A&E Departments

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The impact of the built environment on care within A&E departments

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The impact of the built environment on care within A&E departments
Crown copyright 2003
Executive summary
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 for the 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&E departments; 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.
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.
ACCOUNTING FOR PATIENTS VISITORS AND STAFF

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.
CIRCULATION AND WAYFINDING 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 the department should be tightly controlled so that privacy and dignity of patients is not compromised and to ensure that visitors do not access sensitive areas. 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.
Acknowledgements
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
Contents
Executive summary Acknowledgements
Patient, staff and visitor ratios: assessment rooms
1 INTRODUCTION
Context page 3
Treatment rooms
page 15
Introduction to the A&E departments used in this study page 3 The patients journey Methodology Baseline statistics Design KPIs Space use KPIs page 3 page 6
Provision: treatment rooms Flexibility Recommendations: Provision and flexibility of use Surveillance Recommendations: Surveillance Wayfinding and location of treatment rooms Recommendations: Wayfinding Privacy and dignity in treatment rooms Recommendations: Privacy and dignity Use of treatment rooms by patients, staff and visitors Use of major and minor treatment rooms
Circulation Provision: circulation space Wayfinding Recommendations: Wayfinding Access control Patient, staff and visitor (PSV) ratios Routes
page 24
2 FINDINGS AND RECOMMENDATIONS

Locations of patients, staff and visitors Arrival and entrances Entrance design Access control Recommendations: Access control page 8 page 8
3 CONCLUSIONS
The way forward page 29
Patient, staff, visitor ratios Recommendations: Flexibility
page 10
APPENDIX 1 DEPARTMENTS APPENDIX 2 METHODOLOGY

Entrance and exit counts Staff and patient pathways Space use occupancy survey Room profiles page 38 page 38 page 40 page 40 page 40
Reception and waiting areas Waiting area provision Recommendations: Provision Surveillance of waiting areas Recommendations: Surveillance Wayfinding Recommendations: Wayfinding Patient, staff and visitor ratios: waiting areas
page 10
Triage and assessment Provision Recommendations: Wayfinding Privacy and dignity in assessment rooms Recommendations: Privacy and dignity
page 13
Visibility modelling
ABOUT NHS ESTATES GUIDANCE AND PUBLICATIONS
Introduction
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 the physical 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.
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.
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 to reduce 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
1 Full details can be found in See and Treat, NHS Modernisation Agency, 2002.
INTRODUCTION TO THE A&E DEPARTMENTS USED 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 on the 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
THE IMPACT OF THE BUILT ENVIRONMENT ON CARE WITHIN A&E DEPARTMENTS
Main entrance
ENTER WELCOMING ENTRANCE
Child wait
Waiting area
WCs Baby change Infant feeding
Reception meet & greet
Pharmacy
Communications base
Social care
Assessment rooms including registration
Interview
Treatment rooms
Resuscitation
Sub-wait WC
Head/ neck
Gynae
Clinical decision unit or observation unit
Sub-wait WC
Digital imaging suite
Assessment unit in childrens department
Figure 1 Relationship of rooms and areas for patients arriving through the main entrance
1 INTRODUCTION
The ambulance entrance Ambulance bay
AMBULANCE ENTRANCE
Ambulance store
Sub-wait WC
Treatment rooms Resuscitation
Viewing room
Digital imaging suite
Sitting room WC
DESIRABLE EXIT GARDEN VIEW
Sub-wait WC
Clinical decision unit or observation unit
Assessment unit in the childrens dept
Critical care Operating theatres Acute wards
THESE FACILITIES SHOULD BE LOCATED CLOSE TO THE DEPARTMENT PREFERABLY ON THE SAME FLOOR
Figure 2 Relationship of rooms and areas for patients arriving by ambulance
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 in Appendix 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 clinical examination 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
Figure 3 Treatment times (time spent in the treatment room) in Department 3
1 INTRODUCTION
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 (see Appendix 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, staff and 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.
Findings and recommendations
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.
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 by wheelchair); 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.
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. 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.
Key Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting Cummulative routes by patients, staff & visitors
minor minor minor minor minor minor injuries injuries injuries injuries injuries injuries
resus
triage
reception
staff clustering staff clustering staff clustering staff clustering staff clustering staff clustering trolley waits
staff base route to reception
AMBULANCE ENTRANCE
2 Source: QMNG 2001/20 8
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 nonadjoining 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.
30
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25
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20 Average PPH
15
10
0 Circulation Relatives Room Sanitary Treatment Waiting Triage Store Staff
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
77% visitors
2% visitors
98% visitors
8% visitors
92% visitors
Percentage of visitors using the main and paramedic entrances based on the configuration of the entrances.
paramedic entrance main entrance
free access access control measures
Figure 5
CASE STUDY 2 Consistently in all eight of the departments a separation of staff and patients was noted. This is illustrated in Figure 7. In a recent MORI opinion poll patients indicated that they want to feel a close presence of clinical staff and to receive better communication from staff. Information is crucial lack of information contributes to anxiety and discomfort of patients and carers who are waiting. On entering A&E people want more information on the following: initial expected waiting times; changes to expected waiting times; reasons for changes (for example, intake of serious road traffic accidents); alternatives to A&E (where they can get treatment instead); their condition and priority in the queue. Due to staffing numbers, nurses often observe patients from the staff base. The question is what can be done to strike a balance between the need for observation and patient communication.
patients staff visitors
Space Use
waiting area waiting area waiting area waiting area waiting area waiting area reception reception reception reception reception reception main main main main main main entrance entrance entrance entrance entrance entrance Adj. Department circulation maintenance Relatives Room Sanitary Staff Store Treatment Triage Waiting all others
paediatrics paediatrics paediatrics paediatrics
minor injury treatment rooms minor injury treatment rooms minor injury treatment rooms minor injury treatment rooms minor injury treatment rooms minor injury treatment rooms
staff base staff base staff base staff base staff base staff base
major injury treatment rooms major major injury treatment rooms major injury treatment rooms major injury treatment rooms major injury treatment rooms paramedic paramedic paramedic paramedic paramedic paramedic entrance entrance entrance entrance entrance entrance
resus resus resus resus resus resus
10
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.
Entry/Exit Counts 1,500 750 150 visitor patient staff paramedic Ambulance Entrance Main Entrance
618
1,419
749
1,249
707
10m
Figure 8 Total entrances to A&E Department 6 from 08:00 to 20:00
11
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 waiting 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. CASE STUDY 3
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 of the 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.
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.
to adjacent department
minor injuries treatment rooms & main hospital

