a&e departments
TRANSCRIPT
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The impact of the built environmenton care within A&E departments
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Crown copyright 2003
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To enable a better understanding of the influence of
building layout on the care of patients in A&E departments
a research programme was undertaken by Intelligent
Space Partnership on behalf of NHS Estates. This report
describes the methodology of the project and presents
findings and recommendations from the research.
Eight existing A&E departments were used as a basis forthe research. Comprehensive surveys were carried out for
each department to evaluate current use patterns. In
addition, computer modelling was used to benchmark key
design characteristics. Each stage of the patient care
model was evaluated starting at the entrance leading
through assessment and treatment along with support
facilities such as the staff base.
The project was developed to:
support guidance for the building of future departments;
provide measures to evaluate planned A&Edepartments;
identify potential problems prior to the construction of
new departments;
identify methods for post-occupancy evaluation of
departments.
The key recommendations emerging from the research are
as follows.
ACCOUNTING FOR PATIENTS VISITORS ANDSTAFF
The design phase for new departments should take into
account not only the needs of patients and staff but also
those of visitors and the journeys they make.
ARRIVALS AND ENTRANCES
The route by which a patient, staff member or visitor enters
the department affects the locations they can access. As
the ambulance entrance leads directly to resuscitation and
the major injury area, it is important that access through
the entrance is tightly controlled.
The routes by which visitors enter and leave thedepartment should be tightly controlled so that privacy and
dignity of patients is not compromised and to ensure that
visitors do not access sensitive areas.
RECEPTION AND WAITING AREAS
It is important that the waiting area can be surveyed from
the reception point to:
monitor patients and identify if their condition becomes
cause for concern;
control access into the A&E department;
monitor all those in the waiting area, to identify incidents
of inappropriate or criminal behaviour.
Issues such as this can be identified at the design stage,
which may help to ensure that the people seating in the
waiting area can be overseen.
ASSESSMENT
It is important that patient privacy is fully accounted for in
new designs and improved in existing departments where
privacy is lacking.
TREATMENT
It is important for departments that are currently being
planned to take into account potential changes such as:
fluctuations in patient numbers;
duration of treatment times;
changes to the proportion of patients presenting with
minor and major injuries.
It is important for staff members to oversee multiple
treatment rooms through either direct surveillance or
through use of technology.
CIRCULATION AND WAYFINDING
Layout of the department should support natural
wayfinding.
The key routes for natural wayfinding can be modelled from
design drawings. It is important to identify routes that
people take through the key locations in the department
such as the entrance or from treatment rooms.
The design of circulation space can help minimise time
spent by staff walking between different locations and the
distance they have to walk each day.
Executive summary
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NHS Estates would like to thank all who
participated in this research project including
staff, patients and visitors from the following
NHS Trusts:
Bradford Hospitals NHS Trust
Hull and East Yorkshire Hospitals NHS Trust
Mayday Healthcare NHS Trust
Norfolk & Norwich University Hospital NHS Trust
Northamptonshire Healthcare NHS Trust
Oxford Radcliffe Hospitals NHS Trust
Sherwood Forest Hospitals NHS Trust
Southampton University Hospitals NHS Trust
The research was carried out on behalf of
NHS Estates by:
Intelligent Space Partnership
81 Rivington Street
London EC2A 3AY
http://www.intelligentspace.com
Acknowledgements
http://www.intelligentspace.com/http://www.intelligentspace.com/ -
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Executive summary
Acknowledgements
1 INTRODUCTION
Context page 3
Introduction to the A&E departments used in this
study page 3
The patients journey page 3
Methodology page 6
Baseline statistics
Design KPIs
Space use KPIs
2 FINDINGS AND RECOMMENDATIONS
Locations of patients, staff and visitors page 8
Arrival and entrances page 8
Entrance design
Access control
Recommendations: Access control
Patient, staff, visitor ratios page 10
Recommendations: Flexibility
Reception and waiting areas page 10
Waiting area provis ion
Recommendations: Provision
Surveillance of waiting areas
Recommendations: Surveillance
Wayfinding
Recommendations: Wayfinding
Patient, staff and visitor ratios: waiting areas
Triage and assessment page 13
Provision
Recommendations: Wayfinding
Privacy and dignity in assessment rooms
Recommendations: Privacy and dignity
Patient, staff and visitor ratios: assessment rooms
Treatment rooms page 15
Provision: treatment rooms
Flexibility
Recommendations: Provision and flexibility of use
Surveillance
Recommendations: Surveillance
Wayfinding and location of t reatment rooms
Recommendations: Wayfinding
Privacy and dignity in treatment rooms
Recommendations: Privacy and dignity
Use of treatment rooms by patients, staff and visitors
Use of major and minor treatment rooms
Circulation page 24
Provision: circulation space
Wayfinding
Recommendations: Wayfinding
Access controlPatient, staff and visitor (PSV) ratios
Routes
3 CONCLUSIONS
The way forward page 29
APPENDIX 1 DEPARTMENTS
APPENDIX 2 METHODOLOGY
Entrance and exit counts page 38
Staff and patient pathways page 38
Space use occupancy survey page 40
Room profiles page 40
Visibility modelling page 40
ABOUT NHS ESTATES GUIDANCE AND
PUBLICATIONS
1
Contents
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The common challenges faced by the majority of A&E
departments around the country include:
long waits for patients;
violence towards staff;
criminal behaviour and damage to property;
lack of privacy and dignity for patients;
difficulty for patients and their companions in finding
their way around the department.
Computer modelling is one method of evaluating
examples of practice to assess the impact that the built
environment has on the care process.
This report reviews the findings from the research by
Intelligent Space Partnership on the impact of the built
environment on care within Accident and Emergency
(A&E) departments. The research was based on thephysical observation of eight A&E departments and
computer modelling of the layouts. Some were pilots
from the Modernisation Agencys IDEA programme; one
was nominated by the British Association of Accident
and Emergency Medicine.
CONTEXT
The method by which care is being delivered in A&E
departments is undergoing change. There is a new
service model, which covers both the built environment
and the delivery of clinical and non-clinical services. This
is based on the See and Treat system, designed toreduce waiting time and improve the patient experience
in A&E departments.1
It is fair to say that all eight of the departments surveyed
as part of this study could have been better designed to
support the functionality of the department. For
example:
original design to serve an annual attendance of
40,000 people but now receiving nearer to 60,000;
treatment areas being used as thoroughfares, thus
compromising patient privacy and dignity;
related functional areas not positioned in close
proximity to minimise travel distances, for example
treatment areas situated at a distance from supplies
store.
It is often the case that good care is provided despite
the weaknesses in the design of the facility whereas a
well designed facility can help to enhance and support
patient care.
There are many examples of good practice showing key
design features that support the patient experience.
However, there has been very little quantitative
evaluation of the impact of the existing designs of A&E
facilities on their ability to support the care process.
