Description

In contrast to the popular myth, familiar from television shows, that the emergency ward is the scene of hectic activities, it in fact usually provides patients waiting there with a relatively calm environment. Large-scale accidents are rare exceptions to the rule. In real life, the emergency department is primarily the site of a group of processes that are not necessarily confined to clearly delineated areas. It requires separation of traffic flows, the prioritizing of patients and quick intervention — all these being functions of the location and intensity of patients’ injuries or ailments. An initial assessment (triage) separates patients into five categories: critical care (immediate need of life- or limb-saving medical intervention), emergent (risk of deterioration, time-critical medical issue), urgent (stable, in need of multiple medical investigations and assessments), less urgent (stable, in need of a simple medical investigation and assessment) and non-urgent (stable, no need for medical investigation and assessment). Emergency care usually involves a patient consultation, diagnostics, stabilization, treatment procedures and medical supervision, all at the same time.

Typical components of the emergency department of a large hospital

Patients, Visitors and Staff

Patients arriving at the emergency department might be victims of accidents or crime. Some have medical conditions which can give rise to sudden critical issues requiring immediate attention. Other patients arrive in a critical state due to severe complications stemming from ailments that are relatively straightforward to treat but have long gone untreated (often because the patients are uninsured and cannot afford to pay for regular treatment). For them, the emergency department offers a service of last resort.[143] This can also be the case with psychiatric patients, who might delay seeking medical advice because of the stigma associated with their problems. The proportion of different categories of patients is determined by many factors, ranging from urban safety and type of community to the primary care infrastructure and the accessibility of the healthcare systems, which in turn is directly related to the quality of the public health systems (or the lack of them). Returning to the example of psychiatric patients, their visits to the emergency department become especially problematic when specialized facilities for and medical staff skilled in detecting and addressing psychiatric symptoms are absent. Some patients may arrive at the emergency department by various means of transportation, while others might be brought to the hospital by family, friends and, occasionally, passersby. If patients cannot come by themselves in the usual ways, ambulances are provided for their transportation. In exceptional circumstances or in isolated areas, helicopters are used to transport doctors and /or patients to or from accident sites.

What all patients in this department have in common is the presumed need for immediate action. Time is of the essence, first of all in simply getting there. Then decisions have to be made concerning diagnosis and treatment, and if several emergencies occur simultaneously, the medical staff needs to prioritize on the spot — who should be assisted first and by whom? Once emergency treatment has started, there is no time to waste. One way of wasting time is transporting patients through the hospital, which is a good reason for integrating medical imaging (X-ray machines and CT scanners) in the emergency units, and also for having a dedicated emergency and trauma care specialist at hand.

Spaces

The emergency department can be accessed via three main routes: the central hospital reception area for all patients, a direct entrance to the department with a reception area for patients arriving by regular transportation and the ambulance entrance. Since the emergency department is an expensive facility to build and maintain, some of them have adjoining diagnosis and treatment facilities designed to handle non-life-threatening health issues outside of the normal working hours, staffed by general practitioners serving the area (primary care facilities). Accordingly, the reception area for patients arriving by regular transportation is usually accompanied by a spacious waiting area capable of serving both patients visiting the emergency department and patients visiting the adjoining primary care facility. The presence of several (three to four) triage rooms offers the possibility of quickly conducting triage for a large number of patients and of deciding on treatment plans. If a patient’s condition is not severe, he or she might have to wait some time for a consultation with the general practitioner on duty. Sprained limbs and simple fractures can be treated in a separate area with its own staff.

When the condition is acute but non-life-threatening and needs immediate attention, the patient can be directed to a fast-track diagnosis facility within the emergency department. This reduces waiting time for these patients, allows for the efficient separation of patient flows and frees up the more specialized facilities, equipment and staff to concentrate on the patients with life-threatening conditions. It is recommended that triage take place upon arrival using standardized tools for analyzing the severity of the problem. This helps determine the correct care pathway for the patient in an objective manner. Some emergency departments are equipped to deal with a wide variety of critical conditions such as major trauma and life-threatening illness, myocardial infarctions, strokes, acute exacerbation of long-term illnesses, acute surgical needs or acute mental health deterioration. At others, patients with certain specific critical conditions are transported to specialized facilities, such as a dedicated stroke unit, bypassing the emergency department.

Patients arriving by ambulance are usually in the most urgent need of medical attention. The stabilization and triage procedures are often performed en route by the ambulance staff and the patient is transported to the specific acute care department. The ambulance entrance must therefore be connected to all the acute and urgent treatment routes of the hospital. Critical cases, such as acute myocardial infarction, cerebrovascular accidents (strokes, CVA), suspected multi-organ failure or abdominal aortic aneurysm (AAA), might bypass the emergency department altogether and be transported, respectively, to the acute cardiac care unit (ACCU), the coronary care unit (CCU), the stroke unit, the ICU or the operating block. Surgery can be performed in a centralized operating block or in a dedicated acute surgical unit. Additional spaces that might be included in the emergency department are decontamination facilities for chemical, biological, radiological and nuclear accidents and a waiting and meeting area for ambulance staff and police.

Some patients might arrive highly intoxicated or disturbed at the hospital, so that a special room ensuring sufficient security, supervision and control should be included. Patients with acute psychiatric symptoms should be provided with a space designed to prevent overstimulation and to prevent the patients from hurting themselves or others. In urgent cases children who are rushed to the emergency department follow the care pathway of an adult in the same state. Otherwise, children are best treated in the pediatrics department.

The acute medical unit (AMU) is a recent development, acting as a bridge between the emergency department and the inpatient wards for patients with an acute condition (usually accounting for a third to half of all inpatient admissions). The layout of this unit and its patient rooms are similar to those of the usual inpatient wards. The most important difference is the around-the-clock supervision by specialized medical staff. Patients usually stay for a maximum of 48 hours in the AMU, during which time the stabilization, diagnosis and treatment plan are finalized.

The frequency and nature of visits to the emergency department varies during the course of the day, the week or the year. For example, children with injured, sprained or fractured limbs usually arrive during daytime. Victims of violence and crime and intoxicated patients arrive more often during the evening, night time and weekends. For any given location, it is usually possible to discern patterns, allowing for the forecasting of the average number and types of facilities and staff required. The optimum services, size and configuration of emergency departments needs to be established on the basis of local research in order to ensure not only high quality of care, but also process effectiveness and efficiency.

Perspective of the Patient

Patients visiting an emergency department are usually either traumatized and in a state of stress and anxiety or else hardly conscious of the world around them. After treatment they are either discharged and can go home or are admitted to the AMU or an inpatient ward. The emergency department environment should be conducive to sustaining and increasing the patient’s sense of safety and reducing his or her stress — through, for example, intuitive layout, clear lines of sight and minimal noise and visual clutter.

Position Relative to Other Departments

An emergency department must have a separate entrance, easily accessible by ambulance, private car and, if need be, helicopter. In order to ensure fast transfers to all acute intervention departments, the units should be physically close to each other or else connected by fast access routes. For example, the ACCU should be closely connected to the cardiac intervention facilities, CCU and ICU. Separation of patients with life-threatening conditions needing highly specialized care from other patient flows also reduces confusion and makes processes more efficient.

Emergency department and patient traffic routes

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Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.