WAITING AREA
triage
treatment rooms & resus
The wall blocks views between the reception to the waiting area.
RECEPTION
CIRCULATION
waiting area
reception
main entrance
AMBULANT ENTRANCE RECORDS STORE
paramedic entrance records store

STRETCHER ENTRANCE
Locations that can be overseen from the reception. 2m
12
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 to the security staff. None of the hospitals surveyed had security staff directly overseeing the reception and waiting areas. The surveillance of the waiting 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. Access control CASE STUDY 4
Where only 7% of the waiting area can be overseen from the reception desk, the staff are unable to observe the patients and the service provided is restricted. Recommendations: Surveillance It is important that the waiting area and entrances can be surveyed from the reception desk. This is to ensure that: receptionists can oversee patients in order for them to summon help from clinical staff if they are concerned about a patients medical condition; they can identify any violent behaviour by patients or visitors and contact security staff to deal with the matter; and the routes into the department from the waiting area can be surveyed to help enable visual and physical control over who enters the treatment areas.
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.
main entrance main entrance main entrance main entrance main entrance ambulance ambulance ambulance ambulance ambulance ambulance entrances entrances entrances entrances entrances entrances
Space Use Adj. Dept. Circulation Maintenance Relatives Room Sanitary Staff Store Treatment Triage Waiting
140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140
10m
Figure 10 Access control in Department 2 13
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. 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, during 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.
ACCESS TO RECEPTION DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8 directly accessible directly accessible directly accessible directly accessible directly accessible one change of direction one change of direction two changes of direction ACCESS TO WAITING AREA one change of direction directly accessible directly accessible one change of direction directly accessible directly accessible one change of direction one change of direction
This indicator has been applied to all the departments in the study (see Table 1), and the following results were found: only five of the eight departments in the study have the reception located in a position that is visible from the entrance; of the remaining three departments, two require one change of direction to find reception and one requires two changes of direction; the wayfinding indicator was also applied to the location of the waiting area, showing that only four of the eight departments have waiting areas visible from the entrance, with the other three departments requiring two changes of direction. Recommendations: Wayfinding It is important that the reception is directly visible from the main entrance in order to support ease of wayfinding for those people entering the department for the first time. This is key to ensuring that people go directly to the reception staff and do not access other areas looking for help. It is important that there are good connections from the ambulance entrance to the reception. This is in case of closure of the main entrance resulting in patients entering via a different route, and also for visitors and family members who may be entering the hospital with a patient 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
Table 1 Access to reception and waiting areas
14
% PATIENTS DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8 AVERAGE MINIMUM MEDIAN MAXIMUM 46 44 42 49 52 48 44 40 46 40 45 52
% STAFF 1 10 5 4 1 1 2 1 3 1 2 10
% VISITORS 53 45 53 47 47 50 55 59 51 45 52 59
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 clinical 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.
Table 2 Patient, staff and visitor ratios in waiting areas
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.
patient staff visitor Space Use Adj. Dept. Circulation Maintenance Relatives Room Sanitary Staff Store Treatment Triage Waiting
140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140 140
The department was surveyed once every hour between 08:00 and 20:00. Each dot represents a staff member, patient or visitor that was seen during one of the surveys.
10m
Figure 11 Locations of patients, staff and visitors in Department 2
15
Patient, staff and visitor ratios: assessment rooms

