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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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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What Does the Future of Urban Healthcare Look Like?

Thoughts on a ‘Healthcare Quarter’

August 6, 2018

Principal, NBBJ

Editor’s Note: This post derives from an NBBJ-hosted breakfast talk at the British Library in London focused on the future of the NHS. NBBJ Partner David Lewis was joined by speakers Jodie Eastwood, Chief Executive of the Knowledge Quarter; Peter Ward, Director of Real Estate Development at King’s College London: Guy’s and St Thomas’ NHS Foundation; and Richard Darch, Chief Executive of the healthcare consultancy Archus.

As we celebrate the 70th year of the NHS, the future of healthcare in the UK has arguably never been a hotter topic with no shortage of debate on how the world’s largest publicly funded health service will survive.

The people who work and care within the NHS remain its most valuable asset and they will continue to shape national pride in what polls have shown symbolises ‘what is great about Britain’.

But what about its places? How is the public healthcare estate adapting to the demands of an ageing population, new technologies and severe financial pressures? And how will it look in 10, 20 and 30 years’ time?

 

Creating ‘health engines’

Healthcare estates should be spaces where everyone comes together for the benefit of healthcare. Not in some utopian dream but in the form of ‘health engines’ that combine and convert the power of healthcare, research and development and industry to deliver positive progress. Instead of selling off surplus land for residential use and reducing the NHS estate, there is potential to create health ‘eco-systems’ in our cities — healthcare quarters with hospitals acting as anchor tenants surrounded by layers of research and wellness services, step-down care, commercial tenants and public social spaces.

These aspirations chime with the concept for a ‘health return’ from public assets, land and buildings to promote healthy lifestyle and wellbeing.

 

Everyone needs good neighbours

The Cambridge Biomedical Campus and Royal Liverpool University Hospital demonstrate how healthcare, research and commercial developments can benefit from being co-located. It’s important that spaces knit healthcare sites back into cities and their urban context, promote synergies between healthcare and education and create societal hubs that encourage public access and community use.

This is the point of view championed by Jodie Eastwood of the Knowledge Quarter, a partnership of more than 90 knowledge-rich organisations based around King’s Cross, St Pancras, Bloomsbury and Euston. Jodie espouses the power of cross-disciplinary partnerships saying “the real value of collaboration comes when you cross sectors.”

 

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At the Quadram Institute in Norwich, researchers and clinicians collaborate around an open atrium overlooked by research labs and balconies. (Photo courtesy of Sean Airhart/NBBJ)

Science on show

However, co-locating sectors alone is not enough. We must create buildings that actively promote formal and informal collaboration; spaces that showcase health and science in one place.

Blurring spatial boundaries can bridge the gap between fundamental research and application in practice, allowing those differing aspects of innovation to drive each other.

At the same time putting science on show, making it accessible to the public, helps to demystify scientific endeavour, while sowing seeds for education and future talent.

The Quadram Institute in Norwich is a case in point, incorporating an environment in which clinicians work alongside scientists at the forefront of food science, gut biology and healthcare research under one roof with one shared identity and entrance.

Bringing together the Institute of Food Research, the University of East Anglia and the gastrointestinal endoscopy facility of Norfolk and Norwich University Hospital, the Quadram Institute conducts bench-to-bedside research and clinical care related to health and diet.

Within a hierarchy of spaces, the clinical research facility and patient treatment areas are more private to protect patients’ and participants’ confidentiality, whilst the research space is open to showcase the science within.

 

Future proofing and flexible facilities

There are also many lessons the NHS needs to learn from when designing the next generation of healthcare facilities and buildings.

Purely clinically-led design isn’t working and must be supplemented by research-led thinking that inspires sustainable, adaptable buildings offering operational flexibility.

We must also champion strong and proven healthcare, research and technology hubs, such as the MaRS Discovery District in Toronto and UCSF Medical Center at Mission Bay, as the best breeding ground for future start-ups and world-leading innovation.

Yes, many garage start-ups have turned into multinational powerhouses but most new ventures will have a higher chance of success from being based in well-connected places that benefit from local cultural and heritage amenities.

 

Technology drives talent

Finally is the undeniable importance of digitalisation and AI to the future of healthcare and driving the talent that will drive healthcare forward. It will be fascinating to see how emerging technologies will advance the practice of medicine, improve health and empower patients to be active participants in their own care. Trends in digital diagnostics, robotics and data are allowing hospitals to put the human experience first.

For example, many hospitals in the United States are already being designed with extra-wide corridors, allowing robots to deliver medicine and other critical supplies directly to patient rooms. Meantime, IBM’s Watson is being utilized to diagnosis illnesses — especially those that are hard to detect — which then impacts the experience of patients and the quality of care they receive.

The NHS needs to sell a vision of the future now, instil public confidence and demonstrate it has a plan to create a future for itself. What’s needed is true collaboration, openness and innovation, inclusivity, community and a need to think flexibly. Don’t let’s design for just one need but let’s create a sustainable health and wellbeing community for the next 70 years.

Banner image courtesy of Timothy Soar/NBBJ.

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