One of fifteen

facility components
SECTION 1
Emergency and Urgent Care Services

T
he emergency department (ED) serves as a critical point of entry care 24-7. An urgent care
for patients who require immediate treatment for life-threatening, center may also be co-
traumatic, and other acute health conditions at any time of day. located with an occupa-
The ED is also a gateway to the hospital's other medical resources since tional health clinic or a
many patients who enter the ED receive other services, such as inpatient primary care clinic.
care, specialty consultations, and ongoing outpatient care. In addition, A trauma center is a
the emergency department is the primary source of care for epidemics hospital-based emergency
and other natural and man-made emergency events. department equipped and
Patients arriving by ambulance, private vehicle, or on foot must move staffed to provide compre-
directly from the entrance to the reception or triage station and the hensive emergency medi-
appropriate treatment area. Non-emergency patients who consider them- cal services to patients
selves in immediate need of medical care are screened and directed to a suffering traumatic injuries.
waiting area, an appropriate treatment area for nonurgent conditions, a In the United States, a hospital can receive trauma center verification by
Introductory
primary care clinic, or other outpatient services. Individuals seek care in meeting the criteria established by the American College of Surgeons
descriptive
the ED for many narrative
reasons, including problems with access to services in and passing an on-site review. The Joint Commission also classifies
other settings and the challenge of determining the urgency of symptoms emergency departments according to the level of services they provide.
such as chest or abdomen pain without further diagnostics. However, official designation as a trauma center is determined by indi-
Emergency department visits generally fall into one of three catego- vidual state regulations. In general, the specific capabilities of trauma
ries: those that result in a hospital admission (admitted patient), those centers are identified by level designations, with Level I being the high-
that do not result in hospital admission (treat and release), or those with est. Higher levels have trauma surgeons available, including surgeons
a primary or secondary diagnosis of a behavioral health or substance trained in such specialties as neurosurgery and orthopedics, and sophis-
use disorder regardless of hospital admission. Patients who receive ticated medical diagnostic equipment. Lower levels may only provide
observation services, meaning they are put under observation (usually initial care and stabilization of a traumatic injury and arrange for transfer
less than 24 hours) while determining whether they need to be admitted, of the victim to a higher level of trauma care. The operation of a trauma
can be included in any of these three categories, depending on how their center is costly. Trauma centers often have a helipad for receiving
visit resolves. patients who have been airlifted to the hospital from areas where trauma
Urgent care centers — whether hospital-based or freestanding — capabilities are not available. However, all EDs, regardless of trauma-
offer a limited array of services for patients who need immediate care but level designation, must evaluate and stabilize trauma patients. If the
do not have life-threatening conditions. Unlike an emergency department patient cannot be treated at that facility, they are transferred to an appro-
or a freestanding emergency center, urgent care centers do not provide priate facility for further treatment.