59
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.
3
32
6 1
In this department there was a lower proportion of patients in the waiting area instead a greater proportion of patients in the treatment rooms.
Figure 12 Percentage of people entering A&E in each triage category
Of those entering the A&E department, 83% will be discharged directly from A&E with only 17% of attenders admitted to hospital.3 Recommendations: Wayfinding For the new See and Treat service model it will be important that the assessment rooms are directly visible and accessible from the main waiting area. As the majority of patients will be discharged directly from assessment rooms, it is important to ensure (for the privacy and dignity of other patients) that they do not have access to other areas of the department. To ensure this, the departments should be located off the waiting area with controlled access through to the main treatment areas. Privacy and dignity in assessment rooms It is important when patients are assessed that they have full auditory and visual privacy. This is especially important as the assessment rooms are often adjacent to the main waiting areas, and during assessment the patient may be asked personal questions. Additionally, a nurse is present during this stage so there is no requirement for further surveillance from other staff. Recommendations: Privacy and dignity It is important that there is full auditory and visual privacy for people in assessment rooms. It is in these rooms that they will be asked personal questions regarding their health and their contact details during registration. If a staff member is present constantly during the assessment process, there will be less requirement for casual surveillance from the staff base. However, consideration should be made for any future change in use of the rooms in assessing their ability to be surveyed from the staff bases.
3 Source: Adrian Fletcher, Genflows.ppt
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 (see Table 3). The numbers of major treatment rooms vary between 6 and 11 and minor between 3 and 10.
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NUMBER MINOR DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 6 4 7 10
NUMBER MAJOR 6 11 7 8
NUMBER RESUS 1 (4 trolley bays) 1 (6 trolley bays) 3 bays 1 (3 trolley bays)
PAEDIATRICS 2 2 1 (2 bed bays) 6
OTHER (SPECIFY) 1 Trauma 1 Obs and Gyn 1 Opth/ENT mental heath area 8 observation bays 5 clinic exam rooms 1 minor operation room (not used) 1 recovery room (not used) 8 CDU 1 X ray 1 Soft Room 1 Side Room (lockable door for Obs and Gyn etc) 1 clean theatre 1 plaster room 1 suture 3 3 1 1 treat Plaster eye/treatment Gyn/GU
DEPARTMENT 5
11
1 (3 bays)
DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8
3 6 5
one large area, no separations 11 6
1 area (not separated) 5 3
4 7 0
Table 3 The number and type of treatment rooms in each department
Major and minor treatment rooms On average, 28% of the space in the department is devoted 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, which is 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;
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.
they are smaller; and the rooms are not fitted out to the specification required 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 minor conditions.
LOCATION SIZE SPECIFICATION (TOGETHER (SAME (SAME Y/N) SIZE Y/N) Y/N) DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8 Y Y N Y N N N Y N Y N Y N N N N Y Y N Y N N N N
Table 4 Flexibility of treatment rooms
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One hospital (Department 2) has solved this problem by providing a treatment area designed to contain four minor treatment rooms and 11 major treatment rooms. However, when the department is under pressure and requires more major treatment cubicles, two of the minor rooms are used for major injury patients. This is possible because: the room specification is the same as for the major treatment rooms. All rooms are the same width and length and contain the same equipment; there is one staff base for both major and minor injuries patients, which means that there is no distinction in care terms. Additionally, all of the treatment rooms can be overseen from the staff base. This can be seen in the example in Figure 13. The role of treatment rooms in the new care model will change from existing departments. The majority of minor injuries patients will be assessed and treated in assessment rooms. Only patients requiring tests, more extensive clinical examination, and treatment will be moved to treatment rooms.
A department that has not been able to support changes for patients presenting with major and minor conditions is shown in Figure 14. In this case the minor treatment rooms remained vacant for 50% of the survey yet there were patients waiting on trolleys in corridor spaces due to the lack of available major treatment rooms. Recommendations: Provision and flexibility of use The number of both assessment and treatment rooms required in the new model of care will be based upon the number of: patients and the average duration of assessment; patients requiring further treatment and the average duration of the treatment that they will need; and staff members present and allocated to assessment or treatment rooms. It is likely that a greater proportion of patients that present themselves to A&E in the future will require treatment. This may be due to the use of Minor Injuries Units and other care measures that will divert a high proportion of patients with minor injuries away from A&E departments.
LIT UTI AY X-R BAY
ICE OFF
G. /RE
S S O O OM O O O O O OM O O O O O O O O O O O O O O O O O O O ROO R O R OO R O R O R O R O R O R O R O R O R O R O R O R O R O N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R ENT EN T ATM A A M A M A M A A M A M A M A TM A A M A M A M A M A A M A M A M A M A RA REA RA REA RA RA RA RA RA R R R R R R R R R R R R R R R R R R R R R R R R R R R R R TR R R R R R R R R R R R TR R R R R R R R R R R R R R R R R R R R R R R R R R R R R JOR JOR MA M M M M M M MA M M M M M M M M M M M M M M M M M M M M M M
TRO TRO Y LLE BAY
Y LLE BAY
C ELE
TRO
Y LLE
S S OM OM T RO T RO EN EN ATM ATM TRE TRE JOR JOR MA MA

TRO Y LLE BAY TRO Y LLE BAY BAY
T EQP RE
STO
TRO
Y LLE BAY
TRO
Y LLE
BAY
TRO
Y LLE BAY
-01 521
NG LKI WA P PRE WO NG LKI WA UN D DE UN D DE
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UG (DR
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Department 2 has 11 major treatment rooms and 4 minor treatment rooms, these are shown in blue in the map.
S HE TC CRU STO RE
AIT -W SUB
1m
The staff base has direct surveillance over all 15 treatment rooms.
Figure 13 Flexible use of treatment rooms
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DA1
S S O O O O OM S O O O O O MS O O O O O S O O O O O O O O O O O O O R O R O R O R O R O R OO ROO R O R O R O R O R O R O R O R O R O N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R N R ENT EN T A M A M A M A M A M ATM A M A M A M A M A M A M A M A M A M A M A M A M A A M A M A M A M A M REA T REA RA RA RA RA R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R TR R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R OR T OR M M MN MN MN MN MIIIN M M MN MN MN MN MIIN M M MN MN MN MN MIIN MN M M MN MN MN M IIN M M MN MN MN MN MN M M M MN MN MN MN M MN

