part of the design team), “So
when will the CNO or COO or CEO be able to join us for a project update?”
Dead silence. The vice president told me they didn’t know anything about the
project. “I wanted to get the scope and cost for the project established so we can
get it approved more quickly,” is what I recall his saying. Imagine the look on my
face when I realized that senior administration (those over the VP) had no idea
we were on campus developing a design for a new emergency department. Well,
I scheduled a private meeting with this same vice president, and my message to
him was that doing all of this work with no knowledge or support by his senior
administration could be a problem for him in the long run. He took no heed to
my warning; after another meeting, he told me and my team to wrap up the scope
definition work, which at this point included a conceptual design and expected
project cost in the $30-million range. The vice president thanked us and told us
that we had completed our task. To make a very long story short, a year later I
was finally summoned to a meeting in the CEO’s office of this same organization.
The CEO’s first statement to me, as I recall, went something like this: “We hear
you were on our campus last year working with the emergency department staff.
Please update us on what occurred since the VP over emergency services no longer
works here.” (By the tone, I could tell, and you can probably guess, that it wasn’t
the vice president’s idea to leave the organization.) Thank goodness the CEO and
his administrative team weren’t angry with me since the emergency physician
previously involved with our work had relayed to them that I had recommended
getting senior administration involved the previous year. The story has a happy
ending, and an emergency department project was finally defined, designed, and
constructed. But the schedule was delayed 24 months because of the need to
reevaluate all findings and decisions with the input of the senior administrative
team.
x Managed expectations. Another key to project success: always manage
expectations. This might seem to conflict with “think outside the box.” Successful
thinking outside the box results in new ideas and innovative solutions; it does
not mean “build a long wish list of everything you can think of and everything
you could ever possibly want in the future emergency department.” No project
has unlimited money or available space (however, if you have unlimited money
and unlimited space, please call me as soon as possible because I want to work
with you!). Managing the expectations of the design team, the overall emergency
department staff, and the ancillary department representatives will lead to a
focused effort on defining true needs for the project. Consistently remind your
design team that designs and budgets will go through a detailed review by your
hospital, organization, or health system, and that every part of the recommended
design must be justified. The intent is not to crush everyone’s dreams, but to design
and build an emergency department within reasonable expectations that will serve
your clinicians, staff, patients, and families for years to come.

x A focus on the patient experience. Finally, always bring decision-making back
to this question: “How will it affect the patient experience?” We all get myopic
at times and tend to focus on how every decision affects our own little worlds. In
reality, every design decision you make will affect hundreds of thousands of people
over the coming years: you, your staff, the ancillary department staff members,
the facilities department (who will keep the facility running), the families, and the
patients. Any time you’re confronted with a tough decision or a combative issue
among your team members, step back and ask yourself: “How will each possible
solution affect the patient experience?” The best design teams ask themselves this
question consistently.
In summary, develop your design team with the following cultural mandates:
9 A view to the future
9 A defined clinical leader
9 Multidisciplinary teams
9 Nurses and physicians integrated from the beginning
9 A commitment to focused time
9 Strong support from administration
9 Managed expectations
9 A focus on the patient experience
Rethinking the Basics From 2000