SpaceMed Guide Emergency and Urgent Care Services 1-1

 Every hospital ED is different because it reflects the community's pick back up by the end of 2020 but declined again in January 2021 to
needs and resources. Some hospitals offer the full continuum of emer- about 25 percent below pre-pandemic levels. Starting the third year of
gency services — including trauma and emergent care, nonurgent care, the global pandemic, EDs continue to struggle with new waves of the
an observation unit, a chest pain unit, pediatric services, and a behav- coronavirus while seeing an increased number of high-acuity patients
ioral health crisis unit — while others provide only basic services. The who delayed their care in the previous two years. Patients who post-
location of imaging services and specialty diagnostics, intensive care poned care are now much sicker than before the pandemic, requiring an
beds, the surgery suite, and the labor and delivery suite also need to be extended stay in the ED and admission to an inpatient bed. At this point,
Currentdepartment.
considered when planning an emergency forecasting future ED visits and inpatient bed need is challenging at best,
Trends and there appears to be no agreement on what will be the new normal.
CURRENT TRENDS
Shortages of nurses. Even before the pandemic, the United States was
Emergency departments account for a large percentage of inpatient projected to experience a shortage of registered nurses (RNs) as aging
admissions, and they serve as an initial point of contact with the health- baby boomers require more health services, and a large portion of the
care system for many patients. The public's perception of a hospital may nursing workforce is retiring. The global pandemic has put further stress
well depend on the level of efficiency, professionalism, and customer on an already dire situation. With many nurses leaving the profession
service experienced during a visit to the ED. Unfortunately, hospital due to burnout, the Bureau of Labor Statistics projects that 1.2 million
emergency departments have spent the last two years trying to balance new RNs will be needed by 2030 to address the current shortage. Many
being in a state of emergency readiness waiting for the next COVID-19 hospitals are forced to hire traveler nurses whose rates are rising expo-
wave and safely delivering care to injured and acutely-ill patients. The nentially, dramatically increasing costs for hospitals. Consequently, EDs
usual challenges that existed before — overcrowding due to a lack of are being designed to facilitate efficient staffing patterns, reduce walking
inpatient beds for admitted patients, a rising number of patients with distances, provide a safe working environment, and promote collabora-
behavioral health issues, staff shortages, and narrow operating margins tion and teamwork.
— have become worse during the pandemic. Fluctuating utilization and
new safety protocols have created additional challenges. New safety protocols. For several decades, hospitals have focused on
controlling nosocomial (hospital-acquired) infections with ample hand-
Fluctuating utilization and forecasting challenges. Emergency washing stations and easily-cleaned surfaces. However, the coronavirus
department visits have increased steadily since World War II. That is has brought new attention to airborne transmission. As a result, emer-
until 2020, when the first significant drop in ED volumes occurred. gency departments are modifying their triage processes and implement-
According to the Centers for Disease Control and Prevention, there was ing a split-flow model to cohort patients based on their acuity and the
a 42 percent drop in ED visits in the spring of 2020 at the start of the level of suspected infection. They are also converting staff break rooms
COVID-19 pandemic compared to the year before. This initial reduction to don/doff zones for personal protective equipment (PPE), creating quiet
in ED volume was caused in part by the government's call to stay at spaces for staff respite, and embracing telemedicine. Where possible,
home, which in turn led to fewer accidents and other traumatic injuries. EDs are increasing the number of airborne infection isolation (AII) treat-
Unfortunately, individuals who needed immediate care for medical ment rooms and compartmentalizing spaces that can be efficiently shut
emergencies either delayed care or avoided care altogether due to a fear down and isolated to control the spread of infection.
of being exposed to COVID-19 while in the ED. ED volumes started to

