Patient Experiences in Emergency

ENVISION PATIENT EXPERIENCES IN

EMERGENCY

ENVISION WELLNESS.03

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CONTENTS © NBRSARCHITECTURE 2017

Introduction 4

Authors: Alison Huynh, Bernadette Keenan, Brett Sherson

Case Study 01: Children & Adolescents

First Published: December 2017 NBRSARCHITECTURE. Level 3, 4 Glen Street Milsons Point, NSW 2061 Australia architects@nbrsarchitecture.com nbrsarchitecture.com +61 2 9922 2344

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Case Study 02: Older People

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Case Study 03: Behavioural Health

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Case Study 04: Patient Stress & Wayfinding

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Conclusion 22 References 23

Citation: Huynh, A. Keenan, B. & Sherson, B. (2017). Envision Patient Experiences in Emergency. Sydney: NBRSARCHITECTURE.

Approach 27

INTRODUCTION The Emergency Department (ED) is the principal front-line service for unplanned acute care. Services are profoundly affected by changes in population health, demographics, access and transportation. Record-breaking numbers of ED presentations are regularly reported across hospitals in Australia. In NSW hospitals, almost 700,000 ED presentations were recorded in the last quarter of 2016, up almost 40% from the previous year (Aubusson, 2017). As emergency care environments are complex and highly specialised, the planning and design of these spaces requires current and upto-date knowledge of research, trends and data. Despite constant pressure on operational capacity across the entire health network, service delivery cannot be compromised.

Emergency medicine is a relatively new specialism. This speciality emerged when ‘emergency rooms’ located within clinics and hospitals grew to become entire departments with dedicated nursing and specialist training (AAFP, 2017). It was recognised by the American Board of Medical Specialities in 1979, and in 1984 the Australasian College for Emergency Medicine was founded.

The way in which emergency care is delivered is constantly being adjusted and developed, with new models of care emerging around the world.

Emergency care is delivered in a wide range of environments, from hospitals, to emergency transports, in urban

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We need to question how well we care for people in hospital waiting rooms, as these patients are undiagnosed, untreated and vulnerable.

(Sparkes, 2011).

areas and in remote locations. While the hospital ED is at the epicentre of the delivery network, acute patient care must be supported in all possible contexts.

Delivering high quality acute care for undifferentiated and unscheduled patients is complex because time and space pressures can limit opportunities to support a patient-centred approach. Often, the focus of EDs is improving access, efficiency and patient flow. The built environment has the potential to encourage a more personal approach to care by providing positive stimuli and operational flexibility. For patients, emergency environments can be traumatic and disorientating, and for staff they can be stressful and potentially dangerous workplaces. This paper seeks to explore some current trends in the planning and design of EDs which help facilitate a high quality person-centred care, as well as safe and efficient staff-centred workplaces.

01_ Children & Adolescents In 2004, following a survey of 197 Australian Hospitals, the Association for the Wellbeing of Children in Healthcare (AWCH, 2010, p7) identified EDs as an area within hospitals that needed to be made more child and youth friendly, especially in general hospitals. AWCH research indicated time spent waiting, overcrowding, and lack of supervised play contributed to negative perception of EDs on patients and families.

Case Study 01 investigates the experience of children and adolescents in emergency environments and hospital settings in general. The National Association of Children’s Hospitals and Related Institutions (2008) report outlines a number of design strategies which can guide the design of paediatric EDs. The Royal Children’s Hospital Melbourne provides a striking example of acute spaces designed for interaction and stimulation for children and adults.

02_ Older People Older people make up a large proportion of ED presentations and are more likely to have longer lengths of stay in emergency. This can amplify overcrowding and access block. Furthermore, older people often suffer from cognitive impairment, physical disability and multiple medical conditions.

Providing patient centred care for older people therefore requires a specialised approach to avoid missed diagnoses, prevent complications associated with

frailty, and ensure seamless care and discharge (Gray, 2013).

Case Study 02 reviews the care of older people in EDs with a focus on innovations documented at Westmead Hospital in Western Sydney. A combination of specialist streams has improved flows in ED at Westmead in line with NSW Health emergency models of care. In Victoria, environmental audits of EDs provide insight into the specific needs of older people in hospital settings and how to create more ‘older person friendly’ environments. In the United States, senior EDs are emerging as specialist services to provide environments that are more suited to older people attending emergency.

03_ Behavioural Health EDs are often used as a first point of care for mental health services for a number of reasons. This includes first time incidents, after hours, during psychotic episodes and overdoses.

Mental health-related principal diagnoses have been reported in 3.7% of all Australian public hospital ED presentations in 2015-16. 60% of these presentations were recorded as being resolved without the need for admission or referral. Most of the remaining presentations resulted in hospital admission (MHSA, 2016).

Case Study 03 discusses approaches to dealing with mental health presentations at emergency, including specialist units such as psychiatric

emergency care centres, safe assessment rooms, behavioural health units and crisis management units. These services need to be supported by a range of specialist staff including mental health professionals and nursing. Despite the pressures of emergency environments and space constraints, high quality therapeutic design must be ensured in areas for mental health care.

04_ Patient Stress & Wayfinding Besides ever-increasing demand and long wait times, violence and aggression has been identified as a major problem within EDs, with increased media spotlight on a number of violent incidents against staff in Victorian hospitals (Medew, 2017, Powley, 2017).

Root causes of violence and aggression include patients who are alcohol or drug affected; stressed, frustrated and impatient; or presenting with acute mental illness or other behavioural health conditions.

Case Study 04 explores how wayfinding, guidance and training can be used to reduce incidents of violence and aggression in EDs. “A Better A&E” is a design solution developed to provide a cost-effective method for improving safety and security, supporting staff wellbeing, and increasing patient satisfaction (Frontier Economics, 2013, p5). This approach can be adapted to support the NSW Health Emergency Department Models of Care (2012) and implemented state-wide in EDs dealing with high incidents of violence.