When ACEP approached me many years ago about writing the previous edition of
this book, it seemed like an easy task. There were just so many bad emergency departments
designed over the previous 30 years with tiny curtained cubicles, limited privacy, and
no flexibility. How tough would it be to recommend all private rooms and maximum
flexibility? The emphasis back in the 1970s and 1980s seemed to be jamming in as many
curtained cubicles as you could to maximize capacity. For that very reason, the major
emphasis in the last book was maximize all private rooms; enlarge private rooms to allow
for multiple family members and equipment; and develop all universal rooms to be able to
see any and all types of patients in any space or room. While all of those design ideas are
still being considered as part of the planning process for future emergency departments, the
“new economy” and the impacts of health care reform are reshaping our focus.
Now, as I’m writing the new edition, I’m amazed by how emergency care continues to
evolve, year by year, and day by day. I’ve had to review the 2002 edition of this book and
challenge myself as to what has changed and what design components in the last edition are
still applicable for the future. In researching emergency departments designed over the past
10 years that used the last edition of this book as a baseline, it seems most of the emergency
departments have been successful. Now, as we all look into the future, we need to consider
the impacts of a new economy (limited capital for projects), the unknown impacts of health
care reform (what seems like even more patient volume arriving every day), the ability
to treat the right patient in the right place by the right people, the continued need for
maximizing flexibility, and the integration of key security and control features. We need to
challenge ourselves to continue to develop responsive and flexible emergency department
designs that will last another 15 years. Just saying, “Make all the curtained cubicles private
rooms,” was a great place to start 10 or 20 years ago, but the variables affecting emergency
department design are much more complex as we look to the future.
There’s no such thing as a perfect
emergency department design.
I’ve designed hundreds of emergency departments across the United States and
around the world and have interacted with many more people in ACEP, ENA, and similar
organizations in Europe, and someone always asks me, “Who has the best emergency
department design?” Or, “What’s the perfect design?” While I have my favorite emergency
department designs that are up and operating wonderfully, every project has different
needs, budgets, and existing facility or site conditions that affect a final design. (Note:
any of my past clients reading this book, my reference to having my personal “favorite
emergency departments” was in reference to yours!)
While this book doesn’t attempt to design a single perfect emergency department that
you can all copy, it will outline the components to consider based on your unique variables,
which include potential future volumes, patient types, services you’re providing (or might
be in the future), technology applications, workflow, staffing, and your goals for the patient
experience. Yes, there are examples of excellent designs, but each one supports a unique
set of circumstances. This book will identify such variables and how different operations
and environments were developed (in parallel) to create successful physical designs. The
intent is to deliver past success stories that give you a window into how you might design
your future emergency department. This book will not, and cannot, identify a template or
cookie-cutter solution. It will, however, provide you with a clear approach to identifying
issues and discovering how innovative operational and design solutions can be used to
deliver the very best in emergency department environments for a challenging, and as yet
unknown, future of delivering emergency care.
The History of Emergency Department

Design—Where It’s Been, Where It’s Going,
What Went Right, What Went Wrong
The postwar era, 1945 to 1960, was a time of tremendous growth in the demand for
emergency services as a result of increasing medical specialization, a declining number of
general practitioners, increasing hospital-based medical technology, greater expectations by
the public, and increasing third-party insurance support for emergency care.7,8 The physical
design of the postwar “emergency room” was that of an accident ward, usually a single
room with limited materials, utensils, equipment, and personnel. At the time, emergency
“room” architecture was not a design specialty; this area within a hospital was limited to a
few spaces that had limited design features.
The first ACEP book on emergency department design, published in 1993, provided
this perspective on emergency rooms of the postwar era: “It is estimated that 80% of
[emergency department] visits were for treatment of less-than-life-threatening conditions,
treatment that previously would have been given in a physician’s office; 15% were for
emergencies requiring immediate attention, and 5% were for treatment of critically ill
patients.”7,9 The only thing that seemed to matter was having a door or corridor to the
outside that was most likely accessed by the loading dock, dumpsters, morgue entrance, or
any of the other “back-of-the-house” hospital services. Even though the American College
of Surgeons and other groups were developing loose guidelines for emergency department