1-2 Emergency and Urgent Care Services SpaceMed Guide

comfortable environment with open spaces rather than the frenetic Figure 1-1 provides an estimate of the national distribution of ED visits by
atmosphere of the ED. Behavioral health crisis units may be part of the acuity level (Theiling et al. 2020), although these percentages vary for
Major
ED, located on the same floor, or elsewhere Planning
on the hospital campus. each community.
Issues
MAJOR PLANNING ISSUES As the first point of contact for patients arriving at the ED, the triage sta-
tion is critical to ED operational performance. The triage nurse ensures
Key functional and operational issues that should be documented in the that patients who require immediate treatment are moved directly from
functional program before space planning include: the entrance to the appropriate treatment area. Non-emergency patients
are screened and then directed to a waiting area, appropriate treatment
Patient population and type of services to be provided. Understand- area for nonurgent conditions, or other outpatient services. Even with
ing the demographic composition of the patients to be served and an incentives to direct nonurgent patients to lower-cost settings, utilization of
analysis of expected acuity levels is key to the successful planning of a the ED by medically underserved patients for non-emergency care
new or renovated emergency department. This workbook includes guide- remains a challenge in many communities.
lines for all potential components of a hospital-based ED, including emer- Patients may also be triaged into specific components of the ED.
gent/urgent care, nonurgent care, and observation/holding. It can also be When the total number of patients reaches certain levels, it may be eco-
used to plan freestanding emergency and urgent care facilities. nomically and operationally desirable to design separate areas for medi-
cal, surgical, pediatric, obstetric, geriatric, cardiac, or behavioral health
Patient acuity and triage. Triage in the ED prioritizes incoming patients patients. For part of the day, it may also be desirable to triage nonurgent
and identifies those that cannot wait to be seen. The triage nurse per- patients to another area of the hospital that is more appropriate to their
forms a brief, focused assessment and assigns the patient a triage acuity needs, such as a primary care or specialty clinic.
level indicating how long the individual patient can safely wait for a medi- EDs are also experimenting with new triage concepts to expedite
cal screening exam and treatment. The Emergency Severity Index (ESI) care and reduce overcrowding in the waiting room. Some hospitals have
is a tool commonly used in emergency department triage that provides a implemented a rapid assessment unit (RAU), also called a rapid evalua-
method for categorizing ED patients into five groups from 1 (most urgent) tion unit (REI), as a potential solution. With this concept, when patients
to 5 (least urgent) based on their acuity and resource needs (ENA 2020). arrive at the ED, they register and are seen by a team — including a doc-
tor, nurse, and assistant. The patient has to answer questions about their
 Level 1 (Immediate) — patient requires immediate life- condition only once, and the doctor can move the patient to different
saving intervention areas of the ED, depending on the severity of their condition. Lower-
 Level 2 (Emergent) — patient who is high-risk and requires acuity patients may be sent to a sub-waiting area to wait for an X-ray or
treatment within 10-15 minutes another test.
 Level 3 (Urgent) — patient can remain untreated for 15-60
minutes Accommodating nonurgent patients. In many communities, a large
 Level 4 (Semi-urgent) — patient can remain untreated for number of patients seeking care in the ED have non-emergent conditions
one to two hours that can be safely and efficiently treated in a clinic-type setting without
 Level 5 (Nonurgent) — patient can remain untreated for two consuming the more expensive resources of an ED. Any ED with an
to 24 hours

1-4 Emergency and Urgent Care Services SpaceMed Guide

 Will the ED be designed with surge capacity the random nature of arrivals to the ED, actual
and special design features for infectious Figure 1-2 workloads fluctuate from month to month, week
disease outbreaks or nuclear, biological, or Average Daily Workload Peak Month to week, and day to day ― requiring an analysis
chemical control? Will a human decontamina- (ADWPM) to Peak Daily Workload (PDW) of average versus peak workloads. Most hospi-
Conversion Factors
tion room be provided? Is there a disaster tals already collect detailed data on monthly and
preparedness plan? Will space be designated daily fluctuations in workload to predict staffing
ADWPM to PDW
that can be used by the hospital incident com- Annual Visits Factor levels for annual budgeting. When available, this
mand system team when necessary? data should be used to compare the average
 How will supplies be delivered, stored, and Less than 20,000 1.30 daily number of visits with peak daily visits to
inventoried? What materials distribution system 20,000 to 40,000 1.25 determine the number of patient treatment
will be used to supply the facilities with sterile spaces.
supplies, general supplies, nourishments, and 40,000 to 60,000 1.20 In the absence of such institution-specific
medications? How will trash, hazardous waste, data, a variation of the Poisson distribution for-
Over 60,000 1.15
and recyclables be removed? mula can be used to estimate the peak daily
 What staff/administrative spaces will be workload. First, the peak monthly workload
provided? Which spaces can be shared with (PMW) can be estimated at 10 percent of the
other clinical services — such as staff lockers/changing facilities and total annual visits if actual data is not available. Then, the average daily
conference/classrooms? Who will need private offices? Which workload for the peak month (ADWPM) can be calculated by dividing the
administrative offices and workstations can be located in an adjacent peak monthly workload by 30.5 days. Finally, peak daily workload (PDW)
or remote administrative office suite? Space Planning can be estimated statistically based on the average daily workload peak
Approach month (ADWPM) and the desired level of confidence that a treatment
SPACE PLANNING APPROACH space will be available when a patient arrives. For example, using 2.33
assumes a 99 percent confidence level or that a treatment space will be
Estimating peak workloads. As a starting point, current and historical available at least 99 percent of the time.
workloads should be analyzed by acuity level and time period to deter-
mine trends in utilization. Future projections should be based on a Peak daily workload (PDW) = ADWPM + [2.33 x √ADWPM]
detailed analysis of the hospital’s current and projected service area pop-
ulation, use rates, market share, and expected ED length of stay. Nation- This calculation can be simplified by using the factors, as shown in
ally, ED use rates have increased from 360 annual visits per 1,000 Figure 1-2 to estimate the PDW based on the ADWPM. Furthermore, in
population in 1995 to 437 annual visits per 1,000 population in 2018 a typical ED, the peak shift workload (PSW) generally represents 50 per-
(AHA 2022). The impact of initiatives to redirect nonurgent patients to cent of the peak daily workload and usually occurs from 4 p.m. to 11 p.m.
lower-cost settings should also be taken into account. However, with so Nonurgent patients, who could be triaged to a separate fast track area,
many critical issues facing EDs today, caution should be observed when may represent 30 to 40 percent of the peak daily workload. However, the
using historical workloads to predict future visits. peak shift workload in a separate fast track area is generally 75 percent
Emergency departments typically record total visits per month or of the PDW (rather than 50 percent for urgent care) since most non-
year from which average daily workloads can be calculated. Because of urgent patients arrive during the late afternoon or evening hours.

