Cover Two

Emergency Department Design

Meeting a growing demand

BY By Todd Medd, AIA & Tracy Nicholson

The Evolving Role of the ED

Nationally, hospitals build new emergency departments every 15 to 20 years and renovate them every 5 to 10 years. Although trauma was of prime concern, yesterday’s ED was designed and built for general urgent treatment. For those in rural areas, where there was no urgent care facility, the ED was for everything that needed to be checked sooner than later. Aesthetically and sometimes operationally, expectations were minimal, so a confusing entry, no privacy and an institutional space set aglow by stark fluorescent lighting was the norm.

Today’s EDs are an in-demand, ever-evolving network of care; expected to support a higher standard of treatment, speed, safety, comfort, mental health, staff well-being, diverse family and cultural experiences and operational efficiency — all at once.

Today’s ED must support a growing range of specialized care.

When designing either a brand-new ED, or updating an older one, the first step is to interview the people who will be using the facility. This includes everyone from providers and staff to patients and members of the community. We ask a wide range of questions; from what they would like to see improved, to what they have seen work well in other facilities, to what was not working. Sometimes individuals working in the ED may not be aware of important structural and other architectural advances, so it is important to bring things into the design discussion like infection control, touchless interfaces, managing airborne pathogens and many related topics.

Today’s ED must support a growing range of specialized care, from pediatric to geriatric, from cardiac to trauma to surgery to behavioral and mental health needs. Each requires unique support from a physical space perspective. Imagine experiencing the trauma of abuse, suicidal thoughts, or a severe anxiety attack, then being asked to wait within a general emergency room setting — next to more than 20 people battling fevers, broken bones, or incessant coughing and wheezing. That’s exactly how most emergency departments have operated.

Evidence-Based Evolution

Traditional emergency departments pushed patients straight from the sidewalk into a cramped waiting room, where the front desk single-handedly managed all concerns. A corner TV on mute and several sick patients in nearby chairs were the only company.

Today, the redesign conversation is centered around a continual evolution of needs, with several design considerations setting an entirely new standard in emergency care. Staff now expect safer spaces that accurately support the diversity of urgent care cases and give both the public and staff peace of mind, with built-in security checkpoints at the entry. The new standard further includes evidence-based design solutions for clear arrival sequences, immediate visual wayfinding, real-time location systems, separate entries for ambulance and public arrivals, registration desk privacy, vertical care and rooms designed specifically for the safe holding of patients with behavioral health concerns.

Care space comes at a premium, so finding the ED’s balance of sufficient space versus excessive space is critical. A rule of thumb for addressing this is roughly one treatment space per 1,100 annual ED visits and/or one treatment space per 400 annual hospital admissions.

In the recent completion of Altru Hospital in Grand Forks, North Dakota — serving over 230,000 residents across northeast North Dakota and northwest Minnesota — JLG Architects introduced emergency department vertical care spaces. Instead of assuming all patients need to lie down in a room horizontally on a stretcher or bed, it allows for some patients to be treated upright in recliners, treatment chairs, small-care bays or flexible consult spaces. The concept is straightforward: if a patient is stable and able to sit comfortably, keeping him or her upright and moving through a streamlined care sequence frees critical bed space for those who need it most.

Altru’s emergency care pods have since become the first of their kind in the state to receive approval for medical licensing, prompting modular workstations that allow visibility and proximity to the low-acuity pods — putting the provider as close to the patient as possible. These solutions required significant due diligence from the state to ensure the intent was understood, what kind of patients would be treated within the pods, and maintaining appropriate nursing practices while training for a new on-stage/off-stage operating model.

The hospital’s departmental adjacencies were also carefully considered, with design supporting clinical needs and patient flow. Because seconds save lives, Altru’s design includes a trauma elevator that creates a fast, direct and controlled route for critically ill or injured patients moving between the emergency department, surgery, intensive care, imaging and other high-acuity areas. Another important adjacency was central sterile processing below, which allows for quick cycling of surgical instruments.

Practical Considerations 

Increasing demand for behavioral health care has been a major force driving redesign, with many emergency departments exploring separate arrival or more private waiting areas for patients experiencing a mental or behavioral health crisis.

In emergency departments that have the need for more defined mental and behavioral health care, architects are leaning into trauma-informed design and the impact of amplified privacy in entries and waiting areas, quieter, low-stimulation treatment spaces, streamlined security integration, dedicated behavioral health pods and separate observation areas.

