Three Ways of Reimagining the Emergency Department

Ideas for Shaping the Emergency Department of the Future

February 12, 2019

Principal, NBBJ

Editor’s Note: This post is adapted from a white paper co-authored by Bryan Langlands and Durell Coleman, Founder/CEO of DC Design, and originally published by the Facility Guidelines Institute (FGI). The white paper is based on the “Reimaging the ED” workshop sponsored by FGI and the American College of Emergency Physicians (ACEP) and held at the 2017 Healthcare Facilities Symposium & Expo in Austin, TX, where more than 100 ED clinicians, design professionals and students gathered.

Today in the United States, nearly 50 percent of all hospital care begins in the emergency department (ED) and, over the last 20 years, ED patient volume has increased by 23 percent as many Americans use the ED to access primary care services. Many factors have contributed to these trends, including:

  • The aging of the baby boomer generation
  • Increased longevity of people with chronic diseases
  • Gaps in provision of care for behavioral health patients
  • Limited operating hours of primary care providers
  • Lack of affordable insurance and other issues affecting individual access to medical care
  • Requirement of the Emergency Medical Treatment and Labor Act (EMTALA) for EDs to treat everyone, whether they have insurance or not

While the U.S. health care system struggles to determine how to address these difficult and complex issues, there are changes that can be implemented now to improve the function and flow of emergency department services and facilitate quality patient care: by (1) improving arrival and front-end operations, (2) reducing patient length of stay, and (3) improving the experience of behavioral health patients.

 

(1) Improve arrival and front-end operations with technology.

Technology could be deployed to make patient arrival, sorting, and waiting processes more efficient. One idea: providing a registration kiosk for low-acuity patients. Another idea is a vitals-monitoring bracelet that could be used to assess and monitor patients in the waiting area. Such approaches could result in reduced stress and better flow for triage and front-end operations.

 

(2) Reduce low-acuity patients’ length of stay.

A significant problem is the treatment of low-acuity, non-emergency patients in spaces designed for patients who require a bed. Some solutions: smaller treatment spaces for these “vertical” patients, or treatment rooms that could easily and quickly be converted to hold multiple low-acuity patients during peak hours. Such spaces would speed up delivery of care for low-acuity patients and reduce the amount of time they — and consequently all patients — spend in the ED.

As one way to identify these low-acuity patients, the ED could be zoned by Emergency Severity Index (ESI) level. Creating ESI zones would support more flexible and efficient use of space and could decrease patient waiting times. Each area in the ED would be designed with patient care stations sized appropriately for the type of patient seen there.

 

(3) Create spaces for behavioral health patients.

There are many concerns surrounding behavioral health services provided in the ED setting, including the tendency to hold these patients in the ED for two to three days before placement in an inpatient unit or transfer to a psychiatric hospital. Spaces are needed that better suit this patient population. Because the ED is not specifically designed to provide care for the behavioral health population and the typical patient stays longer and requires different attention than typical ED patients, the flow and throughput of the entire emergency department is negatively affected when suitable behavioral health facilities are not provided.

 

It is important to remember the ED is not a “place” but a “process,” a point that underscores that many problems seen in EDs are the result of operational processes rather than design issues. Further, the primary factors of many problems are neither design nor operational, but issues that result from demographic changes, behavioral health and insurance deficiencies, and EMTALA requirements. For this reason, quite a few problems might not require specialty operational or design solutions if the overall health care system were doing a better job of addressing the larger issues that bring many patients to the ED.

Nonetheless, it is an important first step when health care organizations and designers work together to address operational and design problems through careful project planning.

Banner image courtesy of Frank Oudeman/NBBJ.

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Micro-Units: Good for the City, Good for Citizens?

Thinking More Holistically About Housing Typologies and Zoning Will Improve Our Public Realm

January 10, 2019

Urban Design Director, NBBJ

Editor’s Note: This post was additionally published by Building Design + Construction.