physical plants in the late 1950s,7 few architects were incorporating the needs of emergency
department care clinicians. In the architectural world of the 1950s, very few architectural
firms specialized in health care design.
In the late 1960s and early 1970s, when emergency medicine started to emerge
as a medical specialty, new architectural designs were being constructed in response to
growing patient volumes. In turn, specialized “health care design firms” were starting to
develop. Health care architecture was expanding as an architectural specialty. Only the
most innovative health care design firms were incorporating caregivers into the design
process. But because the number of hospital design projects far outnumbered the available
specialized health care architects, most of the architects hired to do hospital designs
were the same architects who were designing homes, commercial buildings, apartment
complexes, and other non–health care projects.
During this boom period, the majority of the non–health care architects took their
best shot at designing what they perceived were large doctors’ offices designed for sicker
patients. The cumulative effect of the absence of insight into emergency care, failure to
incorporate caregivers in the design process, and rapidly changing services provided in
emergency departments is this: 25-year-old emergency departments that have been physical
and operational disasters since the day they opened.
At the same time emergency medicine was becoming the 23rd certified medical
specialty in the late 1970s,7 the general design and construction industry was coming to a
standstill as a result of the declining US economy. The only industry in the late 1970s that
still seemed to be doing new construction, out of necessity to meet patient growth, was the
health care industry. And at that time, the majority of health care construction projects
were undertaken to meet the rapidly expanded need for medical office buildings (MOBs).
Most non–health care architects who needed to keep their firms alive in the depressed
economy pursued and completed MOB projects. At the time, very few MOBs actually had
imaging or outpatient surgical facilities within the buildings. Although any architectural
project has its own complexities, the MOB projects were, in effect, general office buildings
with examination rooms.
By the early 1980s, the specialty of health care architecture was flooded with architects
whose only health care design experience was through their work on low-tech MOBs.
These MOB architects were being identified as hospital design specialists. In turn, MOB
architects were being hired to design highly complex hospital structures, many of which
included emergency departments. Subsequently, numerous emergency department designs
completed in the late 1970s and early 1980s were the first real high-tech, highly complex
hospital projects for many aspiring health care architectural firms.
Many of these emergency department designs were not based on caregiver input or
any functional knowledge of how emergency care was being delivered (or how it would
be changing in the future). Even designs based on caregiver needs were not adequate as a
result of the understandably limited foresight of emergency department caregivers into the
rapid changes affecting emergency care.
Although some of the longstanding health care architectural firms completed
successful emergency department projects, most of the emergency department designs
completed in the 1980s were nonfunctional. The only saving grace was that most of the
new departments had limited patient volumes, and the nonfunctional designs were not
having tremendous impact on functional efficiency and patient throughput times. The tidal
wave of emergency department volumes that was just around the corner in the early 1990s
was going to expose these nonfunctional departments as a threat to efficient, effective, and
safe emergency care.
During the 1980s, more architects began to include emergency department caregivers
in the design process. The timing was excellent; emergency departments were being
reinvented with specialties and included more trauma spaces, pediatric and psychiatric
components, fast track and urgent care areas, and so on. By partnering with emergency
department caregivers in the design process, health care architectural firms gained intimate
knowledge of emergency department operational workflow. In turn, more functionally
efficient designs were created. However, too much of a good thing can be a bad thing. The
increasing need to accommodate specialty care within the emergency department was going
to have a negative impact on overall emergency department design.
By the late 1980s and early 1990s, the emergency department specialties (fast track,
observation, chest pain, psychiatry, and so on) were starting to influence caregivers into
requesting completely separate care components, or modules, for each specialty. This
began a wave of what I termed “segregated” emergency department designs. For example,
numerous fast track modules were being designed completely separate from the emergency
department, some even down the hall or on a separate floor. Chest pain units were also
being constructed across corridors or down the hall from the main emergency department.
Some designs completely segmented four or five or more acuity levels (trauma, emergent,
urgent, nonurgent, medical, surgical, psychiatric, and so on) into separate units. This
segregation eliminated the flexibility for sharing examination rooms as needed between
patient care areas, increased the amount of materials and equipment duplicated in each
area, and increased staffing needs to cover each separate component.
Granted, some of these separate modules still function relatively effectively for some
hospitals. However, I still believe that separating emergency department modules across
public corridors, in remote areas of a building, or even on separate floors can jeopardize
efficiency and effectiveness. This is especially true when patient volumes change within each
segregated module and there are no more adjacent spaces available to handle overflow.
Dr. Charles Eckert, in his 1967 (yes, 1967!) book on emergency care, stated: “Since the
workload of an emergency room cannot be easily controlled or compartmentalized, all
space should be planned so it can serve multifunctional purposes.”7,10 Funny how what
goes around comes around! I believe the overspecialization and segregation of emergency
department modules severely affected the flexibility, efficiency, and effectiveness of many
emergency department designs throughout the 1990s.
Dawning of the New Millennium: A New Front Door