Patient stress, mental health crisis, and the experience of old and young are just some of the elements addressed in this research. Together, they provide insight into the diverse issues that need to be considered when addressing existing departments, optimising and refurbishing services, or building new. A deeper understanding of the people attending emergency can inform our approach to emergency care and the built environment in which it is delivered.

Emergency health care of the future must operate more efficiently and effectively to accommodate both the growth in demand and the introduction of new clinical technologies which expand the scope of acute care.

(Fitzgerald, 2012).

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CASE STUDY 01: CHILDREN & ADOLESCENTS In 2004, following a survey of 197 Australian Hospitals, the Association for the Wellbeing of Children in Healthcare (AWCH) identified Emergency Departments (ED) as an area within hospitals that needed to be made more child and youth friendly, especially in general hospitals (AWCH, 2010, p7). AWCH research indicated time spent waiting, overcrowding, and lack of supervised play contributed to negative perception of EDs on patients and families.

The difference between adult and paediatric care affects how EDs manage check-in and triage for children. Paediatric EDs need to take care to properly identify the child patient and ascertain guardianship upon arrival. This is especially important in urban settings that deal with a high amount of foot traffic.

This may be supported by secured vestibules and registration desks, visual transparency and security cameras (Vickery, 2011(1)). Space planning should consider how to maintain security and safety for children while being processed, in waiting rooms and play areas. Children are usually accompanied by 1 or more family members who may stay with them throughout the ED visit. Treatment areas and waiting rooms that are large enough to accommodate multiple families, while maintaining separation and privacy, help to relieve anxiety.

Children and adolescents have very different social needs depending on age. Adolescents require a balance between privacy, intimacy and social interaction between people. Activi-

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ties need to be suitably stimulating for older children and teenagers.

Programmed spaces such as music areas and games rooms are likely to be preferred by adolescent patients to provide distraction and alleviate boredom (NACHRI, 2008, p3). In the U.S. and Canada, child life specialists have developed hospital based services to support children and families in paediatric units. They focus on providing support in stressful environments through therapeutic play, art and age-appropriate activities. This is intended to relieve anxiety about upcoming procedures and parents are encouraged to participate. Medical information, through digital, online and print resources can also be provided in a variety of languages for parents to research their child’s condition, as well as child-friendly books and magazines.

All these services can be combined to provide parents and children relief from stress and boredom at the hospital (Vickery, 2011(2)).

In 2003, a dedicated paediatric waiting area and treatment area was constructed in an Australian metropolitan teaching hospital with 34,000 ED presentations per year. The Center for Health Design conducted a study to explore how redesign affected patient and staff satisfaction, as well as other members of medical/nursing staff.

The study found that the most striking change was in the patient-family group who showed an increased level of satisfaction with the physical environment and their overall care (Judkins, 2003).

Evidence-based design strategies that relate to paediatric health services have been outlined by the National Association of Children’s Hospitals and Related Institutions (NACHRI) in the report ‘Evidence for Innovation: Transforming children’s health through the physical environment’ (2008). A number of these strategies are relevant to the design of paediatric EDs: Improving sound absorption through ceiling tiles in all environments: This is a relatively low cost strategy designed to reduce noise levels and reverberation times. They can be incorporated into nearly any environment and an acoustic consultant can provide advice regarding placement and selection to achieve maximum effectiveness. Noise audits can provide valuable information and lead to a comprehensive noise reduction plan. Low cost solutions can be developed to deal with specific noise problems, and change management and nursing to reduce noise impacts.

Providing space for families in all patient rooms and in all units: Single family rooms provide the most supportive environments, however this is generally only possible in new build or renovations. However, family spaces can be created in existing facilities to allow parents and siblings to stay close to the patient.

Fig. 12

Children and adolescents’ feeling of wellbeing in hospital is dependent on their capacity to remain engaged, maintain a positive frame of mind and to feel comfortable in the hospital setting.

(Bishop, 2008)

1. Evidence Based Design Strategies for Children in Hospital. NACHRI, 2008.

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Providing patient and family control over privacy and environmental conditions where possible: This may include simple, low-cost approaches like providing storage space and furniture partitions to provide privacy, especially for adolescents who indicate a strong preference for privacy and individual control.

Playing calming music before and during procedures: Music therapy and ambient music can be introduced into any facility. This has proven to be an effective and efficient non-pharmacological strategy in reducing anxiety and perception of pain. It has also proven to reduce medication use among children undergoing procedures.

Positive distractions for adolescents and age appropriate play areas: Therapeutic play can reduce tension, anxiety, anger, frustration and conflict among paediatric patients, especially when experiencing stress. Age appropriate play needs to capture all age groups, in particular providing positive experiences for adolescents.

Access to nature through gardens and natural light: Exposure to nature is shown to have a calming and restorative effect on paediatric patients, families and staff. Natural light helps to reduce depression and length of hospital stays. Exposure to light has a similar impact on adults and children.

Abundant natural light and accessible gardens are easier to incorporate in new construction than in existing facilities.

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Overall attractiveness and positive ambiance in design: Pleasant, clean and attractive settings are associated with increased contentment from patients, staff and families. Even small modifications are associated with increased staff satisfaction. Any refurbishment and renovation can include improvements in interior design and low cost options include the introduction of plants and art into existing settings.

The design of child-friendly interiors has changed over recent decades, with a distinct move away from primary colours, geometric shapes and cartoon characters. Engaging spaces with a ‘fresh and timeless feel’ are preferred, with themes involving nature, education and technology (Silvis, 2013). Artwork is used in a large scale within the building, as well as outside, to signify amenities important to families; such as cafés, lounges, laundry facilities, games areas and educational spaces.

The Royal Children’s Hospital in Melbourne, completed in 2012, expresses design and art across the entire façade, with key features along the length of a broad ‘main street’ spine. Designers focused on research which indicated the need for activities and distractions in paediatric health spaces that relieve anxiety and create engaging experiences. However, the design aims to suit both children and adults in its striking design features (Australian Design Review, 2012).