As economically booming cities such as Boston, New York, San Francisco and London struggle with housing their growing populations, there is an increasing fixation on the micro-unit in the name of increasing residential provision. Also referred to as the compact unit, architects and developers are bringing ingenuity and investment to creating spaces that have pared domestic life down to its minimalist essentials. These small units have catalyzed a new relationship with the public realm.

Looking to Europe one can see a long tradition of using the city as one’s living and dining room, where urban middle-income units are small in relation to North American dwellings. In the United States, however, it is relatively recent that Americans are choosing to live in city centers. Part of the appeal of the suburbs was the generous indoor and outdoor private space. The move downtown, where the offer is generally a smaller dwelling, has meant less private space. And so our new city dwellers are venturing out of their homes to pursue their social lives. This is good for our cities. This is good for our local economies.

But who are these micro-units for? On the face of it this “progress” is meant to help address both the accommodation of sheer numbers of people and the affordability of living in the city. However, it is impossible not to question how tiny units truly answer this need.

It has become apparent that we are creating city centers that cater to a thin slice of the population: pre-nesters and empty-nesters. The problem is threefold: the units being built are, even if not micro, rarely larger than 2-bedrooms (and a tight 2-bedroom at that); secondly, only a very small percentage are “affordable,” not to mention that the definition of “affordable” means many lower-middle-income people do not qualify for support; and, thirdly, the city’s amenities and services are often unaffordable as they cater to the affluence of those who can afford the newly built units.

For the millennials currently sharing a dwelling unit, they are forced out of the urban center to the suburbs when they want to have families. Even if housing and services affordability is not the barrier, there are few homes catering to households requiring 3-bedrooms or more. People are left little choice but to join the swathes of commuters emitting carbon, undoubtedly against their better judgement.

There is a further related concern. Thanks to policy and design guidance, many condominium buildings are designed to accommodate retail or food & beverage on the ground floor. However, despite the fact that people may be looking to the city to fulfill their entertainment needs, we find increasing numbers of empty shopfronts on our main streets and city centers. In this era of on-line shopping and food delivery, it is acutely obvious that we can no longer rely only on shops, cafes, bars and restaurants to activate our streets. Meanwhile, competing for market share, developers provide their condo buildings with gyms, meeting spaces, makers’ spaces and indoor dog runs. It is time these amenities are literally brought down to the ground. Let’s redistribute the activity.

As learning and making become more widely accessible and less institutionalized, one can imagine these sorts of uses occupying ground floors and attracting public interaction. Boston’s downtown was boosted when Suffolk and Emerson Universities came to occupy both bespoke and existing buildings. As students do not lead a nine-to-five lifestyle, ground floor activity and “eyes on the street” have improved round-the-clock.

Similarly the contemporary public library can become a space that projects and attracts vibrancy. The Idea Store in London is a good example of this. Community infrastructure — from gathering space to recreation to cultural events — provides clues as to the sorts of uses that co-exist well with the public realm. This may call for revisions to existing zoning to allow for diverse ground-floor uses — indeed, redefining “active frontage.”

The concept of the Business Improvement District (BID) has been a fantastic mechanism in many city centers, improving the safety, cleanliness and temporary events in many downtowns. However, it may also be time to redefine the scope of the BID, enforcing ground-floor activity even if that means providing space to a tenant that is not a commercial enterprise, such as a cultural institution or community use. Positive, or negative, incentives to lease empty shopfronts may be required.

It is time to promote — even demand — building types that accommodate larger households and instigate mechanisms that facilitate the distribution of amenities and services across the scale of not just a building but an urban block or blocks. This entails exploiting the trend to blur the distinction between dwelling, working, leisure and learning. In this way those people living in micro-units — as it is unrealistic, nor even desirable, that they all disappear — as well as larger multi-generation households, will have a more interesting city to venture into.

Banner image courtesy of Kamen Atanassov/Unsplash.