Well, after we all survived Y2K (ha!), emergency department design was taking on
added importance in a large number of hospitals around the country. The C Suite (ie, CEO,
COO, CFO, CNO, and so on) in many organizations seemed to realize for the first time (or
admit for the first time) that the majority of the patients in their hospital inpatient units or
using their outpatient facilities had gotten there through the emergency department. With
rising competition in nearly all corners of the United States, the emergency department was
becoming a major piece in the chess game of outmaneuvering the competition for increased
market share. Many older emergency departments were being renovated for the first time
in 20+ years, and many emergency departments with minor renovations in the previous
few years were being expanded again. Many of the emergency departments that I worked
on personally were being relocated to the front side of the hospital with easier access and
better visibility for automobile traffic. Emergency department design seemed to be hitting
its stride, and with the help of the previous edition of this book, many of those emergency

departments were designed for maximum flexibility. Add to this the increase over the past
decade in the number of freestanding emergency departments, and it became obvious the
emergency department was becoming an important tool in the push for market share and
organizational success.
The emphasis of the 2002 edition was to eliminate overspecialization of emergency
department space, maximize flexibility, and decentralize materials, supplies, charting areas,
and so on to maximize efficiency. While I had personally integrated emergency department
process redesign into my standard process with every project since 1994, many times we
had to persuade hospital and emergency department leadership to redesign operations as
part of the physical design process. But as we got closer to year 2010, it seemed all areas of
the United States, Canada, and Europe were focusing on lean operational redesign. Now, as
the lean movement (or some form of operational redesign) became more readily acceptable
in most hospitals, I was finding that emergency department staffs around the world were
already accustomed to rethinking the way they work as part of an emergency department
design project.
However, I was still touring other emergency departments that were designed and
constructed without thinking about streamlined operations. This led to many emergency
physicians finding me at conferences and saying, “I have a beautiful department that
doesn’t work.” Luckily, in this day and age, it is very uncommon to find an emergency
department being physically redesigned that is not considering new, streamlined operations
at the same time. In fact, that should be the first red flag in your emergency department
design journey. If your architect asks you how you work now so he or she can redesign
the emergency department to meet your old way of working, you need to challenge your
architect to forget about the past and think about the future.
Even emergency department clinical teams that have redesigned operations in older
emergency departments (without physical redesign) have still had to make operational
compromises, or workarounds, due to inflexible or challenging physical environments.
The challenge for these staffs as they enter a new emergency department design project is
to determine what newly designed operational flows that they currently use in the existing
emergency department would still be considered best practice in their future emergency
department.
Two Decades Into the New Millennium: The New Normal