A two storey coral reef aquarium is located in the Emergency waiting area, visible from the Main Street. This feature acts as a wayfinding marker, as well as a welcome and engaging distraction for patients and families.

Children and young people’s experience of hospitals are influenced by their personal situation, social experiences, their interaction with the physical environment, and the effect of time (Bishop, 2008). Maintaining a positive engagement through architecture, art and the environment is important in affecting patient wellbeing and experience. These aspects should form the basis of the design of spaces for children in emergency environments.

Fig. 13

Fig. 14

Fig. 15

Royal Children’s Hospital Melbourne.

Location: Melbourne, VIC. Architects: Billard Leese, Bates Smart, HKS. Wayfinding: Buro North

2. Colourful Facade. Photo Credit: John Gollings. Australian Design Review, 2012.

3. Hanging artwork in Hospital Main Street.

Photo Credit. Shannon McGrath. Ibid.

4. Emergency Department Waiting room featuring aquarium. Photo credit: Fraser Marsden. Johnson, 2012.

Completed: 2012 ENVISION WELLNESS Acute Health Design

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CASE STUDY 02: OLDER PEOPLE Australia’s aging population is a significant challenge across the health system and is recognised as having a disproportionate effect on EDs. Older people require emergency care more often than other populations, as well as experiencing longer lengths of stay and higher admission/readmission rates. The rapid triage and care process of EDs is often inadequate to manage the needs of older people with multiple medical conditions, a long list of medicines, communication challenges, and slowly evolving problems that impair effective understanding of the patient’s current need (Adams, 2003).

The appropriate care for older people needs to be integrated into the design of EDs. Functional decline reduces the ability for some older people to navigate the physical environment, communicate effectively, and maintain a level of independence in EDs (Fisk, A, Rogers, W, Charness, N, Czaja, S & Sharit, J, 2004, as cited in State Government of Victoria, 2009).

A 2008 initiative by Victoria Health focused on improving the experiences of older people in ED as part of a broader Patient Experience Program.

An environmental audit of 21 major hospitals was used to identify and fund high priority items necessary to create more ‘older person friendly’ hospital environments (State Government of Victoria, 2009, p6). This audit revealed that there was a range of simple physical changes that could make considerable difference to older

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patients. Supporting sensory and physical impairment with mobility aids; volume-adjustable phones; improved lighting, signage and visual contrast supported better patient experiences.

The opportunity for clinicians to be involved in the audit also increased their awareness and understanding of the issues experienced by older people.

In 2013, the Aged Care Emergency (ACE) model of care was developed by the Emergency Care Institute NSW. The ACE Service model aims to support RACF staff to better manage residents experiencing acute onset symptoms within their facilities and avoid unnecessary transfer to ED. This includes providing telephone triage, and educational support for RACF. A collaborative working relationship between GPs, the community, RACFs and hospital care providers is required to ensure strong care continuity and case management.

Medical Assessment Units (MAU) have been established as an ED model of care in NSW since 2008. They are intended as inpatient short stay units co-located with emergency to provide care for the elderly, as well as those with chronic conditions, and as an alternative to treatment in ED. These services can deliver reductions in length-of-stay and waiting times for transfers to medical beds. Direct referral to MAU can improve a hospital’s ability to manage patient flow and reduce the number of complex non-critical medical patients presenting to ED (ACI, 2014). These services

provide specialist care to adults, and especially older people, who have a chronic and/or complex condition, or issues that may take time to assess and require a range of clinical expertise to diagnoses and treat.

Westmead Hospital in Western Sydney has developed a comprehensive model for aged care within hospital settings which has expanded over more than 10 years. A particular focus on ED streaming has led to innovations in the models of care. In 2005, the Older Persons Review and Assessment (OPERA) Unit was established as a patient-centred short stay unit. In 2008, Health Care for Older Persons Earlier (HOPE) strategy was established to better manage the increasing numbers of older people presenting at hospitals and reduce access block in emergency.

A small rapid assessment unit known as HOPE_ED is located within the emergency apartment, providing initial assessment and treatment within 4-8 hours. Patients are then transferred to the HOPE/OPERA unit which provides a ward-based medical unit and allied health unit along with cardiac monitoring. Specialist assessment and management plan development occurs over 24-72 hours. The design of these units is focused around the specific needs of older patients including; delirium management, wandering patients, frailty and risk of falls, and the ‘trauma of admission’ (Loh, 2017).

The HOPE/OPERA strategy is able to provide better specialist care within comprehensive aged care service;

Fig. 7

Fig. 8

“The chief complaint-centred, single-encounter emergency visit typical of modern EDs is not an optimal setting for delivery of care to many complex geriatric patients.�

(Burton, Young, & Bernier, 2014)

5. Victorian Emergency Departments Audit Improving Experienced for Older People in ED. State Government of Victoria, 2009.

6. Frequently Requested Items in ED. Ibid.

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stream older patients out of the ED, and support improved linkages with community care and Residential Aged Care Facilities (RACF) (Westmead Hospital, 2008). This is well aligned with the ED Senior Assessment and Streaming Model of Care and Toolkit (known as ED-SAS) was developed by NSW Health (2012(2)).

Alongside the Westmead HOPE-ED Unit, the Emergency Short Stay Unit (ESSU) was built in 2010 and expanded in 2016 to include 6 beds and 4 chairs. The ESSU is a discharge-stream model for patients with an expected length of stay of 4-24 hours and a high likelihood of discharge. The model of care is designed to support ED patient flow and the NSW Emergency Treatment Performance (ETP) commitment of 4-hours to transfer/discharge for 81% of all patients. It provides an alternative to inappropriate early discharge, while reducing length of stay for patients who would otherwise be admitted into a hospital ward. In order to ensure that the ESSU is not simply a ED overflow area, strict admissions criteria must be enforced to confirm suitability for admission. HOPE, OPERA and ESSU models of care at Westmead Hospital represent innovations in ED flow by targeting those presentations that are most likely to cause access block and overcrowding.