SpaceMed Guide Emergency and Urgent Care Services 1-7

Estimating treatment room turnaround times. Appropriate treatment and examination) in a low-acuity treatment station. The low-acuity treat-
room turnaround times can be estimated once the peak shift workload is ment station provides a space-saving alternative to the traditional
projected and a decision made whether or not to create a separate fast multiple-patient cubicle or bay, as shown in Figure 1-3. Once the number
track area. Room turnaround time refers to the patient's actual time in a of general treatment spaces has been calculated (for both the emergent/
treatment room, cubicle, or bay ― not the time the physician spends with urgent care and nonurgent/fast track areas), some of these spaces can
the patient or the total time the patient spends in the ED. The specific be designed for use by special patient populations. Additional observa-
room turnaround times used for planning space in a given facility repre- tion or holding spaces and other unique treatment spaces are added to
sent a major decision in the planning process because they have a arrive at the total number of patient care spaces to be programmed for
significant impact on the number of treatment spaces. Although this deci- the emergency department.
sion will be somewhat arbitrary, it should be based on some combination
of historical data and realistic expectations.
Figure 1-3
Comparison of Multiple-Patient Treatment Bays/Cubicles and
Some typical ranges are shown below: Low-Acuity Treatment Stations

 180 to 360 minutes for an admitted patient

 120 to 180 minutes for a discharged patient
 60 to 120 minutes for a fast track patient

On average, an emergent patient remains in a general treatment cubicle

for 150 minutes. The patient is then either discharged, moved to a spe-
cialty diagnostic or treatment area, moved to an observation unit, or
admitted to the hospital. This excludes patients who are initially triaged to
a trauma/resuscitation area or separate fast track area. The Quick Space
Calculation for an Emergency Department template on the following
page can be used to estimate the number of treatment spaces required
based on different treatment room turnaround time assumptions.

Estimating the number and type of treatment spaces. The number of Treatment rooms for the following special patient populations can be
general treatment spaces can be calculated by multiplying the expected designed flexibly to also serve as general treatment spaces:
peak shift workload by the average room time and dividing this figure by
480 minutes (eight hours). Patients receiving general care may be  Airborne infection isolation (AII) treatment room. At least one AII
placed on a stretcher in a single-patient treatment room or multiple- treatment room with a contiguous patient room should be located in
patient treatment area with cubicles (with three walls and a curtain the ED. Personal protection equipment (PPE) storage must be
closure) or bays (with a headwall and curtain closure on the remaining located either directly outside the room, in an anteroom, or inside the
three sides). Alternately, less acute patients may be placed in a chair (a entry door to the room. The AII treatment rooms can be used for
typical chair, lounge chair, or recliner chair appropriate for patient consult non-infectious patients when not in use for isolation.

