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In the emergency departments of the future, there are no overcrowded waiting rooms, stretcher-lined halls or grungy privacy curtains. Wency Leung reports on an overhaul in the way hospitals approach urgent care

Carol Mark was worried her husband was suffering from intracranial pressure after his brain surgery last month. He had suddenly developed a tremor, which the Toronto nurse recognized was a sign something was wrong. She immediately took him to a hospital emergency department. The experience, she says, was “horrible.”

There was no one to direct patients upon arrival. She couldn’t find him a wheelchair. The toilet in one of the waiting-room washrooms was covered in blood.

When it came time for him to take his medication, staff told Mark she’d have to exit the emergency department to buy a bottle of water – there was no drinking water available. The couple waited from 4 p.m. to 11 p.m. before they finally saw a neurological specialist.

“They should have been able to see him somehow, clear [him] and get [us] out of the emergency clog. It was craziness,” Mark says.

“Nobody talks to you. … You have no idea who’s who. And as a nurse, I had to hunt people down and I had to confront them to ask them questions.”

Mark’s story is not atypical. Overcrowding, grim environments and lengthy waits are a common part of the emergency-department experience. But it doesn’t have to be this way.

As hospitals across the country retrofit their aging emergency departments and construct new ones, many are finding the opportunity to overhaul the way they operate, building a safer, more pleasant and efficient way of providing care.

It signals a radical shift in emergency-department culture, one that draws on principles of evidence-based and generative design to move away from simply scrambling to make do. It’s a pro-active approach toward orchestrating patient flow, containing infectious diseases and improving patient satisfaction. And what’s more, after the initial investment, it can lead to savings.

Large catch-all waiting rooms are being replaced by multiple smaller ones that separate patients according to the nature of medical attention they require, splitting up acute cases from those in less serious condition.

Cluttered treatment areas, sectioned off by infrequently laundered curtains, are replaced by quieter private rooms, each fitted with sinks near the entrance that encourage doctors and nurses to wash their hands when they enter. Skylights and windows are installed to provide natural light, contributing to a more soothing atmosphere and allowing patients and staff to remain oriented to the time of day.

In the past, “there was a certain fatalism that … you can never completely keep up. There wasn’t a really co-ordinated system approach. So individuals [in emergency departments] worked hard, but they didn’t necessarily get together and restructure their processes and the design in the way we are successfully doing today,” says Dr. Howard Ovens, director of the Schwartz-Reisman Emergency Centre at Toronto’s Mount Sinai Hospital, which is redesigning its emergency department.

(Photos by Artez Photography Corporation; Bob Matheson Photography)

Ovens envisions that Mount Sinai’s redesign, which does not yet have an opening date, won’t just increase its square footage to 28,000 from its current 11,400. A reception and triage desk will be located prominently near the entrance. Patients will be directed to internal waiting rooms, close to where they will be examined, and, ideally, won’t have to wait very long before they’re seen by a doctor or nurse. Those in less serious condition will be sent to a rapid-assessment zone, where they can be treated in seats, situated in pods or cubicles, instead of on beds or stretchers, thus unblocking a major existing bottleneck.

“You’ll get taken care of, and people will explain what they’re doing and why. And either you’ll get admitted, or hopefully you’ll go home and say you had a good experience,” Ovens says.

The picture he paints may sound utopian, but Nanaimo Regional General Hospital offers proof it can work. The Vancouver Island hospital’s new emergency department, which opened in September, 2012, has transformed the way staff and patients experience it. Not only did it win a Generative Space Award for design this fall at the Healthcare Facilities Symposium and Expo in Chicago, the new emergency department, designed by architectural and engineering firm Stantec, has led to significant operational savings and attracted visitors from various Canadian hospitals looking for inspiration for their own emergency departments.

Among its design features are five verdant courtyards, which provide natural light to the interior of the department and offer a calm space for patients and caregivers. Instead of traditional privacy curtains, which collect germs, individual treatment rooms are fitted with electronic glass that becomes opaque with the flick of a switch. And a joint triage and admitting area, where a registration clerk sits beside a triage nurse, means patients only need answer one set of questions when they arrive.

Vancouver-based architect Bruce Raber, the health-care sector leader at Stantec who helped design the $25-million department, says it took some effort to persuade hospital authorities that the cutting-edge design elements would provide a return on investment. Data collected over the year after it opened show positive results: The incidence of C. difficile infection, a common cause of infectious diarrhea in hospitals, was cut by half; 90 per cent of patients surveyed rated the care they were given as “very good;” sick time for staff went down; and overtime was about half a million dollars less than the previous year.

Many similar principles are incorporated into the design of other new emergency departments, such as the one at Toronto’s Centre for Addiction and Mental Health, which opened in October, and at Montreal Children’s Hospital, which is scheduled to open in May, 2015. Both, for instance, have separate zones for patients with acute conditions and those with less serious conditions, situated around a central nursing station, where staff can see all areas of the department.

This new emergency department paradigm is fuelled, in part, by a growing interest in evidence-based design, which relies on research to determine best practices for hospitals and clinics. Proponents point to the classic 1984 study by researcher Roger Ulrich that found patients who had a view of nature from their hospital rooms recovered more quickly than those who had a view of a brick wall.

While critics say it’s impossible to create a controlled research environment, and thus difficult to conclude that positive patient outcomes are a direct result of a hospital’s design, Terri Zborowsky, a research associate for the U.S.-based Center for Health Design, notes that identifying key metrics can help hospitals improve their space and the way they operate. Because staff job satisfaction is highly correlated with patient satisfaction, a hospital that adopts measures to improve nurses’ working conditions, such as reducing their walking distance, could potentially ultimately increase patient satisfaction, she says.

“What we’re seeing is sort of a movement toward more analysis before we design, and understanding that form follows function,” she says.

Re-imagining the entire operation and design of an emergency department requires the input of everyone from doctors to housekeeping staff, as well as patients and family members, Zborowsky says. Without that collaboration, “you can really see how this can be ripe for not being successful.”

It also involves a great deal of modelling and numerous dry runs. Dr. Harley Eisman, medical director of pediatric emergency at Montreal Children’s Hospital, says staff will be rehearsing with mock patients in the hospital’s new emergency department over the next few months. “It’s changing the way people have worked for years and years and years,” he says.

Yet until staff actually begin working in a new space, it’s hard to identify design flaws, says Martha Cloutier, director of the new emergency department at British Columbia’s Surrey Memorial Hospital, which opened in October, 2013. Though the design included advanced infection-control measures and a separate entrance for patients brought in by police and paramedics through a large ambulance garage, which can be turned into a triage area in the event of a disaster, it didn’t include a fast-track area to ensure that less urgent and non-urgent patients were quickly seen and discharged – a problem remedied after patients and staff complained of backlogs and lengthy wait times.

Raber, who has worked on several emergency-department projects over the past seven years, says one of the biggest mistakes that hospitals make is continuing to build massive waiting areas, which only promote logjams. While he has designed new emergency departments in the United States with no waiting area at all, some hospital officials insist they need large waiting rooms to match the ones they currently have.

“I go, ‘Yeah, but you’re totally dysfunctional now,’” he says, adding they’re “continuing bad practice because they’re leaving the patients out there where they can’t see them.”