Hospitals build new emergency departments every 15 to 20 years and renovate them every 5 to 10 years.

We are currently working with the Department of Health and Human Services on the design of the new North Dakota State Hospital. Although this project doesn’t have a traditional emergency department, it has an all-under-one-roof design that includes an admissions unit, specialized therapeutic spaces, advanced security and expanded capacity for several departments, including psychiatric inpatient care. The new state hospital, scheduled for completion in 2027, will reinforce the behavioral health care workforce with designated education spaces for both staff and regional higher education institutions, including collaborations with the University of North Dakota’s medical school. This space takes cues from emergency care, designed to quickly transition from education and simulation to a secure facility for the care of the most vulnerable.

Rural Health Care Reimagined 

In rural regions, the needs of immediate and surrounding communities also come into play, as local demographics, behavioral health trends, rural access challenges and patient volumes all shape how emergency departments are planned.

At the new Heart of America Medical Center (HAMC), we recently replaced an 80-year-old, five-level hospital with a one-level hospital designed for the modern health care needs of Rugby, North Dakota, and beyond. To serve several surrounding communities, the project united a full spectrum of services — emergency medicine, imaging, surgical suites and an acute patient wing — under a single, modern roof. A USDA-funded project, the facility was designed to support the complexities of rural health care delivery, integrating a pharmacy, outpatient clinic and physical therapy center to ensure the region has access to high-quality care in a centralized, sustainable environment.

Like many hospitals in rural areas today, the nursing staff for the emergency department is the same staff that sees patients within the hospital. In the old hospital these departments were on opposite sides of the building. Within the new hospital the nurse stations for hospital and emergency are separated by a single set of doors — reducing the travel distances for the nursing staff by 175 feet one way. Patients are welcomed into a central “main street” spine — a public circulation path flooded with natural light that provides intuitive wayfinding to major departments. This allows patients to know exactly where they are going, which is especially important in situations where they are seeking emergency care.

Fixed vs. Flexible 

To prepare for a future that is difficult to predict, rather than building fixed environments, health care systems are prioritizing flexibility through adaptable treatment rooms, scalable infrastructure and built-in expansion potential that can accommodate changing patient acuity, new technologies or future health crises.

Recent innovations — including split-flow triage, fast-track treatment zones, telehealth integration, direct bedding strategies and vertical care models for lower-acuity patients — are reshaping how emergency departments improve throughput and reduce wait times.

Post-pandemic lessons have further elevated the importance of surge capacity, staff respite spaces and trauma-informed environments that reduce stress for both patients and caregivers — all starting in the ED. Increasingly, the most effective emergency departments are designed not only to meet today’s needs, but to evolve alongside the communities they serve.

For a successful redesign, it is important to address current operational realities, including new regulatory requirements around infection control and prevention, patient privacy, accessibility, visibility and behavioral health safety. The ED increasingly serves as a front door to both physical and mental health care, so emergency spaces must support everything from trauma care and rapid triage to secure, ligature-resistant behavioral health environments. Some patients may become violent and present a threat to those around them. Multiple exits from these rooms with remote lock-down security is one way to address this concern.

Navigating the Future 

Ultimately, staff and providers don’t need to quiet their concerns and “make it work” anymore. As health care architects, one of the most important things we can do is walk in their shoes — not just identifying challenges, but uncovering opportunities. We invite nurses, physicians and support teams to discuss and inform workflow mapping, simulations and design mockups to identify bottlenecks, reduce unnecessary walking distances, improve sightlines and nurse station proximity and create environments that support both efficient care delivery and caregiver well-being.

Evidence-based design is a tried-and-true road map, but the only thing we can be certain of is change. Together we can navigate a well-informed shift, from fixed environments to adaptable treatment rooms, scalable infrastructure and built-in expansion. Emergency departments may not be able to foresee a rapidly changing future, but they can prepare to meet the challenge, seamlessly flexing for the inclusion of new treatments, on-demand infectious disease control, university partnerships, new workflows and the reality of ever-changing technologies.

Todd Medd, AIA, is a principal architect and the health care practice studio leader at JLG Architects. He is a renowned national expert on the innovation of rural health care, telehealth, trauma-informed design and mental and behavioral health care design.

Tracy Nicholson is based in Fargo, North Dakota, and is an award-winning architectural and interior design writer at JLG Architects.