A Design for the 21st Century By Neal E. Flomenbaum, MD, Editor-in-Chief

Have you ever looked around your emergency department on a day when nothing is going right and asked yourself, “What were they thinking when they designed this place?” Most emergency physicians spend their entire careers working in departments that were designed decades ago by others. Like sports stadiums, emergency departments last about 25 to 40 years, so the chances are very good that however well suited to its purpose an emergency department may have been on the day it opened, it will rarely, if ever, remain so throughout its lifetime.

The designs for the current generation of emergency departments were determined largely by concepts and clinical problems that appeared, disappeared, or emerged rapidly during the past 20 years. In the late 1980s the expectation that managed care would eliminate “needless” visits and thus reduce patient volume resulted in the construction of smaller departments. Unfortunately, managed care’s requirement for more extensive diagnostic testing in the emergency department prior to approval of hospital admissions was never factored into the equation.

The 1980s and ’90s were also marked by the unexpected and overwhelming challenge of caring for acutely ill and dying patients with HIV and AIDS, followed by their disappearance from the emergency department population in the mid-1990s when more effective treatments transformed HIV and related illnesses into more manageable chronic diseases. The not-yetrealized promise of paperless emergency departments, the additional volume contributed by the alphabet soup of EMTALA, SARS, MRSA, and VRSA, the specters of terrorism and disaster—all coming and going, or coming and staying—have dramatically affected the efficiency of our workplace.

So it is with some trepidation that I approached the opportunity to design a new emergency department expansion for the next quarter-century. Which conditions are likely to remain with us for some time? And which new and emerging diseases are likely to be important in the next 25 years? I envision increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy. Unfortunately, my design would also include provisions for the handling of disasters, both natural and man-made.

Ideally then, the emergency department of the 21st century should include multiple enclosed patient-care spaces that can be used for isolation or reverse isolation. I would install a separate entrance and separate air handling for this entire unit so that it can be sealed off from the rest of the hospital or emergency department if necessary. I would equip all of the rooms with adjustable stretcher-chairs to accommodate the orthopedic needs of the elderly and notso-elderly. I would also incorporate adequate hand-cleansing facilities at each bedside in full view of patients, appropriate floor patterns and signage for older adults, and safety features such as LEDs that would point the way out during power outages and smoke conditions. I would even want to install more natural background lighting with 24-hour rheostats to compensate for the lack of diurnal rhythm resulting from the absence of windows in most emergency departments.

There are further considerations and additional possibilities, ranging from absolute necessities to patient and staff comfort features. But even when funding is adequate, it is never limitless and choices must be made.

I am confident that our emergency department expansion will be a great addition to our current facility. At the same time I can’t help but wonder whether 25 years from now a future emergency physician (currently in kindergarten) will find herself looking around this emergency department and asking herself, “What on earth was he thinking?”

Emerg Med 38(10):7, 2006