M EXA W CL) VIE (RE M EXA W CL) VIE (RE
FF STA E BAS
E E BAS BAS AFF AFF ST ST
M EXA
HT T/ OP (EN
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T EQP RE
STO
WC
(PU
B) WC
M EXA
W CL) VIE (RE
S S OM OM T RO T RO EN EN ATM ATM TRE TRE JOR JOR MA MA

WO UN NG LKI WA UN D DE WO
T EN ATM TRE (O & G)
NG LKI WA D DE
TY DIR LIT UTI Y
WC
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Space Use In hospital 3, the major and minor injuries are completely separate and it is not possible except on an adhoc basis to use the minor treatment rooms for major injuries patients. Because of this it was found that there was redundant space in the minor treatment rooms and under provision for major injuries patients. This resulted in some patients waiting on trolleys in the circulation space. 7 minor treatment rooms: occupied 54% of the survey (08:00 to 20:00) 7 major treatment rooms: occupied 96% of the survey (08:00 to 20:00) 1m Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting
RESUS RESUS
ROUTE FROM ROUTE FROM MAIN ENTRANCE MAIN ENTRANCE

Figure 14 Building within redundant treatment areas Department 3
ROUTE FROM ROUTE FROM AMBULANCE ENTRANCE AMBULANCE ENTRANCE
To ensure that the departments can cope with the current demand by minor injuries patients, and to ensure that valuable space within A&E in future is fully utilised, designs should be flexible to allow change of use of assessment rooms if there is no longer the requirement for them. Without this flexibility, redundancy could be built into the design.
For a plan to support flexibility of room usage there are two main indications: that staff can survey both the treatment and assessment rooms based in one single location; and that both rooms are of the size to support use for each purpose.
TROLLEY WAITS IN MAJOR'S CORRIDOR TROLLEY WAITS IN MAJOR'S CORRIDOR
MINOR TREATMENT ROOMS MINOR TREATMENT ROOMS
REDUNDANT ROOMS REDUNDANT ROOMS
STAFF BASE STAFF BASE
MAJOR TREATMENT ROOMS MAJOR TREATMENT ROOMS