A new adult and paediatric ED is currently under construction at Westmead Health Precinct as part of a new acute services building, due to be

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Health carers need to be trained in dealing with the issues of the ageing population, and we need to be able to identify appropriate models of care that reflect the whole person’s needs.

(Parker, 2017).

completed in 2020. The design of this facility will incorporate the models of care developed in the existing department.

Increased understanding into the experience of older people in emergency and the complexity of their care has led to specialist geriatric emergency rooms in the U.S. The Holy Cross Hospital in Silver Spring, Maryland, commissioned the first Senior Emergency Department in 2008 with dedicated facilities and specialised nursing, emergency services, and social workers. This trend has responded to the demographic change in the U.S. The focus of the Holy Cross Hospital senior ED is on making patients more comfortable through increased privacy, natural lighting, acoustic separation and calming environments. Specialised nursing and social workers are provided training and support to prevent falls, assist with mobility, and support continuity of care. Screening for problems such as memory impairment and risk of

falls occurs at registration to support nursing during the visit (Noonan, 2012).

In 2017, a Senior Emergency Center was established at Atrium Medical Centre in Middletown, Ohio. The renovation of the 8-bed unit focused on safety features for older adults; adjustable temperature and lighting, private rooms, and specialist training (Schwartzberg, 2017). Warm tones, material selection and contrast have been considered in the design to provide a restful environment. The seniors unit operates as a specialist stream out of the core ED, improving patient flow and providing extra support for older people.

Streaming services, specialised nursing, support and approaches to design are combined in these examples to address the needs of older people in emergency. The increasing proportion of older people in emergency will likely lead to more EDs developing specialist branches to address demand. Cost effective renovations are possible even within existing services, but these need to be supported with improved training and knowledge of geriatric emergency care.

Fig. 9

Fig. 10

Fig. 11

7. Emergency Department Senior Assessment and Streaming. NSW Health, 2012.

8. Atrium Medical Center’s Senior Emergency Center front desk and nurse station.

WCPO, 2017.

9. Atrium Medical Center’s Senior Emergency Center private single room. Ibid.

Atrium Medical Center - Senior Emergency Center.

Location: Cincinnati, Ohio.

Completed: 2017

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CASE STUDY 03: BEHAVIOURAL HEALTH People can experience a mental health crises at any time of the day or night, therefore specialists and urgent care services need to be available around the clock. In the UK, a national report identified gaps in mental health care that resulted in many patients coming into contact with 3 to 10 services during a crisis event (CQC, 2015). CQC identified a need for better integration between services such as telephone helplines, GPs, mental health professionals, home and community services, acute inpatient services as well as EDs. A shortage of acute mental health inpatient beds in Australia has been identified since the beginning of the shift towards deinstitutionalisation and the move to integrate patients into community facilities where possible. A need for both inpatient and community care settings has been highlighted by the National Association of Practising Psychiatrists (2016) and the National Mental Health Commission Report has recommended a shift of $1billion to expand sub-acute beds.

Accurate mental health triage is necessary to ensure the safe and effective delivery of mental health care in ED. This triage should determine urgency, identify initial risks and levels of observation required. The NSW Health (2015(1), p6-7) reference guide for mental health in EDs identifies de-escalation and distraction is the preferred approach to managing safety risks. However, adequate clinical training and resources are required to

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ensure that staff can manage a diverse range of behavioural health issues and maintain safety and security for all.

provide expertise in dealing with mental health assessment (NSW Health, 2012(1)).

In the U.S., designated care coordinators for behavioural health are becoming increasingly common in primary care environments to support integrated care across physical and mental health in 1 setting (Sanders, 2017). This extends to the emergency care environment, where undifferentiated patients may present with a combination of health issues that have to be quickly and accurately assessed and treated. The design of EDs must also support the mental health of patients and provide a safe and calming environment.

Where there is no PECC located close to ED, Safe Assessment Rooms (SAR) are recommended to support mental health presentations at emergency (Garling, 2008, p27). SARs are multi-purpose rooms designed to provide privacy for patients and relatives, and to undertake high level observation and assessment. They are not intended as seclusion rooms and therefore patients should not be held alone in a room which they believe they cannot exit (NSW Health, 2015(1), p15). The approach to safety should be focused around providing comfortable environments with minimal barriers that minimise opportunities for self-harm, but which are residential in character. Small group rooms with direct visual monitoring by staff can support reductions in attempted suicide (Stroupe, 2014).

Psychiatric Emergency Care Centres (PECC) are specialist services introduced in NSW to enhance emergency mental health services. PECCs are intended for patients with low to medium acuity mental health problems who need short term mental health treatment, care and observation that cannot be provided in a community setting. They operate as part of a network of community-based and inpatient care environments. A proportion of patients are also transferred from triage in adjoining or collocated EDs (NSW Health, 2015(2)). However PECC units are not suitable for patients with ongoing medical instability or require complex acute interventions. In NSW, Mental Health Liaison Nurses operate in hospitals to provide support to EDs including education and direct clinical care. These nurses

The concept of expressed emotion is a measure that can be helpful in understanding the nature of relationships between patients, staff and family in a healthcare environment. Field research into the impact of the built environment on expressed emotion indicates 4 key themes (Liddicoat, 2016).

01_ Lack of or relinquishing control: Environments which seem to restrict control or lack personal space may reinforce feelings of disempowerment for patients and carers. Physical features which restrict control include inoperable windows, staff-only zones

Fig. 16

It is not acceptable for people with mental health problems to be treated differently to those with physical health problems.

(Dr Paul Lelliott, as citied by CQC, 2015)

Fig. 17

Fig. 18

10. Nurse station with views of waiting area and courtyards.

11. Lounge area with kitchen.

12. Acute inpatient room.

Glenside Mental Health Campus Location: Glenside, SA Architects: Swanbury Penglase and MAAP Architects.

