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Emergency department layout
Essentials
- 1
The layout of the emergency department should functionally promote efficacy of care, safety and efficient patient flow by maximizing access to every space with the minimum of cross-traffic.
- 2
The triage location should enable staff directly to observe and gain access to both the ambulance entry and the patient waiting areas.
- 3
The acute treatment area should be open, with all spaces directly observable from the staff station.
- 4
Supporting areas, such as the clean and dirty utilities, the medication room and equipment stores, should be centrally located.
- 5
Areas poorly planned include office, clinical support areas, clinical spaces and tutorial rooms. Storage space and future information and communication technology requirements are often underestimated.
- 6
Planning should consider the implications on night staffing when minimal staff are on duty.
- 7
The security of staff and patients is paramount in planning an emergency department.
Introduction
The emergency department (ED) is a core clinical unit within a hospital. The experience and satisfaction of patients attending the ED are significant contributors to the public image of the hospital. Its primary function is to receive, triage, stabilize and provide emergency care to patients who present with a wide range of undifferentiated conditions, which may be critical to semi-urgent in nature. The ED may contribute between 15% and 75% of a hospital’s total number of admissions. It plays an important role in the hospital’s response to major incidents and trauma, and in the reception and management of disaster victims. To optimize its core function, the department should be purpose-built, providing a safe environment for patients, their carers and staff. The physical environment includes an effective communication and appropriate wayfinding system, adequate ambulance access and clear observation of relevant areas from triage. There should be easy access to the resuscitation area and quiet and private areas should cater for patients and their relatives. Adequate staff facilities and educational areas should be available. Clean and dirty utilities and storage areas are also required.
Design considerations
The design of the department should promote rapid access to every area with the minimum of cross-traffic. There must be proximity between the resuscitation and the acute treatment areas for non-ambulant patients. Supporting areas, such as clean and dirty utilities, the pharmacy room and equipment stores, should be centrally located to prevent staff traversing long distances. The main aggregation of clinical staff will be at the staff station in the acute treatment area. This is the focus around which the other clinical areas should be grouped.
Lighting should conform to national standards and clinical care areas should have exposure to daylight whenever possible to minimize patient disorientation. Climate control is essential for the comfort of both patients and staff. Each clinical area needs to be serviced with medical gases, suction, scavenging units and power outlets. The minimum suggested configuration for each type of clinical area is outlined in Table 30.2.1 .
Table 30.2.1
Configurations for clinical areas
| Resuscitation | Acute treatment adult/paediatrics | Specialty plaster/procedure | Consultation room | |
|---|---|---|---|---|
| Oxygen outlets | 3 | 2 | 2 | 1 |
| Medical air outlets | 2 | 1 | 1 | — |
| Suction outlets | 3 | 2 | 2 | 1 |
| Nitrous oxide | 1 | 1 | 1 | — |
| Scavenging unit | 1 | 1 | 1 | — |
| Power outlets | 16 | 8 | 8 | 4 |
| Data outlets | 6 | 4 | 6 | 4 |
(Reproduced with permission from Australasian College for Emergency Medicine Emergency Department Design Guidelines 2014. https://acem.org.au/getattachment/cde7e04a-fb7d-423a-bfef-217965809d7a/Emergency-Department-Design.aspx . Accessed January 2018.)
Medical gases should be internally piped to all patient care areas, and adequate cabling should ensure the availability of power outlets to all clinical and non-clinical areas. Although patient and emergency call facilities are often considered, frequently there is inadequate provision for telephone and information technology access. The availability of wireless technology to support equipment, such as workstation on wheels (WOWs), is desirable. Emergency power must be available to all lighting and power outlets in the resuscitation and acute treatment areas. Computer terminals should have access to emergency power, and emergency lighting should be available in all other areas. Electronic and computer equipment should be electrically surge protected, while physiological monitors and other patient care areas be cardiac and body protected, respectively.