19
Surveillance 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.
Example of Cubicles with Good and Poor Surveillance 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. 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.
Space Use Other Depts A&E Treatment Area Visible from Staff Base 10m
staff base
staff base
Figure 15 Example of cubicles with good and poor 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 surveillance, visibility modelling has been used 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, regardless of windows into the treatment rooms, it is not possible to provide casual surveillance.
Recommendations: Surveillance It is important to ensure that there is surveillance of all patients treated in the A&E departments. Patients can be surveyed by three methods: observing patients remotely through use of technology; 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.
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Wayfinding and location of treatment rooms It is important that there is controlled access to treatment rooms and that staff are aware of who is in each room. To help ensure this, it is important that the patients and visitors can easily find their way around the more public parts of the department to help prevent them inadvertently accessing a treatment area. The wayfinding for patients accessing the treatment rooms will be controlled mainly by the staff member leading them into the department. It is important that the wayfinding is managed to ensure that, on leaving the treatment room, patients can find their way back to reception. The wayfinding for visitors differs from that for the patients, as visitors may enter and leave the treatment room a number of times while the patient is being treated, to go outside for a break. It is therefore important that visitors can find their way back to the main entrance along a route that does not compromise the privacy and dignity of other patients. To measure the ease of wayfinding, the locations of treatment rooms were audited to outline the most accessible routes for visitors leaving the treatment rooms (see Table 5).
CHANGES PASS OPEN CONTROLLED OF TREATMENT ACCESS DIRECTION ROOMS Y/N FROM Y/N MAJOR TREATMENT TO MAIN ENTRANCE DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8 3 4 5 4 4 3 3 4 N Y Y N Y Y Y Y N Y N N N N N N
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 ambulance entrance for any reason becomes unusable.
MAIN DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8 MEAN MEDIAN MINIMUM MAXIMUM 2 3 6 4 4 2 4 6 3.9 4 2 6 AMBULANCE 2 1 2 3 2 2 2 1 1.9 2 1 3
Table 6 Changes of direction required to access resus from the two entrances
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 the department from the main entrance (see Figure 16). The second is in Department 2. This department has two ambulance entrances; the first goes directly into resus, the second into the main corridor which leads directly onto both resus and the major treatment area. This department requires only two changes of direction to get from the main entrance to resus (see Figure 17). Recommendations: Wayfinding The wayfinding requirements for staff, patients and visitors to A&E departments differ, with: patients requiring direct (but controlled) access from the waiting areas to treatment rooms;
Table 5 Wayfinding from treatment rooms
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:
21
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.
major staff resus minor ambulance entrance
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:
waiting main entrance 10m
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.
Figure 16 Where wayfinding from the main entrance is not supported (Department 8)
Space Use Adj. Department Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting
main entrance
ambulance entrance
resus
ing wait
140 140 140 140 140 140 140 140 140 140 140 140
n ptio rece
ambulance entrance
or maj or maj
f staf
or min
or maj
10m
Figure 17 Where wayfinding from the main entrance is supported (Department 2)
22
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.
Recommendations: Privacy and dignity It is important that the privacy and dignity afforded to the patient is not compromised by the surveillance required by staff members. Whatever method of surveillance used, it is important that observation of patients is limited to staff members and the patients visitor(s). To identify and control levels of privacy and dignity in treatment rooms, each room should be benchmarked. This should be based on who can see inside the room while walking round the department, concentrating on: visitors; other patients; and other staff members (those not directly treating the patient). 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.
PATIENT STAFF VISITOR NUMBER OF % % % VISITORS FOR EVERY 100 PATIENTS
Figure 18
ALL TREATMENT ROOMS MAJOR
46 53 46 24 36 59
19 16 31 57 16 25
35 31 22 19 48 16
75 61 57 83 137 36
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 the cubicle; however, this can limit the ability of staff to oversee patients.
MINOR RESUS PAEDIATRICS GYN/GU
Table 7 Locations of patients, staff and visitors in the 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 major and minor treatment rooms. Critically this shows that there is redundant space in the minor treatment rooms and an insufficient number of
23
cubicle
major injuries corridor
cubicle
cubicle
staff base
cubicle
cubicle
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 from other 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
cubicle
cubicle
cubicle
staff base
cubicle
cubicle
cubicle
cubicle
cubicle
staff base
cubicle
3 Opens to only nurses base curtain closure. This provides visual privacy for patients but enables surveillance of patients from the staff base. Departments using this cubicle design: Major treatment rooms: departments 2 and 5 Minor treatment rooms: departments 2, 5 and 7
2 Opens to only majors corridor curtain closure. This provides no auditory privacy and low levels of visual privacy, as this corridor will be heavily used by patients, staff and visitors. Additionally, this design does not support surveillance from the staff base. Departments using this cubicle design: Major treatment rooms: departments 3 and 7 Minor treatment rooms: department 6
cubicle cubicle
cubicle
cubicle
staff base
cubicle
cubicle
cubicle
cubicle
cubicle
staff base
cubicle
cubicle
5 Opens to both majors corridor and nurses base doors on both sides. This provides full auditory and visual privacy for patients but limits staff surveillance. This also enables patients and visitors to access the treatment rooms without disturbing other patients. Departments using this cubicle design: Major treatment rooms: department 1 Minor treatment rooms: department 1
4 Opens to both majors corridor and nurses base doors on both sides. This provides visual privacy for patients but enables surveillance of patients from the staff base. This also enables patients and visitors to access the treatment rooms without disturbing other patients. Departments using this cubicle design: Major treatment rooms: departments 4 and 8 Minor treatment rooms: departments 3, 4 and 8
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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 all 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.
Figure 19 Locations of patients, staff and visitors in the A&E departments
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 between departments, averaging at just over one-third of the area of the department (see Table 8).
AREA DEPARTMENT 1 DEPARTMENT 2 179 791 635 729 989 273 388 330 539 179 511 989 % DEPARTMENT 43% 36% 39% 30% 40% 26% 29% 39% 35% 26% 38% 43%
resus
major's corridor
to reception
DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8
patients waiting on trolleys in circulation space patients standing or seated staff standing or seated visitors standing or seated
Main entrance is entrance is Main entrance is Main entrance is Main entrance is entrance is due to closed due to closed due to closed due to due to refurbishment work. work. refurbishment work. refurbishment work. refurbishment work. work. All entrances through All entrances through All entrances through ambulance entrance. ambulance entrance. ambulance entrance. ambulance entrance. ambulance entrance. ambulance entrance.
AVERAGE MINIMUM MEDIAN MAXIMUM Table 8 Circulation space
ambulance entrance
1m
Figure 20 Example of trolley waits Department 3 at 19:00
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 to circulation, the lower the proportion of space provided for treatment. This can be seen in Figure 22.
Figure 21 Percentage use of major and minor treatment rooms
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
Figure 22 25
treatment area
Wayfinding The locations of the corridor spaces greatly influence the wayfinding ability of those using the department. It is important that the wayfinding is split between the different people using the department, as the needs of clinicians are very different from those of visitors, patients and support staff. For patients and visitors to the department it is important that the wayfinding is controlled to ensure that they can easily find and access the areas that they need, but that they cannot inadvertently find their way into more sensitive areas. To benchmark the natural wayfinding in each of the departments, the visibility of key movement routes have been compared (see diagrams of Departments 18 below).
Recommendations: Wayfinding It is important that the design of the department supports the natural wayfinding of people using the facility as staff, patients or visitors. This will help to ensure that people find their way to locations such as the reception and waiting areas, and also that they do not inadvertently access sensitive areas of the department such as paediatrics or resus.
Locations shown in red have the highest levels of visible space; those that are shown in blue are more secluded. This is calculated using Visibility Graph Analysis (VGA)
Department 1 Waiting area and minors corridor most visible and accessible routes. Natural wayfinding is supported by layout.
Department 3 The majors corridor is the most accessible, then the minor corridor where the waiting area is based. The natural wayfinding supports access along the major injuries corridor; however, this impacts on the levels of privacy and dignity for patients treated in this area
130 100 72 43 23 0
Department 2 Main treatment area and resus are the largest, most visible locations. There is a clear route between the waiting area and the main hospital corridor. Some natural wayfinding is supported.
Department 4 There are three main eastwest routes supported in this plan. The problem for wayfinding is that there are no routes to support northsouth access. Natural wayfinding is limited for the northsouth access, but support for eastwest movement along the minor injuries corridor from the main entrance.
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Department 5 The key routes supported by the layout are from the waiting area north through the minor injuries corridor and through the major injuries corridor up to the staff base to the north. There is also a strong eastwest route to the south of the plan. Natural wayfinding supports access between the major injuries area and the ambulance entrance, which may result in this corridor having higher use than planned.
Department 7 The most accessible route is along the major injuries corridor, with the minor treatment rooms in a very secluded location.
The natural wayfinding supports access from the ambulance entrance along the major injuries corridor and it is likely that this route would have higher than average levels of use.
Department 6 The natural wayfinding leads from the waiting area along the majors corridor through to resus. The wayfinding along corridors is broken up for eastwest movement. The natural wayfinding is not supported in this plan, which is likely to impact on levels of privacy and dignity for patients. The benefits of supporting natural wayfinding are numerous, including: a lower dependence on signage, which makes it easier for those with reduced vision; less time taken up by staff giving directions; less reliance on providing physical control measures to restrict access into sensitive areas; and improvements in the privacy and dignity of patients, as it will be less likely that visitors or other patients walk through private areas.
Department 8 The main routes supported are internal staff routes behind the major treatment areas. As these are routes that patients and visitors have limited access to, this is likely to have little impact on the level of use. Importantly, wayfinding is impeded at the entrance, as there are no direct views between the entrances and the waiting areas. To benchmark the routes that people are likely to take in new departments, visibility analysis can be used to highlight locations that are highly accessible and those that are more secluded. This identifies locations that will be more difficult to find. These measures to support natural wayfinding should go hand in hand with procedures to control access between areas within the department and to the main hospital.
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Patient, staff and visitor (PSV) ratios The circulation space accounts for just over one-third of the space in A&E departments and also accounts for one-third of people within A&E. The main users of circulation space are staff members, averaging 48% of staff based in this location (see Table 9). This is due to a number of the staff bases located in circulation space. There were, on average, a further 21% of patients and 31% visitors here. The high usage of circulation space was due to its mix of uses, including: movement routes; staff bases; waiting areas; and patients waiting on trolleys. Routes CASE STUDY 6
DEPARTMENT 1 DEPARTMENT 2 DEPARTMENT 3 DEPARTMENT 4 DEPARTMENT 5 DEPARTMENT 6 DEPARTMENT 7 DEPARTMENT 8 AVERAGE MINIMUM MEDIAN MAXIMUM
% % % PATIENTS STAFF VISITORS 29 22 28 15 18 21 8 30 21 8 21 30 40 53 32 60 42 57 75 26 48 26 47 75 31 25 40 26 40 23 17 44 31 17 29 44
Table 9 PSV ratios in the circulation space
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 short cut 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 room Sanitary Staff Store Treatment Triage Waiting route between staff route between staff route between staff route between staff route between staff route between staff base and resus base and resus base and resus base and resus base and resus base and resus shortest route route shortest route shortest route shortest route route staff between staff between staff between staff staff staff base and resus base and resus base and resus base and resus base and resus base and resus sampled staff routes sampled staff routes sampled staff routes sampled staff routes sampled staff routes sampled staff routes waiting area assessment resus
major injuries treatment rooms
staff base reception
ambulance entrance
minor injuries treatment rooms
main entrance
28
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 design of 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.
Figure 24
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
Figure 25 Relationship between route lengths and department size
29
Conclusions
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 and visitors. 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.
30
Appendix 1 Departments
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.
Space Use Adj. Department Circulation Relatives room Sanitary Staff Store Treatment Triage Waiting
resus
major
major children
staff
ambulance entrance
minor
main entrance
waiting
Figure 26 Layout of the A&E department
31
DEPARTMENT 2
The A&E department in this hospital is located on the ground floor of the main building. It has three main entrances, one for all patients and visitors and two for ambulance patients. The department covers an area of approximately 1400 m2. The treatment rooms account for 27% of the total space.
Space Use Adj. Department Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting
140 140 140 140 140 140 140 140 140 140 140 140
in in in m in ee maain main main maain cce m ma ma e ncee ne ancce n trancc an c ntraan ntran entra en tr eentr en tr en en
a a ea ea a rrea g are g arre ga ing ing a ing a w itin w aitin wait wait wait
ss ss s ss ss s ss ss r rr rre rre us rre uss rr e u rr r rre rre s rre r rre rre rre su r rre rressu rre r r rressu
cee ce nce ne lancce lan ce lan ulan cc bula n ula mb ula mb ula aambu amb u e am bu aamb cce am a m n cce e ne ran e ra ncce ran ran e n rancc eentra enttra e ttra eentt en ent
r a jorr ajo a jo ajo a a jor a jo r ajo a jo a jo ajo a majo majo majo majo ma
r rr jorr jor majo majo majo ma ma jo ma
inorr in or in in r in in in in or in o in in in in in o in in in in in in in in or in in in mino mino min o min min min

