a&e departments

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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


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


Wayfinding and location of t reatment rooms


Privacy and dignity in treatment rooms


Use of treatment rooms by patients, staff and visitors

Use of major and minor treatment rooms

Circulation page 24

Provision: circulation space

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


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.


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.


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.


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.


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.


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

140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140140

Space Use

Adj. Dept.

Circulation

Maintenance

Relatives Room

SanitaryStaff

Store

Treatment

Triage

Waiting

10m

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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.


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


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 4 direct ly accessible one change of

direction


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


19/48

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.


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








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


20/48

Of those entering the A&E department, 83% will be

discharged directly from A&E with only 17% of attenders

admitted to hospital.3


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.


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.


16

Figure 12 Percentage of people entering A&E in each triage category

3 Source: Adrian Fletcher, Genflows.ppt

16

32

59

3


21/48

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.


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


22/48


23/48


24/48

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.


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.


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


25/48

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).


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;


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


26/48

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.


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)


27/48

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.


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



28/48


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:


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.


design:


departments 2 and 5


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.


design:


departments 4 and 8


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.


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


29/48


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

Main entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance isMain entrance is

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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%








AVERAGE 539 35%

MINIMUM 179 26%

MEDIAN 511 38%

MAXIMUM 989 43%

Table 8 Circulation space

Figure 22

treatmentarea


30/48


31/48


32/48

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


28

%

PATIENTS

%

STAFF

%

VISITORS









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


33/48

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



34/48


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


36/48


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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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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

a&e departments

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