Approximately 35% to 45% of the total area of the department is circulation space. An example of this would be the provision of corridors wide enough to allow the easy passage of two bariatric hospital beds with attached intravenous fluids. Although circulation space should be kept to a minimum, other aspects that also need to be considered are functionality, fire, and work health and safety requirements. The floor covering in all patient care areas should be durable and non-slip, easy to clean, be impermeable to water and body fluids, and have properties that reduce sound transmission and absorb shocks. Administrative areas, and interview rooms utilized to counsel and support distressed relatives, should be carpeted.
Size and composition of the emergency department
The appropriate size of the ED depends on a number of factors: the census, casemix, admission rate, defined performance levels manifested in waiting times, the length of stay of patients in the ED and the role delineation of the department. Departments of inadequate size are uncomfortable for patients; they often function inefficiently and impair patient care. Overcrowding of patients increases mortality and morbidity, enhances the risk of infectious disease transmission and increases harmful cognitive stimulation for patients with mental disturbance. For the average Australasian ED with an admission rate of approximately 25% to 35%, its total internal area (excluding departmental radiological imaging facilities and the Emergency Short Stay Unit) should be approximately 50 m 2 /1000 yearly attendances. The total number of patient treatment areas (excluding interview, plaster and procedure rooms) should be at least 1/1100 yearly attendances, and the number of resuscitation areas should be at least one for every 15,000 yearly attendances. It is recommended that physiological monitoring be available to acute treatment bays.
Clinical areas
Individual treatment areas
The design of individual treatment areas should be determined by their specific functions. Adequate space around the bed should be allowed for patient transfer, assessment, procedures and storage of commonly used items. The use of modular storage bins or other materials employing a similar design concept should be considered.
To ensure privacy and minimize cross infection, each area should be separated by solid partitions that extend from floor to ceiling. The entrance to each area should be able to be closed by a movable partition or curtain.
Each acute treatment bed should have access to a physiological monitor. Central monitoring is recommended and monitors should ideally be of the modular type, with recording and print capabilities. The minimum monitored physiological parameters should include oxygen saturation(SpO 2 ), non-invasive blood pressure (NIBP), electrocardiogram (ECG) and temperature. Monitors may be mounted adjacent to the bed on an appropriate pivoting bracket or be movable.
All patient care areas, including toilets and bathrooms, require individual patient-call and emergency-call facilities. In addition, an examination light, a sphygmomanometer, ophthalmoscope and otoscope, and waste disposal unit should all be immediately available. Alcohol-based hand rub and hand washing facilities should be easily accessible.
Resuscitation area
This area is used for the resuscitation and treatment of critically ill or injured patients. It must be large enough to fit a standard resuscitation bed, allow access to all parts of the patient as well as allowing staff and equipment to move around the work area. The spatial requirements for equipment, monitoring, storage, wash-up and disposal facilities would necessitate a minimum size of 35 m 2 (including storage area) or 25 m 2 (excluding storage area) for each bed space in a multi-bedded room. The area should also have visual and auditory privacy for both the occupants of the room and for other patients, their carers and relatives. The resuscitation area should be easily accessible from the ambulance entrance and the staff station and be separate from the patient circulation areas. In addition to standard physiological monitoring, invasive pressure, capnography and temperature probe monitoring should be available. Other desirable features include a ceiling-mounted operating theatre light, a radiolucent resuscitation trolley with cassette trays, overhead x-ray and lead lining of walls, and partitions between beds.
Acute treatment area
This area is used for the assessment, treatment and observation of patients with acute medical or surgical illnesses. Each bed space must be large enough to fit a standard mobile bed, with adequate storage and circulation space. The recommended minimum space between beds is 2.4 m and each treatment area should be at least 12 m 2 . All of these beds should be positioned to enable direct observation from the staff station and easy access to the clean and dirty utility, procedure room, pharmacy patient shower and toilet.
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