r r jorr ajo majo majo ma ma ma
32
APPENDIX 1 DEPARTMENTS
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 nurses base
resus
main entrance CLOSED
ambulance entrance
major
33
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 Room Sanitary Staff Store Treatment Triage Waiting
waiting main etrance minor staff major ambulance entrance
34
DEPARTMENT 5
This department 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. The department covers an area of approximately 1760 m2. The treatment rooms account for 22% of the total space.
Space Use Adj. Department Circulation Maintenance Relatives Room Sanitary Staff Store Treatment Triage Waiting all others
major major major
minor minor minor
resus resus resus resus resus resus
waiting area waiting area waiting area waiting area waiting area waiting area
waiting area waiting area waiting area waiting area waiting area waiting area
ambulance ambulance ambulance ambulance ambulance ambulance entrance entrance entrance entrance entrance
main main main main main entrance entrance entrance entrance entrance
35
DEPARTMENT 6
This department 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. The department covers an area of approximately 1060 m2. The treatment rooms account for 36% of the total space.
Space Use Adj. Department Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting ambulance entrance resus major main entrance
waiting area
major
36
DEPARTMENT 7
This A&E department is located on the ground floor of the main building. It has two entrances, one for all patients and visitors, the other for ambulance patients. The department covers an area of approximately 1240 m2. The treatment rooms account for 28% of the total space.
major ambulance entrance minor
resus
main entrance
37
DEPARTMENT 8
This department is located on the ground floor of the main building of the hospital. It has three entrances, two for all patients and visitors, the other for ambulance patients. The department covers an area of approximately 940 m2. The treatment rooms account for 23% of the total space.
subwait area
major
staff resus
minor
ambulance entrance
waiting
main entrance
38
Appendix 2 Methodology
Four separate surveys were undertaken to collect information on the space use of the department: entrance and exit counts; staff and patient pathway; space use occupancy survey;
department, whose role was to count the numbers of individuals entering and leaving and to note down whether they were staff, visitor or patient. The count was done in intervals of 15 minutes to determine the peak and off-peak periods. Figure 35 shows the survey locations in Department 3.
STAFF AND PATIENT PATHWAYS