Will there ever be a time when the economy isn’t a challenge? I think we can all admit
that the “old normal” of what seemed like readily available capital isn’t coming back any
time soon. As we deal with this “new normal” of challenging economic times, we in the
United States also have to consider the impact of health care reform.
Recent reports indicate that health care reform and the millions of new covered lives
are leading to immediate emergency department volume increases in all parts of the United
States. I believe this trend will continue until at least 2020: it will take that long for most
hospital systems or standalone hospitals to develop the appropriate facilities, primary care
networks, and implementation strategies for educating, diverting, and staffing facilities
outside of the emergency department that will handle the sudden increase in nonurgent
patient volumes. Emergency departments designed over the coming years will have to
be designed with enough flexibility and capacity to handle this 5+ year rapid increase in
volumes while not overbuilding for the long term. And overbuilding isn’t going to happen
with tightening budgets and limited financial resources that are affecting nearly all hospitals
and health systems.
A Lesson From Europe
If the ability to educate and proactively divert nonurgent patients away from the
emergency department is realized, we only have to look to the Netherlands for the impact
on the emergency department. I led an international design team while I was with DLA
FreemanWhite during an emergency department design project for a facility in The
Hague, Netherlands. It had been mandated by governing authorities that the overuse
of the emergency department by nonurgent patients was going to be addressed by the
development of a general practitioner office immediately adjacent to the emergency
department. With no worries about EMTALA or similar US laws governing a medical
screening examination (MSE) prior to diversion, triage personnel in The Hague could
immediately divert to the adjacent general practitioner office. The successful ability to
immediately divert 15% of their patients to another location yielded short-term volume
reductions and, thus, short-term capacity increases in the main emergency department.
However, after just a few months, the emergency department volume reductions filled in
with higher acuity patients. This led to increased length-of-stay times in the emergency
department because the nonurgent (ie, quicker) patients had all but been eliminated in the
main emergency department (during general practitioner hours).
So, I believe this poses a very interesting operational and design challenge for new
emergency departments in the United States: How do we design an emergency department
in the short term that might have an increase in nonurgent patients due to health care
reform while still designing an emergency department for the long term that will need
to treat a much higher average acuity when (if?) nonurgent patients are successfully and
proactively diverted to more cost-efficient locations? The key is to design emergency
departments so that providers can see the right patient in the right place by the right person
and have the flexibility to change operationally as acuities and volumes change over the
coming years. This book addresses these challenges and more (ie, security, confidentiality,
technology integration, lean operations) by documenting how we’ve addressed these
challenges in recent designs and those new concepts being considered for future designs that
are currently under development.
The Debate Over Future Volumes

The debate will continue over whether emergency department patient volumes will
continue to increase, level off, or decline over the next 10 or 15 years. I believe that
growing populations, increasing patient volumes, and larger numbers of older, sicker, and
more seriously injured patients will dictate the need for expanded emergency departments
with larger, more flexible patient care spaces. In the future, emergency departments will
be high-tech environments to support the sickest of the sick patients. We all will have to
reevaluate traditional design concepts. Staff safety and tightening staffing budgets will
influence the planning and design of emergency departments as well. Finances are getting
tighter and tighter. Hospitals are not throwing money at new facilities as they might have
seemed to in the past. When you get the chance to redesign your emergency department, do
it the very best you can within the resources available.

Next Chapter: Preparing to Lead and
Internal Team-Building
The next chapter covers why you need to lead your in-house design team—or why
you should delegate that responsibility to someone else if you can’t make the commitment
and set aside the time to lead. The next chapter also covers the creation of your in-house
committees and teams to gather maximum input for your project.
References
1. Armour S, Radnofsky L. ER visits rise despite law. The Wall Street Journal. May 21, 2014: http://
www.wsj.com/news/articles/SB10001424052702304422704579574390961658638#printmode
Accessed February 16, 2016.
2. Ungar L. More patients flocking to ERs under Obamacare. USA Today. June 8, 2014: http://
www.usatoday.com/story/news/nation/2014/06/08/more-patients-flocking-to-ers-under-
obamacare/10173015/ Accessed February 16, 2016.
3. AHA Hospital Statistics 2006: The Comprehensive Reference Source for Analysis and Comparison of
Hospital Trends. Chicago, Ill: Health Forum; 2005.
4. Statistical Abstract of the United States: 2003. Washington, DC: United States Census Bureau, US
Department of Commerce; 2002.
5. AHA Hospital Statistics, 2014 edition. Chicago, Ill: Health Forum; 2013.
6. United States Census Bureau QuickFacts. http://www.census.gov/quickfacts/table/PST045215/00
Accessed February 16, 2016.
7. Guenther R. A history of emergency services. In: Riggs LM, ed. Emergency Department Design.
Dallas, Tex: American College of Emergency Physicians; 1993:1–5.
8. Bonine B. Technology: catalyst for change. Presented at: The XVII UIA Congress; June 1989;
Montreal, Canada.
9. Goldsmith J. A radical prescription for hospitals. Harvard Business Review. May/June 1989.
https://hbr.org/1989/05/a-radical-prescription-for-hospitals Accessed February 16, 2016.
10. The Trauma of Transformation in the 1990s. Environmental Assessment. Minneapolis, Minn:
Health One Corp; 1989.
FOR MORE INFORMATION

