When Wellstar Kennestone Hospital in Marietta, Ga., began planning a replacement for its dated and undersized 1970s-era emergency department (ED), the Ebola epidemic was still top of mind. It was 2016, and issues like how to screen potentially infectious patients before entering a facility and the need for isolation rooms were important topics in conversations about healthcare design. That reality influenced the 263,000-square-foot, 166-bed replacement ED, which opened in July 2020 and includes an outdoor decontamination area, 14 negative pressure rooms, and spaces to serve as de-escalation/isolation/decontamination for patients presenting with infectious disease, behavioral health, or chemical contamination issues. “I give [Wellstar] credit for thinking ahead,” says Matthew Manning, principal at ESa who served as design manager on the project, a collaboration between ESa (Nashville, Tenn.) and Huddy HealthCare Solutions (Fort Mill, S.C.).
Those strategies have now served the ED during the current COVID-19 pandemic. “We’ve actually managed quite well with the 14 negative pressure rooms that were designed for the new space, because we can place our highest-acuity positive patients who need to undergo aerosolized treatment interventions in them,” says Mary Chatman, executive vice president at Wellstar Health System and president of Wellstar Kennestone and Wellstar Windy Hill (Marietta) hospitals. Additionally, when Georgia’s state government was looking for treatment spaces to address potential COVID-19 patient surge, the 166-bed Wellstar Kennestone ED was identified as one of the few hospitals with new available beds (it hasn’t been needed in this capacity, to date).
Facilities that didn’t have pandemic-ready ED spaces have also spent the last year seeking solutions to control the airborne transmission of COVID-19 and heightened infection control practices. Approaches have ranged from converting outdoor spaces to alternate care sites for low-acuity patients, adding clear plastic barriers between waiting room seating to support social distancing, and installing window fans in existing patient rooms to exhaust air and create negative pressure rooms.
Moving forward, industry leaders say it’s important to balance long-term strategies that address crisis care with the day-to-day challenges EDs face, such as the rise of behavioral health or pediatric patients presenting at their door as well as supporting staff members and their well-being. “We’re starting to talk about what being truly resilient means,” says Deborah Wingler, health research lead at HKS (Dallas), “and then realizing that our ED environments need to be more nimble and able to respond to not just this pandemic but future things that we can’t even see right now.”
Being (next) pandemic ready
Looking back on the past year, Marvina Williams, registered nurse and associate principal, health, at Perkins&Will (Atlanta), says one lesson that stands out to her is the need for “flexibility and adaptability.” “ED staffs all over the country are having to adapt their facility spaces and workflows to meet the needs of patients, and a lot of places are having a hard time because they don’t have that flexibility designed into their ED,” she says. Without existing airborne isolation rooms or exam rooms with independent ventilation systems, some facilities scrambled to create temporary COVID-19 wings or retrofit existing spaces. Going forward, designers say more attention should be paid to creating EDs that can handle a number of scenarios—from mass contamination events to seasonal influenza spikes. “Flexibility, adaptability, and efficiency are things that you invest in,” says Brian Sykes, healthcare practice leader at Perksin&Will (Washington, D.C.).
For example, an ED project for Orlando Regional Medical Center (Orlando, Fla.), designed by HKS, incorporates a grouping of rooms that serves as an urgent care pod but can change to pandemic mode at the flip of a switch to become negative pressure with 100 percent outside air. The unit also has its own entry and waiting area to use during this mode, to provide physical separation from the rest of the ED. “That’s the kind of resiliency we’re talking about,” says Jason Schroer, principal and director of health at HKS (Dallas).
Rethinking how patients—many arriving with a variety of needs and conditions—enter a facility is also key. “What we’re learning is that the ability to initially separate individuals from the get-go is really important,” Wingler says. Solutions for redesigning the threshold can range from adding a vestibule where screening is done to utilizing an outdoor triage area to having multiple entrances so that during a crisis, one could be identified for specific patients while the others continue to serve the general patient population. “There are many different permutations to do that, but at the end of the day, there needs to be thoughtful consideration given to how you begin to isolate, if needed, and protect others,” she says.
At Wellstar Kennestone Hospital’s new ED, an isolation room located between two adult and pediatric triage areas on the first floor is used to quickly relocate someone who poses infection risk. To maximize flexibility, the room utilizes airborne isolation technology and ligature-resistant features so it can also function as a de-escalation room for behavioral health patients when needed. “When you combine them and use the space in a flexible way, it makes it a lot easier sell and it places [hospitals] in a much better position to take care of patients in today’s climate or the next situation,” Manning says.
Marianne Hatfield, vice president and chief nursing officer of patient care services at Wellstar Kennestone Hospital, says although the system hasn’t returned to pre-COVID-19 volumes yet, the new ED has the flexibility and forward-thinking systems in place to support care teams as they adapt to changing needs. “We want our community to feel confident that they should not delay seeking care due to any fear about being exposed to infectious patients,” she says. “We actually think the hospital’s the safest place to be. Our private rooms and multiple specialty care zones have been developed for just this reason.”