For this reason a research programme was
commissioned to review eight existing A&E
departments. This compares use patterns and identifies
design features that support existing working practices
as well as the ability of departments to adapt to change.
The project was developed around four key actions:
to support guidance for the building of future
departments;
to provide measures to evaluate planned A&E
departments;
to identify some potential problems prior to
construction of new A&E departments; and
to identify methods for the post-occupancy
evaluation of departments.
INTRODUCTION TO THE A&E DEPARTMENTSUSED IN THIS STUDY
Eight A&E departments were selected as the basis for
this research. These departments are of varying ages,
sizes with differing numbers of patients per annum. Of
these departments, one has started to implement the
streaming of patients using the See and Treat model in
A&E. This enables a comparison of the impacts on the
use of the department when patients are categorised
using triage, against the proposals for streaming
patients and use of assessment rooms.
The case studies enable a comparison to be made onthe impact of the building layout on the existing care
model to benchmark what works well and where
improvements can be made. This forges the link
3
1 Introduction
1 Full details can be found in See and Treat,
NHS Modernisation Agency, 2002.
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THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
4
Figure 1 Relationship of rooms and areas for patients arriving through the main entrance
Receptionmeet & greet
Resuscitation
Clinicaldecision unit
or observationunit
Digital imagingsuite
Assessmentunit in childrens
department
Assessment roomsincluding registration
Waitingarea
Pharmacy
WCsBaby changeInfant feeding
Socialcare
Sub-waitWC
Interview
ENTERWELCOMINGENTRANCE
Communicationsbase
Main entrance
Head/neck
Gynae
Childwait
Sub-waitWC
Treatment rooms
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1 INTRODUCTION
5
Figure 2 Relationship of rooms and areas for patients arriving by ambulance
Resuscitation
Assessment unitin the childrens dept
Critical careOperating theatres
Acute wards
Treatment rooms
Clinicaldecision unit
or observation unit
Digital imaging suite
Ambulancebay
Ambulancestore
Viewingroom
Sittingroom
WC
Sub-waitWC
Sub-waitWC
AMBULANCEENTRANCE
The ambulance entrance
DESIRABLE EXIT
GARDEN VIEW
THESE FACILITIES SHOULD BELOCATED CLOSE TO THEDEPARTMENT PREFERABLY ON
THE SAME FLOOR
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between the care model and the built environment,
enabling a quantitative evaluation of the buildings ability
to support the patients journey.
Each department is described in detail inAppendix 1.
THE PATIENTS JOURNEY
To understand how the layouts of the departments
support care, it is important to understand the journeys
that patients make through the department. It is also
valuable to include the paths that visitors are likely to
take, to ensure that their needs are also fully accounted
for (see Figures 1 and 2).
The main difference between the existing system of care
and See and Treat is in the initial assessment and
registration stages:
in the existing care model the patients details are
taken at the reception desk. They are then asked to
wait for a short time before being directed to a triage
room where an initial assessment takes place. Once
the patient has been assigned a triage category, they
sit in the waiting area until they are called. The patient
is then directed to either a minor treatment room, a
major treatment room or a resuscitation room;
in See and Treat there is no triage stage. Instead,
the patient is either directed to an assessment room
or asked to wait a short time before being called to
the next available assessment room. A small number
of patients need to be transferred immediately to the
treatment or resuscitation room. In the assessment
room, registration, assessment, examination and
minor treatment (if appropriate) takes place. Tests do
not take place here. The majority of patients are fit to
be discharged at this stage. Other patients are taken
to a treatment room for tests, more extensive clinicalexamination or treatment.
The current triage system often means that the less
serious the injury, the longer the wait. However, as the
majority of patients presenting at A&E have conditions
that can be treated within half an hour, the people who
wait the longest are those who require only short
treatment times. This can be seen clearly in Figure 3
where in Department 3 over 80% of patients had
treatment times less than 30 minutes. By reversing this
trend, the aim is to reduce the numbers of those sitting
in waiting areas and therefore reduce the overall waiting
time.
METHODOLOGY
For this study comprehensive surveys were undertaken
in each department to evaluate current use patterns.
This provides evidence on how the buildings are
currently being used as well as design features that
can support or hinder the delivery of care. In addition,
computer modelling was used to benchmark key design
characteristics such as ease of wayfinding and
observation of patients.
Each stage of the patient care model was evaluated,starting at the entrance, leading through assessment
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
6
Figure 3 Treatment times (time spent in the treatment room) in Department 3
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and triage, to treatment and through to the support
facilities such as the staff base.
To compare eight very different A&E departments,
a series of Key Performance Indicators (KPIs) were
developed. This enabled the departments to be tested
on a series of objective criteria based on their layout
and use.
Baseline statistics
Baseline statistics were used to evaluate standard
functional aspects of the departments based on the
individual layout plans. These include:
provision (how much space is provided for each
space use type; this includes information on the room
dimensions);
flexibility (the location of treatment room types and
the ability to use treatment rooms for uses other than
those initially designated).
Design KPIs
The design KPIs relate to how the designs of the
departments affect their functional use, which is
measured using visibility graph analysis (seeAppendix 2
for description). This method was used to identify ease
of wayfinding in the departments and the surveillance of
rooms. These KPIs include:
surveillance (the degree to which patients are
overseen by staff members);
wayfinding (the ease by which you can find your way
around departments);
privacy and dignity (the consideration of privacy and
dignity for patients being treated in A&E);
access control (the measures put in place to restrict
access into and within the A&E department).
Space use KPIs
The space use KPIs result directly from the surveys of
the departments. These include:
ratios between patients, staff and visitors (this was
used to identify both the numbers of patients, staffand visitors at different locations as well as the ratio
between each category);
use (length of treatment times in major and minor
treatment rooms);
routes (journey lengths for staff, patients and visitors).
A full description of the methods used can be found in
Appendix 2.
1 INTRODUCTION
7
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This chapter identifies how the building designs in A&E
departments affect how they are being used. It aims to
give examples of good and poor practice that relate to
common problems in A&E departments across the
country. It poses questions and makes
recommendations to be taken into account in the
design of new facilities.
ARRIVAL AND ENTRANCES
The first stage of the care process is the arrival of
patients at the A&E department. This needs to be
managed and controlled through the design of
entrances. The entrances to A&E have two main
functions:
to welcome people into the A&E departments; and
to control access into A&E and the hospital as a
whole.
Design and control of entrances can have a major
impact on the patients journey and running of the
department.
There are three categories of entrance into the A&E
departments:
main entrance (for people entering by foot or bywheelchair);
ambulance entrance (for patients arriving by
ambulance);
internal entrance (these are the entrances that lead
from the main hospital).
Currently around 24%2 of patients arrive by ambulance;
the remainder arrive on foot, or by public or private
transport. A number of these are GP referrals.