Completed: 2013 Photo Credit: Sam Noonan

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which are clearly demarcated, security doors, and obvious security features on doors.

02_ Punishment: Environmental isolation from other patient cohorts and health services can create an experience of separation and difference for patient families. Security features, barren or empty courtyards and seclusion spaces are associated with prison-like environments. Seclusion rooms are also felt to be a form of punishment, as well as spaces which are perceived to be too small, like a “police cell”.

03_ Being abnormal: The design of environments which are not familiar are seen as abnormal, such as unexpected bedroom layouts. Rooms that feel like cells, or lack windows, reinforce a sense of incarceration. Fishbowl nurse stations with panoptic layouts can create an “us-or-them“ mentality from patients and family.

04_ Coldness or Lack of Identity: Powerful negative therapeutic effects are associated with coldness and a lack of identity. This may discourage patients and family from relaxing and engaging in therapy. Being unable to personalise spaces can hinder a patients’ ability to express a sense of individual identity. A perceived absence of warmth can potentially influence a lack of relationship between the patient and their environment. This in turn can impede therapy.

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Inpatient or Crisis Stabilisation Units in the U.S. operate in a similar way to PECC or SAR services. The aim is to immediately commence evaluation and treatment of patients upon arrival, with the aim of stabilising them within the unit, and where possible for discharge home or to community settings. If continued treatment is required, the patient can be transitioned into a suitable inpatient unit.

Facilities are designed with durable materials and minimal ligature points to provide safety, however the focus is on a healing environment which is comfortable and calm to reduce anxiety and encourage communication between patient, family and staff (Pinkerton & Johnson, 2017).

Behavioural Health units are also becoming a part of EDs in the U.S., with standardised rooms which can be used for acute medical treatment.

Retractable headwalls are installed allowing all equipment to be locked securely when required. This provides flexibility in the ED plan, while ensuring safety for patients with mental illness (Mader & Clarke, 2014). This feature can be integrated into existing EDs as part of a specialist treatment pod.

Corridors which can be isolated and separated from the main ED floor can also minimise foot traffic. Centrally located and open staff stations, which are designed to support conversation and interaction, can support observation and assessment in a non-threatening environment.

Specialised nursing and psychiatric can be provided to ensure that patients can be stabilised and adequately managed.

Integrated mental and physical health care relies on good integration between hospital and community based services. The design of all spaces occupied by mental health patients should incorporate evidence-based therapeutic principles.

This includes the use of natural light, connection with nature through windows and courtyards, normalised and domestic scale bedrooms and living spaces, as well as safe and robust materials and fixtures. Space constraints often impedes on the design quality of ED mental health services. Despite this, attention needs to be given to what can be done to support crisis management and de-escalation. High quality design can vastly reduce the negative perception and stigmatisation of mental illness and support the delivery of high quality specialist care in EDs.

Fig. 19

Fig. 20

Fig. 21 13. Narrow light well gardens.

14. Single loaded corridors with views of nature.

15. Courtyard garden.

Dandenong Mental Health Facility Location: Melbourne, VIC. Architects: Bates Smart & Whitefield McQueen Irwin Alsop Completed: 2012 Photo Credit: John Gollings

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CASE STUDY 04: PATIENT STRESS & WAYFINDING Understanding the patient perspective and designing patient flows to accommodate for the wide range of presentations is vital in providing the right care, at the right time, and in the right place. Following a near fatal shooting of a police officer and security guard at Nepean Hospital Emergency Department in January 2016, a review of ED security was commissioned by NSW Health. This review led to a 12 point action plan established by auditors along with recommendations to NSW Health. The report includes a focus on the safety and security of workplaces, funding for security upgrades and ongoing auditing of facilities (NSW Minister for Health, 2016).

and carers (NSW Health, 2011, p7).

For example, an ED model of care which incorporates a Clinical Initiatives Nurse is recommended by NSW Health (2012(1), p15) to maintain a nurse presence in the waiting room, as well as supporting and streamlining the triage process. This approach supports nurse-initiated interventions such as ordering diagnostics and administering pain-relief.

Wayfinding, guidance and training can be used to reduce incidents of violence and aggression in EDs. “A Better A&E” is a design solution developed by PearsonLloyd for The Design Council UK and 3 partner NHS Trusts to provide a cost-effective method of reducing violence in emergency. The design solution successfully reduced hostility, as well as providing social and economic return, with monetised benefits outweighing costs 3 to 1.

(Frontier Economics, 2013, p6).

The physical design of healthcare spaces has transformed in many ways to become more welcoming and inviting, with a renewed focus on light and sound attenuation, positive distraction and access to useful information (Suchomel, 2016). In new Kaiser Permanente health hubs, reception areas are designed as public ‘mall’ with indoor, outdoor spaces, health monitoring stations, and a staffed ‘Thrive Bar’ where patients can access advice on nutrition, exercise and other wellness issues while they wait (Bluestein, 2016). This approach supports Ulrich’s (1991) theory of supportive design for healthcare facilities, which focuses on patient wellbeing and alleviation of stress to provide a sense of control, positive distraction and social support.

Negative patient experiences often cause operational problems and workplace stress in EDs. Studies have shown that there are common psychological principles that apply to the ‘waiting experience’. Understanding and managing these waiting patients appropriately can help to reduce anxiety and frustration of patients

In 2011 the UK Design Council in collaboration with the UK Department of Health sought to deal with the ever increasing numbers of attendances at Accident and Emergency (A&E) departments in England and the negative experiences of staff and patients. The intention was to use design to alleviate tensions, and ultimately to reduce

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violence and aggression. A multi-disciplinary design team led by PearsonLloyd worked with the Design Council and 3 partner NHS Trusts to develop a set of design solutions and an online design kit to provide recommendations to NHS Trusts. An evaluation and findings report was conducted

by Frontier Economics to review the outcome of the project.

