Redesigning Your ED for the Threats of Tomorrow

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Every day it seems that emergency departments become more hazardous places to work. But there are proven design strategies that can help create a safer zone for patients and providers. 

It’s a typical Thursday evening in the emergency department. Treatment stations are fully occupied. Physicians and nurses are busily tending to patients. Families come and go from the department, and the waiting room is full of patients waiting for their turn to receive care.

Suddenly, chaos ensues. Maybe a patient under law enforcement custody overpowers an officer, gains access to a firearm and opens fire. Or a psychiatric patient not properly supervised stabs a nurse with a sharp object from her treatment area. Perhaps an individual, seduced by the opportunity for martyrdom, detonates an explosive vest, sending shrapnel and other projectiles in every direction. In another part of the world, a gang member with a gunshot wound is in the trauma resuscitation bay when a rival gang member enters to finish what he started on the street. Or a lone criminal holds the emergency department staff at gunpoint in an effort to steal narcotics from the department’s medication dispensaries. Different emergency departments, different challenges, but the same unfortunate outcome.


Every day in emergency departments around the globe, safety and security play front and center in the minds of hospital staff. With the increasing frequency of terrorism and mass acts of violence, most hospitals are focused on developing systems and plans to respond to the massive influx of patients associated with external disasters, yet few have exerted the same effort to design their emergency department to withstand such an incident with a minimal impact to life, limb and property. Many hospitals focus on preparing for pandemics of influenza, ebola, SARS and the like, yet few consider how to protect their emergency departments from violence. A review of the literature on planning hospitals for safety and security shows that information in this area is limited, with most research focusing on preparedness, not solutions focused on withstanding a direct assault on the emergency department itself.

Specific Design Components to Enhance Safety and Security
Every emergency department should be designed with the specific intention of ensuring proper lines of sight from staff work zones and security monitoring posts to all areas of the emergency department. This focus on sight lines will ensure that emergency department staff can maintain situational awareness, which can provide early and life-saving detection of a threat within the department, along with easy notification of others to the situation.

Another simple and low-cost solution to ensuring the safety and security is designing the department with a limited number of access points from the clinical, or sterile zone, to the non-clinical areas (reception, administration, etc.) and the hospital complex. Limiting the number of access points will reduce the number of doors that need to be monitored and, when necessary, secured to facilitate a departmental lock down to ensure the safety and security of those inside the sterile area.


A third and equally important design consideration is considering how emergency department staff are positioned in the department relative to patients, visitors, corridors, areas of refuge and the like.

In many parts of the world, emergency departments and other areas of the hospital are being designed using patient-centric, or customer service approaches. These considerations have led to solutions that include decentralized staff workstations — including use of conference tables instead of traditional nursing stations — where the staff may be seated with their backs to the corridors when performing work functions. Going back to the concept of situational awareness and understanding that the emergency department is a chaotic and often somewhat uncontrolled environment, design solutions that limit the ability of the emergency department staff to “duck and cover” or those that position them with backs to corridors or patients, should be considered carefully before implementing.

Security starts from outside of the facility by ensuring that entrances are secure and can block oncoming vehicles, as shown here.
(Project: Kaleida Health, Buffalo General Medical Center Emergency Department at Gates Vascular Institute, Buffalo, NY) © Tim Wilkes Photography

Learning From One Another
Each part of the world is subject to a different set of natural and man-made disasters that, over time, have informed how buildings can be designed to withstand a disaster. While disaster studies may not be the exact safety and security issues an emergency department is attempting to mitigate, the learning principles may be applicable.

When considering how to design environments that can endure the impact of the blast from an explosive event, much can be learned from parts of the world where buildings are designed to withstand a volcanic eruption or the force of a category five tropical cyclone. In the case of the solutions tied to volcanic eruptions, building solutions have been designed to mitigate and absorb the initial blast and the aftermath, including fire which can spread rapidly, as well as falling ash which can add thousands of tons of weight to a roof. Buildings designed to survive hurricanes are intended to withstand massive winds, epic flooding and shrapnel flying at a building in excess of 300 kilometers per hour.


Hospitals and emergency departments designed in some of the most rural areas of the world can teach us about how to design spaces to function “off of the grid” for hours, days or even weeks. These facilities might plan to have adequate supply storage space to function without replenishment for extended periods of time. Or they plan their facility to have access to clean or filterable water and even energy reserves to power emergency generators for extended periods of time.

Medical units designed inside high security prisons can provide vital lessons in how to ensure patient and staff security in the event of a safety or security issue within the hospital or emergency department where it becomes necessary to completely secure and isolate the emergency department from the rest of the hospital complex and the exterior environments. While it is not suggested to design an emergency department to resemble a “prison ward,” there are critical lessons to be learned about access strategies, situational awareness, creating safe spaces, and the speed at which environments can be secured if conditions warrant.

The design of hospitals and emergency departments has continued to evolve as clinical technologies and patient expectations have advanced. The unfortunate reality is that design must also adapt to reflect the dangers of a world where violence is a common occurrence and, in some cases, the emergency department is ground zero for the violence. However, with proper planning and smart operational, technological and physical design solutions, the emergency department can be better prepared with withstand the threat.

Image at the top: 
While secured by key card access, the reception, triage, and entry points to ED treatment areas still provide lines of sight through glass and interior windows.
(Project: Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC) © Christopher Barrett Photography

This article is an excerpt. Read the full text by Dr. Hernandez in Emergency Physicians International.


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