8
2 Findings and recommendations
2 Source: QMNG 2001/20
CASE STUDY 1
In the department shown in Figure 4, as patients leave the car park, the first entrance they reach is the ambulance
entrance. It is human nature that everyone will enter the department through the first entrance that they see.
The ambulance entrance leads directly onto the majors corridor and resuscitation. In this department there were
patients waiting on trolleys in the majors corridor. In the same corridor the cubicles have curtain closures, resulting
in patient privacy and dignity being compromised.
This majors corridor is also a thoroughfare for staff wishing to access different areas of the hospital, once again
compromising patient privacy and dignity.
In addition, wayfinding is not supported by the design of this department. It is difficult to find your way to
reception via the ambulance entrance, further adding to any anxiety of patients and visitors.
trolley
waitsstaff
base
staff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clusteringstaff clustering
AMBULANCE
ENTRANCE
reception
triage
resus
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
minor
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
injuries
route to reception
Key
Circulation
Relatives Room
Sanitary
Staff
Store
Treatment
Triage
Waiting
Cummulative
routes bypatients, staff
& visitors
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Entrance design
Although the eight departments studied all are designed
to support the same care process, there are key
differences in the way that the arrival is controlled and
facilitated.
Access control
The care model for A&E assumes a separation of
pathways at the arrival stage to support the efficient
streaming of care. The physical design and location of
the entrances needs to facilitate and manage this
separation and prevent access to sensitive areas.
All but one of the departments has one ambulance
entrance. One department has an additional ambulance
entrance that leads directly into resus, in addition to the
entrance leading into the majors corridor.
Comparing the use of the main entrance to the
ambulance entrance by visitors, the greater the
proportional use of the ambulance entrance by visitors,
the less efficient is the streaming of arrival pathways. In
the departments surveyed, the difference in efficiency of
streaming for the three main entrance designs can be
seen in Figure 5.
If entrances are adjacent to one another, an average of
23% of visitor movements (external) are through the
ambulance entrance. This is reduced to 8% where the
ambulance entrance is not directly visible. Where the
door is locked and only accessible to ambulance crews
and clinical staff, this is reduced to only 2% of
movements with 98% through the main entrance.
Recommendations: Access control
The design of the building can limit access through the
ambulance entrance if the entrances are aligned on non-
adjoining faades of the building or where there is no
intervisibility between entrances. Physical control
measures may be required to restrict access where
the entrances are intervisible.
LOCATIONS OF PATIENTS, STAFF AND VISITORS
Before assessing the different stages of the care
process in terms of individual rooms within the
department, it is desirable to outline the overall pattern
of space usage by the different categories of user.
One of the most important findings from the space use
surveys of the departments was to identify the locations
where staff, patients and visitors were based during the
course of a 12-hour day.
There was a separation of areas where staff and
patients were treated (see Figure 6). Staff were generally
based in the circulation or staff area (75%). [NB Many of
the staff bases were within general circulation space.]
Patients and visitors were within treatment rooms and
waiting areas.
2 FINDINGS AND RECOMMENDATIONS
9
0
5
10
15
20
25
30
Circulation
RelativesRoom
Sanitary
Staff
Store
Treatment
Triage
Waiting
Av
eragePPH
patients
staff
visitors
Figure 6 Locations of patients, staff and visitors in the A&E
departments
ADJACENT
ENTRANCES
ADJACENT
ENTRANCES WITH
ACCESS CONTROL
ENTRANCES ON
ADJOINING
FACADES
23%
visitors
Percentage of visitors using the
main and paramedic entrances
based on the configuration of the
entrances.
77%
visitors
8%
visitors
98%
visitors
92%
visitors
2%
visitors
paramedic entrance
main entrance
free access
access control measures
Figure 5
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PATIENT, STAFF, VISITOR RATIOS
In the departments studied, there were similar numbers
of patients, staff and visitors (including children and
babies) in the department at any one time; however, the
level and locations of the movements between these
groups differ greatly (see Figure 8 for an example
department).
Visitors primarily use the main entrance; their total
movement flows are over double those of patients and
account for 59% of all movement through the main
entrance. This is probably due to visitors leaving the
department to smoke or for a break.
Over 50% of the movements into and out of the A&E
department are by staff members. The majority of these
are made through the internal entrances, accounting for
between 66 and 90% of movement. This is likely to be
due to them moving between departments.
The use of entrances by patients is, on average, equally
distributed between the main entrance and the internal
entrances with, on average, 44% of movement through
each entrance type.
Recommendations: Flexibility
It is important that the design of the A&E departments
takes into account the implications if one of the
entrances is out of commission.
The two entrances to the A&E department serve
different functions, with priority for the ambulance
entrance to support the swift transfer of patients into the
resus or major treatment areas. The main entrance is
used by all other entrants to A&E and this leads directly
to the main A&E reception.
It is important that consideration is given during the
design phase to the impact on the pathways of patients
and visitors of closure of one of the entrances.
The design should therefore identify the routes taken by
patients and visitors in the case of the closure of the
main entrance or the ambulance entrance. Key
issues that must be taken into account in both cases
are:
the privacy and dignity of patients arriving by
ambulance;
access to resus and major treatment areas in case of
the closure of the ambulance entrance;
limiting direct access to the treatment areas if the
main entrance is closed;
wayfinding to the reception and waiting area.
RECEPTION AND WAITING AREAS
The reception and waiting areas are used to hold
patients and visitors in five main categories:
patients waiting to be assessed;
patients who have been assessed and are waiting to
be treated;
visitors waiting alongside patients;
visitors waiting for patients being treated elsewhere in
the department who choose to stay in the waiting
area;
patients waiting for transport once they have been
discharged.
2 FINDINGS AND RECOMMENDATIONS
11
618
1,249
1,419
749
707
Entry/Exit Counts
1,500
750150
visitor
patient
staff
paramedic
Ambulance
Entrance
Main
Entrance
10m
Figure 8 Total entrances to A&E Department 6 from 08:00 to 20:00
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Waiting area provision
Space provision for waiting areas was similar in the eight
departments studied. It averaged 139 m2 or 9% of the
total department space, which ranges from 7 to 13%.
(NB In the 13% case, the waiting area is shared with an
adjacent department.)
Recommendations: Provision
It is important that the reception and waiting area have
sufficient space for the needs of the patients and visitors
using the A&E department.
The waiting area currently accounts for just under 10%
of the total department area. As discussed previously,
the waiting area is used by visitors and family members
as well as by patients. To ensure that sufficient space is
built into this area, the maximum ratio between patients
to visitors was found to be 1.5 visitors for every patient.
Therefore, if the wait ing area is designed based on
70,000 patients per annum, it should be designed to
cope with a further 105,000 visitors per annum, totalling
175,000 people using the department.
Changes to the clinical care pathways are likely to
result in shorter waiting times for patients, with patients
spending a shorter time in the A&E department as a
whole. This is likely to result in a lower usage of the
waiting areas. However, consideration must be made ofthe fact that visitors often wait for patients in the waiting
area while they are being treated, and these people
will still need to be accounted for in future A&E
departments.