Frontier Economics (2013, p16) and ESRO research agency conducted preliminary research to identify triggers of violence and aggression such as: Clash of people: Many areas in ED departments are crowded with a range of different people, forced together by difficult circumstances – each undergoing their own stresses and dealing with their own complex mix of clinical and non-clinical needs.

Lack of progression: While all Trusts aim to treat 95% of patients within 4 hours, waiting for any length of time can be a difficult experience. There are few situations in our lives when we are forced to wait for such lengths of time without any sense of progression.

Inhospitable environments: Many people describe a dislike of hospitals, not least because they are full of sick people. Beyond the patients, hospitals can be uncomfortable places which are not pleasant to spend time in.

Dehumanising environments: When arriving at ED people can feel ‘out of sorts’ or in a negative mood.

Sometimes the way patients are managed can further lead to a loss of perspective.

Fig. 1

“Patient stress has a variety of negative psychological, physiological, and often behavioural manifestations that work against wellness.”

(Ulrich, R. 1991, p98).

Fig. 2

Fig. 3

16. Patient Flow Diagram indicating models of care. “A Better A&E”, 2017.

17. Bed-side signage aligning with Patient Flow Diagram . Ibid.

18. Printed Material available to patients and visitors. Ibid.

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Intense emotions: ED is a place where people may be experiencing extreme life events, suffering with pain or stress, or having to witness how other people are coping (or not) with their own stressful experiences.

Unsafe environments: ED is typically a very busy environment, with considerable amounts of equipment and large numbers of people using the space.

Sometimes these factors can help to trigger or worsen violence and aggression.

Perceived inefficiency: From a patient’s perspective it can sometimes feel as if staff in ED environments are disorganised and lacking focus.

Patients observe themselves and others seemingly waiting for hours, while staff ‘busy themselves’ with perceived non-essential tasks.

Inconsistent response: Hospital environments are often tightly controlled by policies, guidance, rules and regulations, much of which is difficult to decipher, inconsistently applied, and can be contrary to what happens in practice.

Staff fatigue: Working in an ED department is highly demanding on staff, many of whom work 12-hour shifts.

Over time, staff can become both physically and emotionally tired, struggling to find the energy to deal with the constant flow of patients.

A model for the ideal patient journey was developed comprising of 4 stages of the user experience: Arrival, Wait, 20

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Treatment and Outcome. In each phase, the design team explored impact of positive interaction and clarity, with an emphasis on keeping patients informed and up-to-date throughout their visit to emergency.

The ‘Guidance Project’ was implemented to provide information to patients and visitors including a process map, wayfinding signage, patient leaflets and live digital information. The process map is the central tool used to inform patients and help them understand what their patient journey might look like.

Signage throughout the department was linked back to the process map to help patients understand where they were in their journey. Screens installed in waiting areas provided live digital information such as the number of patients in each area of the department, expected wait time and department operational status. This offered patients a better understanding of the reasons they were being asked to wait.

Human contact and compassion was also identified as an effective way to support patient experiences, however ED staff are often working under intense stress and time pressure. This can lead to fatigue, low morale and poorer care outcomes.

The ‘People Project’ was developed to improve emergency staff skills in working under pressure and managing potentially aggressive patients whilst maintaining empathy. The primary aim was to promote staff engagement, boost morale, and support staff who

may deal with potentially aggressive and violent patients. Staff facilitators were appointed and trained in trial sites and a department engagement programme was developed. Staff discussed personal experiences, identified trends in the nature of incidents and when incidents were likely to happen. Data was collected to improve understanding of when, how and why violent and aggressive incidents occurred, and how these could be better managed. The Project opened a dialogue around key operational issues affecting staff and emphasised the need for design solutions to be sufficiently flexible to support the specific needs of individual departments.

The results of the ‘Guidance’ and ‘People’ projects were collated and published in the form of a design toolkit to support implementation in other hospitals. The research and knowledge collected in this report represents a valuable tool for EDs around the world. The design solution provided a cost-effective retro-fit approach which delivered improvements in patient experience and reduction in aggressive incidents. This approach could be utilised in other health districts around Australia. The NSW Health ED streaming approach to models of care in ED could form the basis of a patient flow diagram for NSW EDs tailored to individual services.

Fig. 4

Waiting in ignorance creates a feeling of powerlessness, which frequently results in visible irritation and rudeness.

(Maister, 2005, p6).

Fig. 5

Fig. 6

19. Ideal Patient Journey with streaming to models of care. NSW Health, 2012.

20. Waiting Room Digital Information. “A Better A&E�, 2017.

21. Installing Ceiling signage above beds. Ibid.

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CONCLUSION The growing use of EDs as diagnostic centers warrants further scrutiny to determine if this is the most clinically and economically efficient way to evaluate complex patients with worrisome symptoms.

(Morganti, Bahuoff, Blanchard, Abir, Smith, Vesely, Okeke, Kellerman, Iyer, 2013).

Demand for emergency medicine continues to grow, and increased services are required to cater for a wide range of population groups, ages and specialisms. However the causes for increased presentations should be critically examined as part of the whole health system and future trends.

The Royal College of Physicians (RCP), NHS Confederation, Society for Acute Medicine and the College of Emergency Medicine in the U.K. outlined a vision in 2013 for the future of urgent and emergency care services. The challenges faced by EDs was reviewed and recommendations for action were outlined across the health network. Effective and simplified alternatives to hospital admission and emergency presentation were recommended. This includes 7-day services which provide hospital admission and discharge, consultation services and ambulatory care. This action plan highlights the need for the whole U.K. health system to support reductions in unscheduled care. Public health, preventative strategies and 22

ENVISION WELLNESS Acute Health Design

improved access to information were highlighted as important aspects to ensure that patients have a clear understanding of services, as well as pathways to obtaining diagnosis and treatment. These recommendations identify current concerns that rising demand for emergency services cannot be met by simply increasing size, capacity and number of EDs within health networks.

been a single department in a local hospital will evolve to become a large network of services in a major metropolitan context. A decentralised but networked approach has the potential to provide better customisation to support the range of patient needs.