Specialty care needs
Beyond the next pandemic, disaster preparedness is another topic being addressed in today’s EDs, particularly in ambulance bays where project teams are layering in multiple systems to enable care delivery to support triage or decontamination in the event of a mass casualty event. For example, as part of the University of Virginia (UVA) University Hospital expansion in Charlottesville, Va., which included a new ED, the ambulance deck canopy was equipped with drop-down showers and curtains so water can be brought in to decontaminate mass groupings immediately, while electrical connections were added to the column to support generators or other power needs. “You want to be able to treat [patients] outside and not bring them into the facility,” Sykes says. “Hospitals are becoming more sophisticated about this topic.”
Facilities also are addressing how to treat specific patient populations arriving at the ED for care, including behavioral health and pediatric patients—making specialty care spaces a must-have in the ED. Recognizing growing demand for pediatric services at Wellstar Kennestone Hospital, the project team created a 16-bed pediatric ED with a separate waiting area within the larger emergency care environment. “Kids aren’t little adults. Their needs are distinct, and you’re usually treating a family, as well,” says Dr. Vik Reddy, chief medical officer of Wellstar Kennestone and Wellstar Windy Hill hospitals. “It was really important to have a separate pediatric emergency department, with pediatric supplies and nurses with expertise, and also a visually and aesthetically pleasant place for children.”
UVA University Hospital took a similar approach with a module of rooms for pediatric patients, with a dedicated check-in and waiting area with kid-sized furnishings and a large interactive wall that represents the topography of the Shenandoah Valley. “It’s a positive distraction element for them while they’re waiting to be seen within the ED,” Sykes says.
Sykes adds that there’s a growing recognition that behavioral health needs to be a priority, as well, with EDs becoming “one of the front lines of treatment.” Manning agrees, saying the topic is coming up more frequently in conversations with clients. “[Behavioral health] is probably the other pandemic that emergency departments have been seeing for years and will continue to see,” he says. “Nobody can adequately predict their behavioral health population, and every time we ask, we always get a number that’s more than you think it will be.”
In response, more facilities are moving beyond a few rooms tucked into a corner of the ED to creating truly designated spaces. At Wellstar, in addition to the de-escalation room on the first floor, the two-story ED houses a 12-bed behavioral health unit on the second floor with eight adult and four pediatric private rooms that are organized into separate pods, as well as a day room and shower facilities. An adjoining pod of general adult patient care rooms are designed with ligature-
resistant features to provide flex space for additional care. “We’re going to see a lot more patients who have behavioral issues, so until they get boarded to a formalized inpatient facility, having a real top-notch secure behavioral unit is key,” Reddy says.
Chatman adds that treating these patients in rooms designed specifically to their needs rather than in a traditional ED exam room not only decreases risk for patients and staff but also saves time during room turnovers by eliminating the need for staff to remove equipment and supplies that pose a safety risk. Furthermore, in addition to ligature-resistant features, project teams are incorporating overall best design practices, including access to daylight and soothing color palettes. For example, at UVA University Hospital, behavioral patient rooms include clerestory windows—an important feature considering that some patients can remain in rooms for 24 hours or more until they can be moved to an inpatient or specialty care facility, Williams says.
Focusing on caregivers
Another one of the biggest takeaways coming out of the last year has been the importance of caring for frontline workers, many of whom have been putting in grueling hours and sustaining intense emotional and physical demands. Traditional solutions such as staff respite rooms in the ED, views to nature, outdoor spaces, and access to daylight remain important. But design professionals say one of the best ways to support caregivers is through the overall environment, including flexible layouts, accessible team stations, and exam rooms where supplies are stocked and easily accessible. “A lot of times when you get into an ED that’s kind of grown amorphously over time, that stuff doesn’t get thought about and it may just be a real bear to work in it,” Manning says.
For the Wellstar Kennestone Hospital, he notes that the 166-bed ED is segmented into 12-bed pods, each with its own dedicated clean supply area, solid holding area, staff toilet, nourishment, and other staff spaces to support efficiency and keep walking distances manageable.
“We know that the ED environment is chaotic, at best,” Wingler adds. “So we need to make sure that the individuals who serve and provide care have the space they need to do that and do that well.” In early 2021, HKS announced that it partnered with the Emergency Medicine Foundation (Irving, Texas), a nonprofit organization founded by the American College of Emergency Physicians (Irving), to award a research grant to the Health Design Lab at Thomas Jefferson University (Philadelphia) to examine how ED design can impact staff stress and burnout. The Health Design Lab’s study will focus on the multiple factors creating stress while also providing tools and processes for redesigning existing ED spaces. “Physician and resident burnout has been a huge issue,” Wingler says. “This is taking the step to say, fundamentally, we believe that the built environment can make a difference.”
Sykes adds that he expects conversations with hospital leadership about delivering the right ED infrastructure for nurses and doctors to treat their patients will gain more urgency and consideration. “Yes, [maintaining] patient care and satisfaction is job one, but perhaps one of the most powerful ways to get really great satisfaction is to treat your staff well by providing that infrastructure,” he says.
For a case study on the Wellstar Kennestone Hospital emergency department and how the project team overcame site challenges to deliver a two-story facility that expanded bed capacity and services, as well as additional images, visit HCDmagazine.com/wellstar-kennestone-ed.
Anne DiNardo is executive editor of Healthcare Design. She can be reached at anne.dinardo@emeraldX.com.