Surveillance of waiting areas
Surveillance of the waiting areas is necessary for a
number of aspects of care delivery, including:
monitoring waiting patients and identifying if their
condition becomes cause for concern so that they
can call for clinical support;
to control access into the A&E department;
to monitor all those in the waiting area to identify any
inappropriate or criminal behaviour.
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
12
CASE STUDY 3
In the department illustrated in Figure 9 it is difficult for reception staff to observe the waiting area, thus preventing
them from:
controlling access into the department;
identifying incidents of inappropriate or criminal behaviour;
monitoring patients and identifying if their condition becomes a cause for concern.
The need for this observation is increased by the lack of clinical presence within waiting areas that was discussed
in case study 1.
AMBULANT ENTRANCE
RECORDS STORE
RECEPTION
WAITING AREA
STRETCHER ENTRANCE
CIRCULATION
main
entrance
paramedic
entrance
reception
records
store
waiting
area
Locations that can
be overseen
from the
reception.
2m
The wall blocks views
between the reception
to the waiting area.
treatment rooms
& resus
triage
to adjacent
department
minor injuries
treatment rooms
& main hospital
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The design of the building can play an important role in
facilitating surveillance of the area, especially as there is
often little formal observation of patients in reception or
waiting areas by clinical staff. Additionally, not all A&E
departments have CCTV covering reception, linked tothe security staff. None of the hospitals surveyed had
security staff directly overseeing the reception and
waiting areas.
The surveillance of the wait ing area can be assessed
by measuring the percentage of the area that can be
overlooked from the reception desk. The KPI was
applied to all departments in the study and resulted in
the following benchmarks:
the waiting area visible from reception varies greatly,
from as little as 7% of the area visible in one
department to as much as 90% in another;
on average, 66% of the waiting area can be seen
from the reception desk.
Where only 7% of the waiting area can be overseen
from the reception desk, the staff are unable to observe
the patients and the service provided is restricted.
Recommendations: Surveillance
It is important that the waiting area and entrances can
be surveyed from the reception desk. This is to ensure
that:
receptionists can oversee patients in order for them
to summon help from clinical staff if they are
concerned about a patients medical condition;
they can identify any violent behaviour by patients or
visitors and contact security staff to deal with the
matter; and
the routes into the department from the waitingarea can be surveyed to help enable visual and
physical control over who enters the treatment areas.
2 FINDINGS AND RECOMMENDATIONS
13
CASE STUDY 4
In the department illustrated in Figure 10, the design supports privacy and dignity by having a direct corridor from
the waiting area to the patient entrance into treatment area. All other routes are access controlled. This helps
support natural wayfinding and prevents unauthorised access to sensitive areas.
A common route that visitors take is from the treatment area, where they are accompanying patients, back to the
entrance or waiting area. This design supports that journey without compromising privacy and dignity of other
patients.
Access control
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Space Use
Adj. Dept.
Circulation
Maintenance
Relatives Room
SanitaryStaff
Store
Treatment
Triage
Waiting
10m
ambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulanceambulance
entrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrancesentrances
main entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrancemain entrance
Figure 10 Access control in Department 2
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As many of the areas within A&E departments are highly
sensitive, it is important that access to these
departments is controlled by means of locks as well as
by limiting the natural wayfinding. This is to ensure that
visitors do not access sensitive areas without the
knowledge of staff members.
Of the eight departments surveyed, only departments 2
and 4 have control measures in place to restrict access.
This is especially important out of hours as, dur ing this
time, the A&E department becomes the main route into
the hospital. Controlling access into A&E additionally
provides control over entrances to the hospital as a
whole.
Department 2 has very tight control over access into
and out of the A&E department from both the main and
ambulance entrances, but importantly also from the
main hospital corridor.
Wayfinding
The reception is the first port of call for all patients and
visitors entering the A&E department. It must be easy to
find. To ensure this, it should be directly visible and
accessible from the main entrance.
A Key Performance Indicator for wayfinding to the
reception is the number of changes of direction
necessary to find the reception desk from the entrance.
This indicator has been applied to all the departments in
the study (see Table 1), and the following results were
found:
only five of the eight departments in the study have
the reception located in a position that is visible from
the entrance;
of the remaining three departments, two require one
change of direction to find reception and one requires
two changes of direction;
the wayfinding indicator was also applied to the
location of the waiting area, showing that only four of
the eight departments have waiting areas visible from
the entrance, with the other three departments
requiring two changes of direction.
Recommendations: Wayfinding
It is important that the reception is directly visible
from the main entrance in order to support ease of
wayfinding for those people entering the department for
the first time. This is key to ensuring that people go
directly to the reception staff and do not access other
areas looking for help.
It is important that there are good connections from the
ambulance entrance to the reception. This is in case
of closure of the main entrance resulting in patients
entering via a different route, and also for visitors and
family members who may be entering the hospital with apatient on a stretcher through the ambulance entrance.
Patient, staff and visitor ratios: waiting areas
In the departments studied, the majority of people within
the waiting areas were patients and visitors with, on
average, 51% visitors, 46% patients and 3% staff (see
Table 2).
Figure 11 shows the cumulative location of patients,
staff and visitors in Department 2 during a 12-hour
period from 08:00 to 20:00. The patients are shown in
red, the staff green, and visitors blue. In the waiting area
to the north of the plan, the people present are
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
14
The design also keeps staff walking distances to a minimum by giving a separate direct route to the resuscitation
bay and other staff areas.
Benefits of natural wayfinding include:
less time taken by staff providing directions to patients and visitors;
improvements in privacy and dignity of patients;
lower dependence on signage which makes it easier for those with visual impairment;
less reliance on physical control measures to restrict access into sensitive areas.
ACCESS TORECEPTION
ACCESS TOWAITING AREA
DEPARTMENT 1 direct ly accessible one change of
direction
DEPARTMENT 2 directly accessible directly accessible
DEPARTMENT 3 directly accessible directly accessible
DEPARTMENT 4 direct ly accessible one change of
direction
DEPARTMENT 5 directly accessible directly accessible
DEPARTMENT 6 one change of
direction
directly accessible
DEPARTMENT 7 one change of
direction
one change of
direction
DEPARTMENT 8 two changes of
direction
one change of
direction
Table 1 Access to reception and waiting areas
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predominantly visitors and patients, whereas the staff
are predominantly located in the main staff base.
The low staff presence in the waiting area where high
numbers of patients and visitors sit makes it essential
that this space can be fully overseen by staff from the
reception areas. Without this view there is little informal
supervision for clinical or security needs.