room profiles. Eight A&E departments of varying ages, sizes, and with differing numbers of patients per annum were selected for this study. Each of the eight departments was surveyed on a Monday during the months of July to October 2002. Within each hospital the surveys ran concurrently between 08:00 and 20:00. This period was selected because the highest demand for A&E services occurs on Mondays, and the 12-hour period selected encompassed the peak in occupancy levels. The demand data for A&E can be seen in Figure 34. A survey was used to show the routes that staff and patients take from multiple origins to multiple destinations during the course of the day. This identified differences in the areas where staff and visitors move around. In addition, it provides information about the average journey lengths in the department. To collect this information, the department was split into a number of observation zones. The observer then surveyed each zone in turn, following the first person leaving a room within the department until they reached their destination, left the department or had moved around for 3 minutes. The status of the individual (staff, visitor, patient) as well as their departing time was recorded, and a line representing the persons pathway was drawn for each zone. A note was added where the person was in a wheelchair or on a trolley. One round consisting of surveying each zone was done once every hour. An example of the pathway surveys is shown in Figure 36.
ENTRANCE AND EXIT COUNTS

A survey of entrance flows took place for all entrances and exits to each department. This included all corridors that lead onto neighbouring departments such as radiography. This survey provides information on the rates of entrance and exit flows by both staff and patients, and also allows us to calculate the occupancy of the department over the course of the day. A staff member was placed adjacent to an entrance to the
Demand by day of week
190
Patients per day
180 170
2000/01
160
150 140 Mon Tues Wed Thurs Fri Sat Sun
Figure 34 Graph of entrances to A&E by day of the week (source: NHS Estates)
39
entrance/exit count locations
1 1 4 4 3 3 2 2
minor nurses base
6 6 7 7
resus
main entrance CLOSED
8 8 ambulance entrance
Figure 35 Survey locations entrance counts
Pathways staff Space Use Fracture Clinic Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting
Figure 36 Routes taken by staff members in Department 3
40
major
APPENDIX 2 METHODOLOGY
SPACE USE OCCUPANCY SURVEY

This survey was used to glean information on the level of usage of different parts of the department over the course of one working day. This helps identify how the layout of the department is supporting the working practices of the staff and the visit by the patients. A static snapshot technique was used, where by an observer walked through the circulation space in the department once every hour and recorded the following information: rooms that were occupied, and those that were vacant; where visible, the number and category of people in each room (staff, patients, visitors and child, adult, elderly); the number of people seated in the waiting area; the locations of patients, visitors and staff standing or sitting in any other part of the department; the locations of trolleys and wheelchairs, both occupied and vacant; whether the individual was stationary or moving.
An example of the space use survey is shown in Figure 37.
ROOM PROFILES
The final survey was used to collect information on the use of three different treatment rooms over the course of one working day. The rooms surveyed were: two minor treatment rooms; one major treatment room; one resus room. This identified the times when staff, patients and family members entered and left the room and the supplies provided to the room including linen, food, equipment and medicines. An observer stood outside the room and marked down details of all the movement in and out of the room during the 12-hour observation period.
VISIBILITY MODELLING
There are two main uses of the visibility modelling in the A&E departments. The first is to determine the ease of wayfinding. The second is to determine the levels of patients privacy from other patients and from visitors, and the levels of surveillance by staff members.
Locations patients staff visitors Space Use Adj. Department Circulation Relatives Room Sanitary Staff Store Treatment Triage Waiting
minor minor
resus resus
main main main iii
waiting area waiting area
main main main iii
Figure 37 Location of staff in Department 3
major major
41
Visibility can be measured objectively using a technique called Visibility Graph Analysis (VGA). This technique places a grid of sample observation points throughout the net internal area of the department, as in the example shown in Figure 38. A computer algorithm calculates the visual field at 360 degrees from each point in the grid by checking which of the other points each point can see. In this manner, it is possible to show from which locations in the department each patient can be seen.
In the example, the points in red are all those that are directly visible from the red square (representing the location of the patients head). The red points show the visual field from the patient, which shows the locations in the ward from where the patient can be seen from a seated position.
furniture patient wall Area seen by patient Area that cannot be surveyed
Figure 38 View by patient from seated height
42
About NHS Estates guidance and publications
The Agency has a dynamic fund of knowledge which it has acquired over 40 years of working in the field. Our unique access to estates and facilities data, policy and information is shared in guidance delivered in four principal areas: Design & Building These documents look at the issues involved in planning, briefing and designing facilities that reflect the latest developments and policy around service delivery. They provide current thinking on the best use of space, design and functionality for specific clinical services or non-clinical activity areas. They may contain schedules of accommodation. Guidance published under the headings Health Building Notes (HBNs) and Design Guides are found in this category. Examples include: HBN 54, Facilities for cancer care centres HBN 28, Facilities for cardiac services Diagnostic and Treatment Centres: ACAD, Central Middlesex Hospital an evaluation Infection control in the built environment: design and planning Engineering & Operational (including Facilities Management, Fire, Health & Safety and Environment) These documents provide guidance on the design, installation and running of specialised building service systems and also policy guidance and instruction on Fire, Health & Safety and Environment issues. Health Technical Memoranda (HTMs) and Health Guidance Notes (HGNs) are included in this category. Examples include: HTM 2007, Electrical services supply and distribution HTM 2010, Sterilization: operational management with testing and validation protocols HTM 2040, The control of legionellae in healthcare premises a code of practice HTM 82, Fire safety alarm and detection systems
Procurement & Property These are documents which deal with areas of broad strategic concern and planning issues, including capital and procurement. Examples of titles published under this heading are: Estatecode How to Cost a Hospital Developing an Estate Strategy Sustainable Development in the NHS NHS Estates Policy Initiatives In response to some of the key tasks of the NHS Plan and the Modernisation Agenda, NHS Estates has implemented, project-managed and monitored several programmes for reform to improve the overall patient experience. These publications document the project outcomes and share best practice and data with the field. Examples include: National standards of cleanliness for the NHS NHS Menu and Recipe Books Sold on Health The majority of publications are available in hard copy from: The Stationery Office Ltd PO Box 29, Norwich NR3 1GN Telephone orders/General enquiries 0870 600 5522 Fax orders 0870 600 5533 E-mail book.orders@tso.co.uk http://www.tso.co.uk/bookshop Publication lists and selected downloadable publications can be found on our website: http://www.nhsestates.gov.uk For further information please contact our Information Centre: e-mail: nhs.estates@doh.gsi.gov.uk tel: 0113 254 7070
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T EQP