1-8 Emergency and Urgent Care Services SpaceMed Guide

 Multiply the total number of treatment spaces by a range of 550 to
650 department gross square feet or DGSF (51.1 to 60.4 department Figure 1-4
gross square meters or DGSM) per treatment space to estimate the Estimating Emergency Department Treatment Spaces
total footprint for the department. If a separate urgent care center is Based on Annual Visits
being programmed, approximately 450 to 550 DGSF Helpful
(41.8 to 51.1
Average
DGSM) per treatment space can be used to estimate the space
Rules-of Thumb Treatment Space Average
required for the center. Turnaround Time Annual Visits per
Performance (Minutes) Treatment Space
The number of treatment spaces can also be estimated based on the Poor 210 1,100 to 1,200
total annual visits, using the guidelines shown in Figure 1-4.
Average 150 1,200 to 1,600
Developing a detailed space program. The space within an ED can be
Best Practice 120 1,600 to 1,900
divided into the following major components:

 Patient intake area begins with the triage station and includes the
registration function, patient/visitor waiting, and related space that is  Staff/administrative space includes administrative offices, staff
not generally part of the patient treatment area. An optional rapid lounges/lockers, and other staff amenities that do not need to be
assessment unit may be provided instead of the triage station if this within the patient treatment areas.
operational concept is being implemented.
 Emergent/urgent care area represents the main emergency depart- The relationship between the functional components in an emergency
ment and includes all spaces related to treating high-acuity patients, department is illustrated in Figure 1-5. Guidelines for planning an MRI
including spaces for trauma/resuscitation, general and specialty suite are provided in Section 3: Imaging and Other Diagnostic Services.
treatment, and associated support space. Some emergency departments may also provide hyperbaric oxygen
 Nonurgent care/fast track area is provided when nonurgent therapy, addressed in Section 9: Ambulatory Care.
patients are triaged to a separate area for treatment, including a sub-
waiting area, treatment spaces, and associated support space. Estimating department gross square feet (meters). A net-to-depart-
 Observation unit is optional depending on the ED’s scope of ment gross space conversion factor is used to convert the sum of all net
services, availability of space in other locations, and an organiza- spaces to an estimate of the actual department footprint. Net-to-depart-
tion’s specific policies and procedures regarding admission. ment gross space conversion factors generally range between 1.50 and
 Behavioral health crisis unit is optional depending on the ED's 1.60 for EDs. A smaller factor of 1.45 or 1.50 can be used in planning an
scope of services and availability in other locations. urgent care center or an observation unit. If staff/administrative space is
 Shared clinical support space includes space that is necessary to located apart from the ED, a reduced factor of 1.25 to 1.30 should be
support all the treatment areas and may include dedicated X-ray, CT, used for this area alone. These factors will vary depending on whether
and ultrasound rooms, or space to house portable imaging new construction is planned (lower factor) or if the function is to be retro-
equipment; a satellite laboratory or pharmacy may also be provided. fitted into existing space (higher factor).

SpaceMed Guide Emergency and Urgent Care Services 1-11

 The same space planning approach is used to plan a
remote or freestanding emergency or urgent care center. Figure 1-5
If a freestanding facility is planned, additional factors may Example of an Emergency Department Functional Layout
be required to estimate the total building gross square feet
(meters) described under the "Space Conversion Factors"
Future
heading in the Using This Workbook chapter. Flexibility and
Adaptability
FUTURE FLEXIBILITY AND ADAPTABILITY