TRIAGE AND ASSESSMENT
The triage system is used to categorise patients into
their priority of care based upon the seriousness of their
condition. The triage categories used in the UK are:
red (Triage Category 1): immediate resuscitation
(patients in need of immediate treatment for
preservation of life);
orange (Triage Category 2): very urgent (seriously ill
or injured patients whose lives are not in immediate
danger);
yellow (Triage Category 3): urgent (patients with
serious problems, but in apparently stable condition);
green (Triage Category 4): standard (standard A&E
cases without immediate danger or distress);
blue (Triage Category 5): non-urgent (patients whose
conditions are not true accidents or emergencies).
The current distribution of patients in NHS hospitals is
such that the majority attending are triage category
green (see Figure 9). However, due to clin ical needs,
the waiting times for treatment increase with the triage
categories, resulting in those in triage category 4 waiting
for between one and eight hours before being seen by a
doctor.
2 FINDINGS AND RECOMMENDATIONS
15
140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140
Space Use
Adj. Dept.
Circulation
Maintenance
Relatives Room
Sanitary
Staff
Store
Treatment
Triage
Waiting
patient staff visitor
10m
Figure 11 Locations of patients, staff and visitors in Department 2
The department was surveyed once everyhour between 08:00 and 20:00.
Each dot represents a staff member,patient or visitor that was seen duringone of the surveys.
%
PATIENTS
%
STAFF
%
VISITORS
DEPARTMENT 1 46 1 53
DEPARTMENT 2 44 10 45
DEPARTMENT 3 42 5 53
DEPARTMENT 4 49 4 47
DEPARTMENT 5 52 1 47
DEPARTMENT 6 48 1 50
DEPARTMENT 7 44 2 55
DEPARTMENT 8 40 1 59
AVERAGE 46 3 51
MINIMUM 40 1 45
MEDIAN 45 2 52
MAXIMUM 52 10 59
Table 2 Patient, staff and visitor ratios in waiting areas
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Of those entering the A&E department, 83% will be
discharged directly from A&E with only 17% of attenders
admitted to hospital.3
Recommendations: Wayfinding
For the new See and Treat service model it will be
important that the assessment rooms are directly visible
and accessible from the main waiting area. As the
majority of patients will be discharged directly from
assessment rooms, it is important to ensure (for the
privacy and dignity of other patients) that they do not
have access to other areas of the department. To
ensure this, the departments should be located off the
waiting area with controlled access through to the main
treatment areas.
Privacy and dignity in assessment rooms
It is important when patients are assessed that they
have full auditory and visual privacy. This is especially
important as the assessment rooms are often adjacent
to the main waiting areas, and during assessment the
patient may be asked personal questions. Additionally,
a nurse is present during this stage so there is no
requirement for further surveillance from other staff.
Recommendations: Privacy and dignity
It is important that there is full auditory and visual
privacy for people in assessment rooms. It is in these
rooms that they will be asked personal questions
regarding their health and their contact details during
registration.
If a staff member is present constantly during the
assessment process, there will be less requirement
for casual surveillance from the staff base. However,
consideration should be made for any future change
in use of the rooms in assessing their ability to be
surveyed from the staff bases.
Patient, staff and visitor ratios: assessment rooms
It was found, on average, that for every 100 patients,
60 visitors attend assessment with them. The maximum
was identified as 130 visitors for each 100 patients and
the minimum as 20.
One of the hospitals surveyed has started using the
See and Treat model. Comparing the results from this
hospital to the other seven surveyed identified some key
findings.
In this department there was a lower proportion of
patients in the waiting area instead a greater proportion
of patients in the treatment rooms.
It was also found that the average treatment time in the
minor treatment rooms was 34 minutes, which was
higher than the average of 29 minutes for other rooms.
In the other hospitals, the average treatment times
varied between six and 54 minutes. This is probably due
to the fact that minor treatment rooms were used for
patients with more serious injuries.
Within the assessment rooms, it was found that the
average treatment time was five minutes. During the
12-hour survey, 73 patients were seen by the consultant
and the room was occupied by patients for 52% of the
time. Although the consultant remained in the treatment
room there were five-minute gaps between patient to
enable the consultant to write up notes and prepare for
the next patient.
TREATMENT ROOMS
The rooms used to treat patients are currently split into
five main designations:
minor rooms;
major rooms;
resus;
paediatrics;
other (mental health, gynaecology etc).
Provision: treatment rooms
Both the number and proportion of the treatment rooms
vary between hospital departments (seeTable 3). The
numbers of major treatment rooms vary between 6 and
11 and minor between 3 and 10.
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
16
Figure 12 Percentage of people entering A&E in each triage category
3 Source: Adrian Fletcher, Genflows.ppt
16
32
59
3
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Major and minor treatment rooms
On average, 28% of the space in the department isdevoted to treatment space, varying from 19% in
Department 1 to 37% in Department 4.
The tendency is that the larger departments devote less
space to circulation and more space to treatment.
In all but two of the departments studied, there were
slightly more major treatment rooms than minor
treatment rooms (an average of 8.6 major and 6.3
minor).4
Major treatment rooms are on average 9.8m2
, whichis 20% larger than minor treatment rooms.
Flexibility
The departments studied differ in the degree of flexibility
that the design allows. Some of the current A&E designs
do not support transfer of use of patients with major
illnesses into minor treatment rooms because:
they are in a different location in the department, with
lack of communication between the areas, and they
cannot be overseen by staff members;
they are smaller; and
the rooms are not fitted out to the specificationrequired for major injuries patients; some rooms
contain only a couch and cannot accommodate a
trolley, which is required.
These three measures have been used to identify the
level of built-in flexibility of each of the departments (see
Table 4).
Where the specification is the same, and they are of a
similar size and location, it is easier to use the treatment
rooms more flexibly, both with day-to-day changes in
demand, but also for the longer-term changes in
numbers of patients presenting with major and minorconditions.
2 FINDINGS AND RECOMMENDATIONS
17
NUMBER
MINOR
NUMBER
MAJOR
NUMBER
RESUS
PAEDIATRICS OTHER (SPECIFY)
DEPARTMENT 1 6 6 1 (4 trolley bays) 2 1 Trauma
DEPARTMENT 2 4 11 1 (6 trolley bays) 2 1 Obs and Gyn
1 Opth/ENT
DEPARTMENT 3 7 7 3 bays 1 (2 bed bays) mental heath area
DEPARTMENT 4 10 8 1 (3 trolley bays) 6 8 observation bays
5 clinic exam rooms
1 minor operation
room (not used)
1 recovery room
(not used)
DEPARTMENT 5 6 11 1 (3 bays) 5 8 CDU
1 X ray
1 Soft Room
1 Side Room
(lockable door for
Obs and Gyn etc)
DEPARTMENT 6 3 one large area,
no separations
1 area
(not separated)
4 1 clean theatre
1 plaster room
DEPARTMENT 7 6 11 5 7 1 suture
DEPARTMENT 8 5 6 3 0 3 treat
3 Plaster
1 eye/treatment
1 Gyn/GU
Table 3 The number and type of treatment rooms in each department
4 Department 6, which has only one major treatment room
with multiple and a variable number of trolley bays, has been
excluded from this calculation.