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Timber Construction Doesn’t Have to Be “All or Nothing”

How Hybrid Curtain Walls Can Drive Sustainable Innovation in Architecture

December 5, 2018

Principal, NBBJ

Editor’s Note: This post was adapted from the white paper “Hybrid Timber: Performative, biophilic and beautiful” [PDF].

The increased use of timber in construction is a growing and robust opportunity. Wood evokes deep passion and motivation, but why? For one, it’s exciting to have technological and structural advancement within an industry that has been fairly constant since wood balloon framing was invented.

In addition, the prospect of managing our forests sustainably is the future. It supports the use of wood while avoiding the use of old growth species, instead using young saplings or beetle kill forests. It creates sustained carbon capture by circumventing the carbon release that occurs at the end of a tree’s life through decomposition, thereby reducing greenhouse gas emissions. Other benefits include low embodied energy, low thermal conductivity compared to aluminum or steel, better indoor air quality (IAQ), biophilic connections supporting a sense of well-being and health, and the outperformance of other building materials “cradle-to-cradle.”

The use of wood in curtain wall construction, in particular, is an emerging trend. A typical approach to long-span exterior curtain wall design is an aluminum curtain wall framing with secondary steel support—but this convention is being challenged by the use of wood as the primary structural support of the glazing.

Given the industry’s unfamiliarity incorporating wood within typical curtain wall assemblies, this proves to be a challenge, for several reasons:

  • Interest in bidding: The curtain wall market has been busy, making it difficult to draw interest in bidding, especially for smaller scale work.
  • Atypicality: The use of wood is not familiar to most large-scale builders.
  • Cost: The prior two variables drive cost upwards, even though the cost of glue-laminated timber is more cost-effective than steel at similar spans.
  • Engineering: Wood does not possess the same properties as steel, and in fact its strength varies by species.

However, the appropriate application of wood is not a matter of “all or nothing.” Hybrid options using wood as the lateral supporting system or as a dead load support, combined with more conventional aluminum systems or a semi-unitized curtain wall system, can yield a more conventional and familiar system design, making wood a more viable option for cost and schedule.

In one example I worked on, the curtain wall subcontractor provided the engineering of the curtain wall and attachments to the glue-laminated timber, and the structural engineer of record provided the engineering of glue-laminated timber and its attachment to the primary structure of the building, similar to the use of a more conventional secondary steel system.

In another example, the curtain wall subcontractor provided the entire engineering of the composite system, including the wood dead load supports, which transfer the window system loads to the primary structure.

With both of these options, the curtain wall consultants worked closely with the full engineering team as the point of intersection and peer-review for the system as a whole. Wood suppliers provided design information on the wood and glue-laminated timbers available, and communicated their unique strength characteristics by species to the design team.

Essential to the success of these projects was our strategic and proactive planning toward connecting markets and suppliers and building consensus between them, defining engineering roles and responsibilities, and effectively addressing fire and combustibility concerns.

Photo © Lawrence Anderson

Building a proper team with supportive and knowledgeable industry partnerships is paramount in being able to meet these challenges with clarity. Therefore, it is critical to partner with both an experienced timber/curtain wall engineer and forestry partners that have an in-depth knowledge of the process and the fluency to ask the right questions at the right time to support success and mitigate risk. I also recommend partnering with local fire authorities early in the process, onboarding them to the use of timber prior to permit submission.

Our hope is to create a ripple effect for the imperative change needed at a larger, industry-wide scale. Similar to code related energy requirements, only larger-scale demand will propel cross-industry advancement and expertise. This will drive innovation towards higher performance, reductions in our carbon footprint, less harmful chemical dependency and beautiful biophilic outcomes. The ultimate outcome will enhance our human experience with respect for our planet.

For more on timber construction, please read my white paper “Hybrid Timber: Performative, biophilic and beautiful” [PDF].

Banner photo courtesy of NBBJ/Sean Airhart.

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