It won’t be long now: Emergency department medical directors and nurse managers will soon be asked to prepare an after-action report on the pandemic. The goal will be to develop recommendations for new processes and designs for a safer emergency department.

After the COVID-19 pandemic subsides, most hospitals and their emergency departments will need to be designed for unscheduled care as it will be practiced over the next 15 to 20 years, which will be the approximate interval for planning the changes and the average life cycle of the redesigned emergency departments. ED leaders must plan for the most important elements for the next-generation emergency department, taking into account key lessons of COVID-19, Ebola, and other emerging infectious diseases. But plans must also include contingencies for active-shooter events, bad weather, and an ED staff that is prepared to succeed in managing any and all of those challenges.

Here are a number of necessary future ED design elements.

Design Considerations

It has never been clearer that the emergency department is the front door to the hospital and that those who work in the emergency department need a correctly designed space to address the full spectrum of patient needs. Space design for the emergency department must demonstrate great flexibility for patient needs and enable ED staff to deliver services safely, supported by technology, to a patient group that is much higher acuity than in the past.

Every patient’s journey to the emergency department starts outside the building. Tents outside of emergency departments are not an acceptable long-term hospital practice for patient care or staff. An alternative is to design ED parking lots and EMS entrances so they can be flexed into treatment areas when major incidents occur. This means the area outside the emergency department must have signage, lighting, intercom, water, electrical, and computer outlets that will make it easier to initiate care. There must be built space that accommodates patient greeting and initial management even if there is a major multiple-casualty incident or victims are contaminated with biologic, chemical, or radiological material. The intake area of the emergency department must be able to accommodate routine intake and screening. Eventually, devices for rapid detection of hazardous substances will be part of every ED entrance, doing surveillance for dangerous contaminants. A separate entrance must be designed—a multipurpose “dirty” entry—for the most dangerous patients, such as those with Ebola.

Emergency departments should be designed for a digital management process, not paper-based systems. Registration of ED patients must be done near the site of care. Innovative use of portable computers, phone systems, and passive tracking of staff can make the department safer and quieter. ED staff in the COVID-19 and Ebola eras needed hands-free access to communication systems. Investment in the right technology needs to be part of the plan.

Mental health and substance abuse patients are increasing in numbers. Their crisis events must be managed in some space in the community. Either the hospital community and mental health resource agencies must plan for appropriate and dedicated care spaces for these patients, or the default site of care will be the emergency department. There must be specific plans to build a dedicated mental health suite in the emergency department designed for safe management of patients, for longer stays of those patients, and for the safety of appropriate hospital staff.

Telemedicine has become an important element of unscheduled care. There should be a dedicated space in the emergency department established as a telemedicine hub for this growing market, where ED staff can contribute to both on-site care and telemedicine-delivered care. Central communication hub functions will be a hallmark of the future emergency department.

Universal ED room design is important for the wide mix of patients emergency departments receive and for the safety of the staff. The use of recliners as an alternative to stretchers can save space and actually be more comfortable for many patients. Rooms must be easy to clean and disinfect, plus must include durable surfaces on all fixtures. Carts that can be pulled into rooms can give specialty care (eg, wounds, enterology, gynecology, seclusion for patients who need quiet care in a safe space, orthopedic, cardiac, pulmonary, and pediatric). All patient care areas need patient-friendly features, such as telephones, televisions, sound systems, and intercoms. Toilets should be plentiful and easy to clean and disinfect.

The COVID-19 era has been family-unfriendly in health care buildings. It is unlikely this will be acceptable in the future. ED rooms should be designed to accommodate guests, with only small central congregation areas used for guest waiting if something is going on in the room that is not family-friendly.

The core staff work areas should have counter-height work spaces, with ample access to the ED information system for physician, nursing, and technician staff to work on without sitting down. Cart systems should also supply the staff work areas.

ED nurses and other staff need a donning and doffing area that is safe and easy to use. That starts with adequate locker space for work entry and exit around the shifts. Importantly, there must be spaces adjacent to critical care areas that allow personal protective equipment changeout. There should be generous space available for patients who need care in negative pressure or laminar-flow rooms.

Emergency departments must be friendly to seniors, both inside and outside the walls, and through all communication needs. (One of the enduring images of COVID-19 is an elderly patient lying on a stretcher with a staff member trying to communicate through a personal protective mask.) Lighting, flooring, signage, wheelchairs, and staff training must reflect the growing number of senior patients in the ED mix.

An observation area or clinical decision unit is an essential element of unscheduled care. In many hospitals, emergency physicians will be responsible for these patients for the duration of the patient stay, so the area should be close enough to the emergency department to allow efficient management and excellent patient care.

Summary

The COVID-19 pandemic will not be an isolated event. The lessons from more than half a million deaths in the United States and tremendous stress on health care workers and the emergency system must be applied. The post-pandemic period will be an important opportunity for every emergency physician and ED leader to redesign our practice environments and systems. The lessons we learn and improvements we make stand to enhance the level of care that we are able to provide for years to come.