LOCATION
(TOGETHER
Y/N)
SIZE
(SAME
SIZE Y/N)
SPECIFICATION
(SAME
Y/N)
DEPARTMENT 1 Y N Y
DEPARTMENT 2 Y Y Y
DEPARTMENT 3 N N N
DEPARTMENT 4 Y Y Y
DEPARTMENT 5 N N N
DEPARTMENT 6 N N N
DEPARTMENT 7 N N N
DEPARTMENT 8 Y N N
Table 4 Flexibili ty of treatment rooms
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Surveillance
The surveys have shown a low level of staff presence
within both types of treatment room. To ensure that the
patients are observed, it is important that they can be
overseen from the staff base if no other remote
monitoring is taking place.
To benchmark survei llance, vis ibility modelling has beenused to identify the number of treatment rooms visible
from the staff base, both when doors are open and
when they are closed. This method can be used while
designs are in the plan phase to identify rooms that are
more likely to be poorly surveyed by staff.
There are two main reasons why surveillance may be
limited in treatment rooms:
the cubicle design does not have doors that enable
views into the treatment room;
the layout of the department is such that, regardlessof windows into the treatment rooms, it is not
possible to provide casual surveillance.
Recommendations: Surveillance
It is important to ensure that there is surveillance of all
patients treated in the A&E departments. Patients can
be surveyed by three methods:
observing patients remotely through use oftechnology;
having a staff member based in the same room as
the patient; or
having a staff base from which it is possible to view a
number of treatment rooms.
With current staffing levels and constraints it will be
important to enable a staff member to survey multiple
treatment rooms, by means of either direct surveillance
or use of technology. Without this, or increases in staff
levels, it will not be possible to oversee all patients in
treatment rooms. This may have a negative impact on
the patients wellbeing.
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
20
CASE STUDY 5
In the department illustrated in Figure 15, nurses often use the staff base to observe patients. This helps to
explain why we see the separation of staff and patients discussed in case study 2.
It is important that cubicles are positioned in a way that allows maximum observation. The diagram illustrates both
good and bad examples of observation. The minor cubicles can be well observed from the staff base but the staff
base on the majors corridor allows observation of only 50% of the cubicles.
Space Use
Other Depts
A&ETreatment
staffbase
Area Visible from
Staff Basestaffbase
Example of Cubicles with Good and Poor Surveillance
The treatment rooms to the west of the plan (minor
treatment rooms) have a high level of surveillance
from the staff base as 5 of the 7 rooms are fully
visible by staff members situated at the base.
The treatment rooms to the east of the plan (major
treatment rooms) have a very low level of surveillance,
resulting in there being no provision for casual
surveillance of these patients from the staff base.
10m
Figure 15 Example of cubicles with good and poor surveillance
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Wayfinding and location of treatment rooms
It is important that there is controlled access to
treatment rooms and that staff are aware of who is in
each room. To help ensure this, it is important that the
patients and visitors can easily find their way around the
more public parts of the department to help prevent
them inadvertently accessing a treatment area.
The wayfinding for patients accessing the treatment
rooms will be controlled mainly by the staff member
leading them into the department. It is important that
the wayfinding is managed to ensure that, on leaving the
treatment room, patients can find their way back to
reception.
The wayfinding for visitors differs from that for the
patients, as visitors may enter and leave the treatment
room a number of times while the patient is being
treated, to go outside for a break. It is therefore
important that visitors can find their way back to the
main entrance along a route that does not compromise
the privacy and dignity of other patients.
To measure the ease of wayfinding, the locations of
treatment rooms were audited to outline the most
accessible routes for visitors leaving the treatment
rooms (see Table 5).
Resuscitation
The use of resus rooms varied between the
departments surveyed. Some departments used the
resus room to monitor patients, while others monitored
patients in major treatment rooms. The main constraint
for the clinicians appeared to be in the equipment
available.
There are three main design considerations regarding
the location of resus:
it should have easy, unimpeded access from the
ambulance entrance;
it should be accessible from other treatment rooms;
it should be accessible from the main entrance, to
account for any temporary closures of the main
entrance.
The eight departments were evaluated based on their
ease of wayfinding from both the main and ambulance
entrances. It was found that it would take, on average,
nearly four changes of direction to access resus from
the main entrance, and two changes of direction from
the ambulance entrance. In some departments this
increased to six changes of direction required to access
the department from the main entrance (see Table 6).
This has serious functional implications if the ambulanceentrance for any reason becomes unusable.
Only two departments have direct access to the resus
room without any changes of direction. The first is in
Department 8, where the resus room links directly from
the ambulance lobby. However, this department requires
six changes of direction to access resus if entering thedepartment from the main entrance (see Figure 16).
The second is in Department 2. This department has
two ambulance entrances; the first goes directly into
resus, the second into the main corridor which leads
directly onto both resus and the major treatment area.
This department requires only two changes of direction
to get from the main entrance to resus (see Figure 17).
Recommendations: Wayfinding
The wayfinding requirements for staff, patients and
visitors to A&E departments differ, with:
patients requiring direct (but controlled) access from
the waiting areas to treatment rooms;
2 FINDINGS AND RECOMMENDATIONS
21
CHANGES
OF
DIRECTION
FROM
MAJOR
TREATMENT
TO MAIN
ENTRANCE
PASS OPEN
TREATMENT
ROOMS
Y/N
CONTROLLED
ACCESS
Y/N
DEPARTMENT 1 3 N N
DEPARTMENT 2 4 Y Y
DEPARTMENT 3 5 Y N
DEPARTMENT 4 4 N N
DEPARTMENT 5 4 Y N
DEPARTMENT 6 3 Y N
DEPARTMENT 7 3 Y N
DEPARTMENT 8 4 Y N
Table 5 Wayfinding from treatment rooms
MAIN AMBULANCE
DEPARTMENT 1 2 2
DEPARTMENT 2 3 1
DEPARTMENT 3 6 2
DEPARTMENT 4 4 3
DEPARTMENT 5 4 2
DEPARTMENT 6 2 2
DEPARTMENT 7 4 2
DEPARTMENT 8 6 1
MEAN 3.9 1.9
MEDIAN 4 2
MINIMUM 2 1
MAXIMUM 6 3
Table 6 Changes of direction required to access resus from
the two entrances
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visitors requiring access to and from the main
entrance to the treatment rooms, as they are likely to
take breaks outside;
staff members requiring direct routes between the
treatment rooms and the staff bases as they visit
different patients.
It is important to ensure that the routes patients and
visitors take do not compromise the privacy and dignity
of other patients in the department and do not lead
directly into sensitive areas such as paediatrics or resus.
The designs should limit:
the number of changes in direction needed to access
the main entrance;
the distance between the treatment rooms and the
main entrance;
the number of treatment rooms that visitors and
patients will pass when travelling between these
areas.