These five online resources have a lot of good information about emergency department
utilization.
x National Hospital Ambulatory Medical Care Survey/cdc.gov
x The National Center for Biotechnology Information/ncbi.nlm.nih.gov
x The National Emergency Department Sample/hcup-us.ahrq.gov/nedsoverview.jsp
x The RAND Corporation/rand.org
x The Robert Wood Johnson Foundation/rwjf.org
Chapter 1: An Architect’s Retrospective
Key Considerations Worksheet
Some of the chapters in this book lend themselves to a workbook approach. So I’ll summarize some
key points and define a few items to consider and give you space to jot down notes and ideas.
Your Personal Viewpoint on Health Care Reform and Emergency

Department Volumes
If your organization’s administrative leaders ask you how health care reform will affect future
emergency department volume, what will you say?
______________________________________________________________________________________
______________________________________________________________________________________
Your Personal Design History

Are there past emergency department experiences that you’ve had that are applicable to your new
emergency department project? Are there operational systems, physical design components, or
technology applications you would use again in the future emergency department? Or some you
would avoid repeating?
______________________________________________________________________________________
______________________________________________________________________________________
Any Help Out There?

Do you have colleagues who have been through an emergency department design recently that can
offer you insight?
______________________________________________________________________________________
______________________________________________________________________________________
What Will Be Your Design Team’s Cultural Mandates?

A view to the future A defined clinical leader
Multidisciplinary teams Nurses and physicians integrated from the beginning
A commitment to focused time Strong support from administration
Managed expectations A focus on the patient experience
Other?
______________________________________________________________________________________
______________________________________________________________________________________

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Emergency

JON HUDDY, AIA

Tracy G. Sanson, MD, FACEP

AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

COVER DESIGN James Normark, Irving, Texas

About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1 An Architect’s Retrospective . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 2 Preparing to Lead and Internal Team-Building . . . . . . . . . . . 19

Chapter 3 Project Delivery Options and Selecting Your Consultants,

Chapter 4 Project Justiﬁcation and Needs Assessment . . . . . . . . . . . . . 61

Chapter 5 Scope Deﬁnition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Chapter 6 The Design Puzzle: Pieces and Parts . . . . . . . . . . . . . . . . . . 133

Chapter 7 Design Components, Conﬁgurations, and

Chapter 8 Insights for Specialty Emergency Departments . . . . . . . . . . 237

Chapter 9 Wrap-Up – Imagine an Emergency Care Environment

PART TWO Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

iv Emergency Department Design

• American College of Emergency Physicians (ACEP, US)

Special thanks to my international friends who have consistently given me insights to

The American College of Emergency Physicians gratefully acknowledges the

James Lennon, AIA Charleston Area Medical Center, Memorial

United Hospital, Peter J. King Emergency University of Texas MD Anderson Cancer

University Hospital of Bern, Intensive Care,

University of Colorado Health,

University of Michigan Hospital and Health

An Emergency Department Architect

The variables shaping future emergency department designs are multiplying

Whom This Book Can Help

2 Emergency Department Design

New Points of Emphasis

So, what’s new since the last edition?

4 Emergency Department Design

Have we seen these trends before?

Doing More With Less

6 Emergency Department Design

Am I hearing what you’re saying?

The Design Experience

Cultural Similarities of Successful Projects

8 Emergency Department Design

10 Emergency Department Design

Rethinking the Basics From 2000

The History of Emergency Department

12 Emergency Department Design

Dawning of the New Millennium: A New Front Door

14 Emergency Department Design

Two Decades Into the New Millennium: The New Normal

The Debate Over Future Volumes

16 Emergency Department Design

FOR MORE INFORMATION

Your Personal Viewpoint on Health Care Reform and Emergency

Your Personal Design History

Any Help Out There?

What Will Be Your Design Team’s Cultural Mandates?

18 Emergency Department Design

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