The impact of the built environment on care within A&E departments

OMS OMS T RO T RO N N TME TME TREA TREA OR OR MAJ MAJ

W CL) VIE (RE

MS MS ROO ROO T T MEN MEN REAT REAT T T JOR JOR MA MA

The impact of the built environment on care within A&E departments

Crown copyright 2003

RECEPTION AND WAITING AREAS

ACCOUNTING FOR PATIENTS VISITORS AND STAFF

CIRCULATION AND WAYFINDING ARRIVALS AND ENTRANCES

Executive summary Acknowledgements

Patient, staff and visitor ratios: assessment rooms

2 FINDINGS AND RECOMMENDATIONS

Patient, staff, visitor ratios Recommendations: Flexibility

APPENDIX 1 DEPARTMENTS APPENDIX 2 METHODOLOGY

ABOUT NHS ESTATES GUIDANCE AND PUBLICATIONS

INTRODUCTION TO THE A&E DEPARTMENTS USED IN THIS STUDY

THE IMPACT OF THE BUILT ENVIRONMENT ON CARE WITHIN A&E DEPARTMENTS

ENTER WELCOMING ENTRANCE

Reception meet & greet

Assessment rooms including registration

Clinical decision unit or observation unit

Digital imaging suite

Assessment unit in childrens department

The ambulance entrance Ambulance bay

Treatment rooms Resuscitation

Digital imaging suite

DESIRABLE EXIT GARDEN VIEW

Clinical decision unit or observation unit

Assessment unit in the childrens dept

Critical care Operating theatres Acute wards

Figure 2 Relationship of rooms and areas for patients arriving by ambulance

THE IMPACT OF THE BUILT ENVIRONMENT ON CARE WITHIN A&E DEPARTMENTS

THE PATIENTS JOURNEY

Figure 3 Treatment times (time spent in the treatment room) in Department 3

Findings and recommendations

ARRIVAL AND ENTRANCES

staff base route to reception

2 Source: QMNG 2001/20 8

2 FINDINGS AND RECOMMENDATIONS

LOCATIONS OF PATIENTS, STAFF AND VISITORS

0 Circulation Relatives Room Sanitary Treatment Waiting Triage Store Staff

Figure 6 Locations of patients, staff and visitors in the A&E departments

ADJACENT ENTRANCES WITH ACCESS CONTROL

ENTRANCES ON ADJOINING FACADES

paramedic entrance main entrance

free access access control measures

THE IMPACT OF THE BUILT ENVIRONMENT ON CARE WITHIN A&E DEPARTMENTS

patients staff visitors

paediatrics paediatrics paediatrics paediatrics

resus resus resus resus resus resus

2 FINDINGS AND RECOMMENDATIONS

PATIENT, STAFF, VISITOR RATIOS

RECEPTION AND WAITING AREAS

Figure 8 Total entrances to A&E Department 6 from 08:00 to 20:00

THE IMPACT OF THE BUILT ENVIRONMENT ON CARE WITHIN A&E DEPARTMENTS

minor injuries treatment rooms & main hospital

treatment rooms & resus

paramedic entrance records store

Locations that can be overseen from the reception. 2m

2 FINDINGS AND RECOMMENDATIONS

Figure 10 Access control in Department 2 13

THE IMPACT OF THE BUILT ENVIRONMENT ON CARE WITHIN A&E DEPARTMENTS

A&E Departments

A&E Departments