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
22
waiting
minor
major
resus
ambulance
entrance
main
entrance
staff
10m
Figure 16 Where wayfinding from the main entrance is not
supported (Department 8)
140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140
Space Use
Adj. Department
Circulation
Relatives Room
Sanitary
Staff
Store
Treatment
Triage
Waiting
waiting
minor
major
resus
ambulance
entrance
main
entrance
receptio
n
10m
ambulance
entrance
major
ma
jor
staff
Figure 17 Where wayfinding from the main entrance is supported (Department 2)
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Privacy and dignity in treatment rooms
The design of the treatment room and the location
within the A&E department affect the level of privacy and
dignity of patients.
Privacy and dignity is measured in two ways: visual
privacy and auditory privacy. For the former, the design
of cubicles may be such that curtains visually separate
the patients from other patients and visitors. For full
auditory and visual privacy, individual cubicles with full
door closure are required.
Of the hospitals surveyed, each conformed to one of the
five layouts which are shown in the example on the next
page.
Figure 18 identifies the number of departments using
each cubicle design category for their major and minor
treatment rooms.
Where there is only one entrance to the treatment room,
the placement of the room within the context of the
department greatly affects the level of privacy
experienced by patients.
The lowest level of auditory and visual privacy takes
place when the treatment rooms are based on a
corridor with public access and where only curtain
closures are used.
One method that provides surveillance by staff but visual
privacy from the main corridors and the majority of
patients and visitors is to provide visual access from
only the staff base (as in example 2). Although it does
not supply full auditory and visual privacy, this design,
through layout alone, does provide a much more private
and quiet space away from the main through routes.
Where there are two entrances to the treatment rooms,
privacy depends the use of a curtain or door limiting
visual access to the room. The levels of privacy are
greatest where there are doors on both sides of thecubicle; however, this can limit the ability of staff to
oversee patients.
Recommendations: Privacy and dignity
It is important that the privacy and dignity afforded to
the patient is not compromised by the surveillance
required by staff members. Whatever method of
surveillance used, it is important that observation of
patients is limited to staff members and the patients
visitor(s).
To identify and control levels of privacy and dignity in
treatment rooms, each room should be benchmarked.
This should be based on who can see inside the room
while walking round the department, concentrating on:
visitors;
other patients; and
other staff members (those not directly treating thepatient).
Use of treatment rooms by patients, staff and
visitors
Overall in the departments studied, there were only
75 visitors attending treatment rooms for every 100
patients (see Table 7). However, the rates vary
considerably between different treatment room types.
The highest visitor presence is found in the paediatric
treatment rooms with, on average, 137 visitors for every
100 patients. In Department 2, this ratio was raised to
211 visitors for every 100 patients.
There was a very low proportion of staff in the treatment
rooms, dropping to an average of 16% in major
treatment rooms. This can also be seen in Figure 19,
which highlights the average percentage of staff, patient
and visitor locations in each A&E department.
Use of major and minor treatment rooms
There is a large difference in the levels of use in majorand minor treatment rooms.
Critically this shows that there is redundant space in the
minor treatment rooms and an insufficient number of
23
PATIENT
%
STAFF
%
VISITOR
%
NUMBER OF
VISITORS
FOR EVERY
100PATIENTS
ALL TREATMENT
ROOMS
46 19 35 75
MAJOR 53 16 31 61
MINOR 46 31 22 57
RESUS 24 57 19 83
PAEDIATRICS 36 16 48 137
GYN/GU 59 25 16 36
Table 7 Locations of patients, staff and visitors in the different
treatment room types
Figure 18
2 FINDINGS AND RECOMMENDATIONS
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THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
24
staff
base
cubicle
cubicle
cubicle
cubicle
cubicle
majorinjuriescorridor
staff
base
cubicle
cubicle
cubicle
cubicle
cubicle
majorinjuriescorridor
staff
base
cubicle
cubicle
cubicle
cubicle
cubicle
majo
rinjuriescorridor
1 Opens to majors area, no
cubicle only curtain closures
on all sides.
This provides no auditory
privacy and very low levels of
visual privacy for patients fromother patients and visitors.
This design does support some
surveillance from the staff base if
the curtains are left open.
Departments using this cubicle
design:
Major treatment rooms:
Department 6
Minor treatment rooms: none
2 Opens to only majors
corridor curtain closure.
This provides no auditory privacy
and low levels of visual privacy,
as this corridor will be heavily
used by patients, staff and
visitors.
Additionally, this design does not
support surveillance from the
staff base.Departments using this cubicle
design:
Major treatment rooms:
departments 3 and 7
Minor treatment rooms:
department 63 Opens to only nurses
base curtain closure.
This provides v isual pr ivacy for
patients but enables
surveillance of patients from the
staff base.
Departments using this cubicle
design:
Major treatment rooms:
departments 2 and 5
Minor treatment rooms:
departments 2, 5 and 7
4 Opens to both majors
corridor and nurses base
doors on both sides.
This provides visual privacy for
patients but enables surveillance
of patients from the
staff base.
This also enables patients and
visitors to access the treatment
rooms without disturbing other
patients.
Departments using this cubicle
design:
Major treatment rooms:
departments 4 and 8
Minor treatment rooms:
departments 3, 4 and 8
5 Opens to both majors corridor
and nurses base doors on both
sides.
This provides full auditory and visual
privacy for patients but limits staff
surveillance.
This also enables patients and visitors
to access the treatment rooms without
disturbing other patients.
Departments using this cubicle
design:
Major treatment rooms: department
1
Minor treatment rooms: department
1
staff
base
cubicle
cubicle
cubicle
cubicle
cubicle
m
ajorinjuriescorridor
ma
jorinjuriescorridor
staff
base
cubicle
cubicle
cubicle
cubicle
cubicle
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2 FINDINGS AND RECOMMENDATIONS
major treatment rooms, resulting in some patients
waiting on trolleys in the corridors. Indeed, in
Department 3 the minor treatment rooms were only
occupied just over 50% of the time, yet during the same
period people were found to be waiting on trolleys in
circulation space. The differences in the levels of use
between these two room types can be seen in
Figure 21.
CIRCULATION
The circulation space is the glue that holds together al l
of the different areas within the department. It is used
for a number of functions and often is highly controlled,
with restrictions on access for visitors and patients.
This section outlines how circulation space is being
used in existing A&E departments and the impact on the
location and control of the space on how it is used.
Provision: circulation space
The amount of circulation space varies betweendepartments, averaging at just over one-third of the area
of the department (see Table 8).
There is an inverse relationship between the area
provided for treatment and the area given to circulation
space. There appears to be a trade-off between the
area provided for treatment and the area available for
circulation. On average, the greater the area provided tocirculation, the lower the proportion of space provided
for treatment. This can be seen in Figure 22.