Before the COVID-19 pandemic, emergency department

planning efforts were routinely focused on improving treat-
ment space turnaround time to combat ever increasing-
workload volumes. Improving treatment space throughput
can dramatically increase the capacity of an ED without
adding staff or expanding the physical space. For exam-
ple, using the average treatment space turnaround times
in Figure 1-4, an emergency department with 40,000
annual visits could increase its capacity by 25 percent
(adding 10,000 annual visits) if it improved its treatment
space turnaround time from "average" to "best." Going
from "poor" to "best practice" could increase its capacity
by 75 percent (adding 30,000 annual visits).
Improving treatment space turnaround time usually
begins with a detailed analysis of the key transition points
in the patient care process, as shown in Figure 1-6. How-
ever, moving patients from arrival to the point where a decision is made injured, with little thought given to the design implications if many
on their disposition is not always within the control of ED staff. Emer- patients were infectious. Although airborne infection isolation (AII) rooms
gency departments are complex operational systems impacted by many were provided to accommodate local or seasonal outbreaks of infectious
other parts of the hospital and healthcare delivery system. For example, patients, hospitals were typically focused on infection prevention and
when the decision is made to admit a patient, an inpatient bed may not reducing healthcare-acquired infections (HAI). Very few people antici-
be available, resulting in patient boarding within the ED. Treat-and- pated an event that would cause the numbers of patients with an
release patients may still have to wait in the ED for a diagnostic test or infectious disease to rise beyond dozens locally, let alone into the
while the ED staff are waiting for their test results. ED staff may also hundreds of thousands nationally. As a result, emergency departments
need to rely on a specialist for consultation before they make a decision. have shifted their focus from throughput to just keeping their patients,
Before the COVID-19 global pandemic, it was commonly assumed staff, and community safe.
that most patients arriving at an emergency department would be ill or

1-12 Emergency and Urgent Care Services SpaceMed Guide

 Future planning must also include contingencies for weather, wild-  When a human decontamination room is provided, it should have a
fires, chemical exposure, and other natural and man-made emergency separate independent exterior entrance no closer than 10 feet (3.1
events. In response, identification of surge space elsewhere in the meters) from other entrances, along with an interior entrance to an
hospital should be part of any disaster preparedness plan. In addition, ED corridor.
emergency departments may need to enhance their perimeter security  The reception/triage station should allow staff to monitor the patient
and access control, provide a means for detecting weapons, such as a and visitor waiting area and control access to the ambulatory
Facility
metal detector, and install video surveillance systems at each Layout
entrance. entrance and the treatment areas. Ideally, the triage station should
Considerations be adjacent to the care team work area within the emergent/urgent
FACILITY LAYOUT CONSIDERATIONS care area so that staff can circulate between the two areas. Patients
arriving by ambulance should not be visible from the patient/visitor
The ED should be designed with a major emphasis on creating an waiting area.
efficient flow of patients through the department and adjoining fast track  A public corridor should be provided that links the emergency
and diagnostic areas. Patients who require immediate treatment for life- department walk-in entrance and patient/visitor waiting area to the
threatening, traumatic, or other acute health conditions must move to the main hospital entrance and elevator lobby. Visitors may need to
appropriate treatment area as quickly as possible. A separate ambulance access the hospital cafeteria, an inpatient unit, or another hospital
entrance should be provided because it is assumed that patients arriving area and should not have to travel through an ED treatment area.
by ambulance will bypass the triage station. The triage nurse ensures However, visitors should be restricted from circulating throughout the
that all other patients who need immediate care move directly from the hospital during the evening and nighttime hours for security
walk-in entrance to the appropriate treatment area. Non-emergency purposes. Depending on the overall building layout, food and
patients who consider themselves in immediate need of medical care beverages may need to be provided adjacent to the patient/visitor
must be screened and then directed to a waiting area until an appropri- waiting room.
ate treatment space is available.  Convenient access to wheelchair and stretcher storage is required
Within a medical center, the ED interacts most closely with the imag- for arriving patients but should not impede circulation.
ing department, labor and delivery suite, intensive care unit, and surgical  Emergency department staff need PPE donning and doffing areas
suite. These areas should be adjacent to the ED or directly accessible that are safe and easy to use. In addition, adequate locker/changing
via an oversized elevator designed to accommodate a stretcher, space should be provided near a designated Potential Facility
staff entrance/exit.
transport staff, and several pieces of patient care equipment. Ideally, separate circulation patterns should be provided for
Planning staff
Pitfalls
arriving and departing.
Specific facility layout and design considerations include the following:
POTENTIAL FACILITY PLANNING PITFALLS
 The emergency (or urgent care) entrance should be at grade level
with clear signage, supported by other visual cues or architectural Potential facility planning pitfalls that may result in inappropriate ED
elements, and protected from the weather. Direct access from a facilities include the following:
heliport (if provided) and public roads for ambulance and vehicle
traffic is also necessary.

1-14 Emergency and Urgent Care Services SpaceMed Guide