This should be reflected in building designs which provide connectivity and flexibility, as well as opportunities for future growth and adaptive spaces.

EDs started off as treatment rooms for assessment and stabilisation of unplanned or unexpected cases.

However, the unique challenge of emergency medicine has encouraged the evolution of new models of care and clinical specialisms. Over time, EDs have become the first point of entry for an extremely broad spectrum of care needs from ambulatory urgent care, to complex and chronic illness.

The wide range of needs has driven demand for a wide range of diagnostic services, pharmacy, treatment and specialist care and nursing. Today, EDs demand collocation and proximity to nearly every aspect of acute care.

In hospital planning and design, the centre of gravity almost always lies close to the ED along with the surgery and treatment spaces.

For patients, a timely response, with accurate assessment and diagnosis, and clear pathways for care are major concerns when accessing emergency care. The triage, registration and coordination of patients is critical to ensuring integrated care throughout the patient journey. The experience of people should remain at the centre of the design challenge for EDs. A humanistic and supportive environment should be the first priority, regardless of the situation or context.

Collocation and adjacency of support services becomes difficult as physical space requirements increase. Travel distances also rise with the introduction of specialist streams for children, older people, behavioural health, medical/surgical assessment, and urgent care. What has traditionally

To address the challenges faced by urgent and emergency care services, we must change the way we deliver and organise care across the whole system.

(Royal College of Physicians, NHS Confederation, Society for Acute Medicine and The College of Emergency Medicine, 2013).

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Garling, P. (2008). Final Report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals - Overview. Retrieved from https:// www.dpc.nsw.gov.au/?a=34194 Gray, L. (2013). Older patients need special care in emergency departments. University of Queensland News. Retrieved from: https:// www.uq.edu.au/news/article/2013/07/older-patients-need-special-care-emergency-departments Healthcare Design Magazine. (2008). Evidence that pediatric settings can heal. Retrieved from https://www.healthcaredesignmagazine. com/architecture/evidence-pediatric-settings-can-heal/ Johnston, A. (2012). Wayfinding Solution for the Royal Children’s Hospital Melbourne by Buro North. Dexigner. Retrieved from https://www.dexigner.com/news/24905 Judkins, S. (2003). Paediatric Emergency Department Design: Does it Affect Staff, Patient and Community Satisfaction? Emergency Medicine Australasia 15:1, P63-67. Retrieved from https://www.healthdesign.org/chd/knowledge-repository/paediatricemergency-department-design-does-it-affect-staff-patient-and-com Liddicoat, S. (2016). Expressed Emotion and the Hospital Environment [Doctoral Thesis]. University of Melbourne, VIC. Loh, M. (2017). HOPE-ED + OPERA - A Geriatrician’s Experience [Presentation]. Ultimo: GEM Seminar 2017. Retrieved from http://www. phemc.org/wp-content/uploads/2017/05/Ming-Loh-HOPE-ED.pdf Mader, M. & Clarke, K. (2014). Today’s ED: Designing Efficient Emergency Departments in the 21st Century. Medical Construction & Design. Retrieved from https://mcdmag.com/2014/05/todays-er-designing-efficient-emergency-departments-in-the-21stcentury/ Maister, D. H. (2006). The Psychology of Waiting Lines. Retrieved from http://www.columbia.edu/~ww2040/4615S13/Psychology_of_ Waiting_Lines.pdf Medew, J. (2017). Violent patients put into comas to protect staff, emergency doctor says. The Age Victoria. Retrieved from http:// www.theage.com.au/victoria/violent-patients-put-into-comas-to-protect-staff-emergency-doctor-says-20170413-gvkmu7. html Mental Health Services in Australia (MHSA). (2016). Mental Health Services provided in emergency departments. Canberra: Australian Institute of Health and Welfare. Retrieved from https://mhsa.aihw.gov.au/services/emergency-departments/ Morganti, K.G., Bauhoff, S., Blanchard, J.C., Abir, M., Smith, A., Vesely, J., Okeke, E., Kellermann, A.L., & Iyer, N. (2013). The Evolving Roles of Emergency Departments [Research Brief]. Santa Monica, CA: RAND Corporation. Retrieved from https://www.rand.org/ pubs/research_briefs/RB9715.html National Association of Children’s Hospitals and Related Institutions (NACHRI). (2008). Evidence for Innovation - Transforming children’s health through the physical environment - Executive Summary. Retrieved from http://www.premiersafetyinstitute.org/wp-content/ uploads/evidenceforinnovation-execsum-small.pdf National Association of Practising Psychiatrists. (2016). Shortage of acute hospital beds for patients with mental illness is a national disgrace.

Retrieved from https://www.ranzcp.org/Files/Fellowship/Sections/NAPP-Media-Release-Shortage-of-Acute-Mental-Illnes. aspx

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Noonan, J. (2012). For the Elderly, a New Kind of ER. ABC News. Retrieved from http://abcnews.go.com/Health/kind-emergencyroom-elderly/story?id=16132826 NSW Health. (2012(1)). Emergency Department Models of Care. Sydney: NSW Ministry of Health. Retrieved from http://www.health.nsw. gov.au/Performance/Publications/ed-model-of-care-2012.pdf NSW Health. (2012(2)). Emergency Department Senior Assessment and Streaming Model of Care and Toolkit. Sydney: NSW Ministry of Health.

Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/273816/ed-sas-model-of-care-and-toolkit. pdf NSW Health. (2015(1)). Mental Health for Emergency Departments: A Reference Guide. Sydney: NSW Ministry of Health. Retrieved from http:// www.health.nsw.gov.au/mentalhealth/publications/Publications/mental-health-ed-guide.pdf NSW Health. (2015(2)). Psychiatric Emergency Care Centre Model of Care Guideline. Sydney: NSW Ministry of Health. Retrieved from http:// www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_009.pdf NSW Minister for Health. (2016). Roundtable Delivers Hospital Security Action Plan [Press Release]. Retrieved from http://www.health.nsw. gov.au/news/Documents/20160208_00.pdf Parker, D. (2017). Aussies are getting older, and the health workforce needs training to reflect it. The Conversation. Retrieved from https://theconversation.com/aussies-are-getting-older-and-the-health-workforce-needs-training-to-reflect-it-67710 Pinkerton, P. J. & Johnson, J. L. (2017). Design practices contribute to stabilization unit safety. Behavioural Healthcare Executive.

Retrieved from https://www.behavioral.net/article/facility-architecture/design-practices-contribute-stabilization-unit-safety Powley, K. (2017). Victorian hospital emergency departments flooded by drunks taking up beds, hogging staff time. The Herald Sun. Retrieved from http://www.heraldsun.com.au/news/victorian-hospital-emergency-departments-flooded-by-drunks-takingup-beds-hogging-staff-time/news-story/de11068f3037c742525c42764166cc37 Royal College of Physicians, NHS Confederation, Society for Acute Medicine and The College of Emergency Medicine. (2013).

Urgent and emergency care: a prescription for the future. Retrieved from https://aace.org.uk/resources/urgent-and-emergency-care-aprescription-for-the-future/ Sanders, R. K. (2017). 6 Behavioral Health Design Trends. Healthcare Design Magazine. Retrieved from https://www. healthcaredesignmagazine.com/trends/architecture/6-behavioral-health-design-trends/ Schwartzberg, E. (2017). New Middleton emergency department designed with seniors in mind. Journal-News. Retrieved from http://www.journal-news.com/business/new-middletown-emergency-department-designed-with-seniors-mind/ MjwdYDYLHiRRvAisQtFLMM/ Silvis, J. (2013). Children’s Hospital Design Grows Up. Healthcare Design Magazine. Retrieved from https://www. healthcaredesignmagazine.com/architecture/childrens-hospital-design-grows/ Sparkes, L. (2011). Who’s really looking after emergency department waiting rooms? The Conversation. Retrieved from https:// theconversation.com/whos-really-looking-after-emergency-department-waiting-rooms-4549

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State Government of Victoria. (2009). Improving the Patient Experience Program - Improving the environment for older people in Victorian Emergency Departments - Audit Report. Melbourne: State Government of Victoria. Retrieved from https://www2.health.vic.gov.au/hospitalsand-health-services/patient-care/acute-care/emergency-care/patient-experience-in-eds/improving-the-ed-experience Stroupe, J.M. (2014). Behavioural health design - Effective patient spaces for treating mental illness. Health Facilities Management.

Retrieved from https://www.hfmmagazine.com/articles/1370-behavioral-health-design Suchomel, J. (2016). Design Solutions To Improve Waiting In Healthcare. Healthcare Design Magazine. Retrieved from https://www. healthcaredesignmagazine.com/trends/interior-design/design-solutions-improve-waiting-healthcare/ Ulrich, R. (1991). Effects of Interior Design on Wellness: Theory and Recent Scientific Research. Journal Of Health Care Interior Design, 3, 97-109. Retrieved from https://www.researchgate.net/publication/13173950_Effects_of_interior_design_on_wellness_ Theory_and_recent_scientific_research Vickery, C. G. (2011(1)). Design Choices in Pediatric Emergency Departments. Healthcare Design Magazine. Retrieved from https://www. healthcaredesignmagazine.com/architecture/design-choices-pediatric-emergency-departments/ Vickery, C.G (2011(2)). Assessing Design Choices in Pediatric Units. Healthcare Design Magazine. Retrieved from https://www. healthcaredesignmagazine.com/architecture/assessing-design-choices-pediatric-units/ Westmead Hospital. (2008). Health care for Older Adults Earlier (HOPE) Strategy. Retrieved from https://www.aci.health.nsw.gov.au/ networks/acute-care-taskforce/mau-nsw/2/hope-westmead.pdf WPCO. (2017). New Senior Emergency Center at Atrium Medical Center expands services for older adults. WCPO Cincinnati News.

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APPROACH NBRSARCHITECTURE is a multidisciplinary practice offering services in architecture, landscape architecture, urban design, interior design, heritage and compliance.

to-date knowledge is vital in ensuring a high quality of design as well as an understanding of the social, cultural and political context within which we operate.

We believe in creating life-changing environments for patients, families, carers, staff and communities. We are particularly interested in helping our clients deliver best-practice, person-centred care. Our experience across a wide range of spaces for living, gathering and working supplements our interest in health care delivery. We develop creative partnerships with our clients to ensure high quality design outcomes, and regularly engage in public discourse on architecture and design.

Envision papers incorporate case study, literature review, desktop analysis and other research. Case studies are useful as they focus on individual projects rather than sweeping statistical or data-analysis based study. By analysing built projects, it is possible to gain an understanding of the effectiveness of design in achieving its desired results. While a case study may not directly answer to a research question, they provide a real-world example with site and context to test theories and ideas.

Literature review is conducted across a range of local, interstate and international sources to ensure our designs are responding to international best practice, as well as regional issues and

In order to ensure the relevance of the spaces we design, we conduct research into current and projected trends in the way people live and interact with the built environment. Up-

trends that directly affect our clients.

This provides us with the knowledge to provide strategic advice and guidance to our clients.

The NBRS Student Partnership Program engages architectural students to work in conjunction with mentors within the practice to do further in-depth research and design around key topics relevant to our work.

If you are interested in knowing more about a topic covered in our research, please feel free to contact us. We are also interested in engaging in new research with current and future clients to support business case development, feasibility and concept design.

Brett Sherson Studio Principal - Wellness brett.sherson@nbrsarchitecture.com +61 2 9095 5618 +61 421 606 449

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Sydney: +61 2 9922 2344 nbrsarchitecture.com