25
Figure 19 Locations of patients, staff and visitors in the A&E
departments
ambulance
entrance
to reception
major'sc
orridor
resus
patients waiting on
trolleys in circulation space
patients standing or seated
staff standing or seated
visitors standing or seated
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1m
Figure 20 Example of trolley waits Department 3 at 19:00
Figure 21 Percentage use of major and minor treatment rooms
AREA % DEPARTMENT
DEPARTMENT 1 179 43%
DEPARTMENT 2 791 36%
DEPARTMENT 3 635 39%
DEPARTMENT 4 729 30%
DEPARTMENT 5 989 40%
DEPARTMENT 6 273 26%
DEPARTMENT 7 388 29%
DEPARTMENT 8 330 39%
AVERAGE 539 35%
MINIMUM 179 26%
MEDIAN 511 38%
MAXIMUM 989 43%
Table 8 Circulation space
Figure 22
treatmentarea
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Patient, staff and visitor (PSV) ratios
The circulation space accounts for just over one-third of
the space in A&E departments and also accounts for
one-third of people within A&E. The main users of
circulation space are staff members, averaging 48% of
staff based in this location (see Table 9). This is due to a
number of the staff bases located in circulation space.
There were, on average, a further 21% of patients and
31% visitors here.
The high usage of circulation space was due to its mix
of uses, including:
movement routes;
staff bases;
waiting areas; and
patients waiting on trolleys.
Routes
THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
28
%
PATIENTS
%
STAFF
%
VISITORS
DEPARTMENT 1 29 40 31
DEPARTMENT 2 22 53 25
DEPARTMENT 3 28 32 40
DEPARTMENT 4 15 60 26
DEPARTMENT 5 18 42 40
DEPARTMENT 6 21 57 23
DEPARTMENT 7 8 75 17
DEPARTMENT 8 30 26 44
AVERAGE 21 48 31
MINIMUM 8 26 17
MEDIAN 21 47 29
MAXIMUM 30 75 44
Table 9 PSV ratios in the circulation space
CASE STUDY 6
In the department illustrated in Figure 23, walking distances and common journeys taken by staff members are
largely affected by the design and layout of the department.
The treatment rooms in this department are set out in the shape of a horseshoe. A problem arises when staff
need to access the resuscitation bay, which is positioned just outside the treatment area. This requires staff to
walk all the way round the outside of the treatment bays. In practice the staff use the treatment bays as a shortcut through to resuscitation, thus compromising the privacy and dignity of any patients in the treatment room.
A positive feature of the design shows that the placement of supplies cupboards at either end of the horseshoe
are perfect for keeping staff walking distances to a minimum.
The convenient placement of supplies also minimises the amount of time patients are left alone while staff fetch
supplies.
Room Uses
Circulation
Relatives roomSanitary
Staff
Store
Treatment
Triage
Waiting
main
entrance
ambulance
entrance
minor injuries treatment rooms
major injuries treatment rooms
staff base
reception
assessment
resus
waiting area
route between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staffroute between staff
base and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resus
shortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest routeshortest route
between staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staffbetween staff
base and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resusbase and resus
sampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routessampled staff routes
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The average route lengths taken by patients, staff
and visitors varied substantially between the different
departments surveyed. This is shown in Figure 24.
From the survey of all eight departments it is clear that it
is not the size of the department that effects walking
distances but the design layout (see Figure 25).
The majority of journeys were made by staff members,
which account for, on average, 72% of all trips
surveyed. These movements by staff, in particular
clinical staff, are likely to be due to:
the high number of support service tasks that they
undertake, such as restocking of treatment rooms;
and
the fact that they treat more than one patient, so will
be moving between different treatment rooms as well
as to the staff base.
The average lengths of these journeys vary. For visitors
and patients, on average, 16% of trips are made by
visitors and a further 12% by patients. The locations of
these trips are important, as any routes by visitors
through the majors corridors affect the privacy of
patients treated in the adjacent rooms.
The surveys of existing departments, alongside
computer modelling of the layouts, have shown how
quantitative evaluation of existing departments can
identify the design features that support existing work
practices and the ability of departments to adapt to
change.
Designs of a similar age have responded very differently
with the changing demands placed on the departments.
Some have found it more difficult to cope with the
increasing patient and visitor attendances because the
layout does not support flexible working and the use of
the rooms could not be changed, creating redundancy
in a location where space is at a premium. The designof departments can support or hinder the care of
patients. Through better understanding of the lessons
learned from A&E departments that have been built,
this knowledge can help support the vast body of
information and expertise on other aspects of design
that impact on the care process.
29
Figure 24
Figure 25 Relationship between route lengths and department
size
2 FINDINGS AND RECOMMENDATIONS
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THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
30
THE WAY FORWARD
Through identifying good practice and evaluating
some key design flaws in existing departments, this
information can be used to help ensure that the
departments currently being built or redeveloped
support rapidly changing clinical practices and provide
the best possible environments for patients, staff andvisitors. This will also help to ensure that redundancy is
not built into the design.
Continuing post-occupancy evaluation of departments,
and the evaluation of plans at design stage, will help to
ensure that the design guidance remains up-to-date and
reflects both change to the delivery of care within A&E
and the consequences for the built environment.
3 Conclusions
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31
DEPARTMENT 1
This department has adopted the See and Treat model of care. It is located on the ground floor of the main
building of the hospital. It has two main entrances, one for all patients and visitors, the other for ambulance patients.
The department covers an area of approximately 880 m2. The treatment rooms account for 30% of the total space.
Appendix 1 Departments
Space Use
Adj. Department
Circulation
Relatives room
Sanitary
Staff
Store
Treatment
TriageWaiting
resus
major
major
children
waiting
mainentrance
ambulanceentrance
minor
staff
Figure 26 Layout of the A&E department
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33
DEPARTMENT 3
The A&E department in this hospital is located on the ground floor of the main building. It has two main entrances,
one for all patients and visitors, the other for ambulance patients. However, the department is currently undergoing
refurbishment and has only one entrance, which is used by patients arriving by ambulance and all other visitors
and patients. This is a temporary measure, but impacts on the way that the department is used.
The department covers an area of approximately 1400 m2. The treatment rooms account for 28% of the total space.
Space Use
Fracture Clinic
Circulation
Relatives Room
Sanitary
Staff
Store
Treatment
Triage
Waiting
minor
major
nurses
base
resus
ambulance
entrance
main entranceCLOSED
Figure 28 Layout of the A&E department
APP END IX 1 D EPAR TME NTS
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THE IMPA CT OF THE BUI LT E NVI RON MEN T ON CAR E W ITH IN A&E DEPARTM ENT S
34
DEPARTMENT 4
The A&E department in this hospital is located on the ground floor of the main building. It has two entrances, one for
patients and visitors, the other for ambulance patients.
The department covers an area of approximately 2100 m2, of which the treatment rooms account for 33% of the
total space.
Space Use
Adj. Department
Circulation
Maintenance
Relatives RoomSanitary
Staff
Store
Treatment
Triage
Waiting
main