In 2015, Optimus Architecture developed a design for a new ED at HealthAlliance of the Hudson Valley’s (HVHA) Mary’s Ave campus as part of a consolidation project to combine their two campus hospital system to one campus. The Mary’s Ave campus had no Emergency Department, as the original ED had been closed when the two hospitals merged. The Broadway campus had developed a new expanded ED which Administration and ED staff determined was operationally expensive to operate due to its layout and segregated treatment areas.
The ED doctors and staff wanted the new ED at the Mary’s Ave campus to improve their operations and staff efficiency. They learned of the Ribbon ED concept, which appealed to them. Our studies found that the Ribbon ED concept, which we had not used before, has many benefits but also some challenges. The HAHV ED staff ideally wanted one large concentric treatment area with one central nurse station able to view all patients without obstruction. However, as ED’s get larger, the central area becomes too large for just the nurse station. This large core fills up with rooms that block staff visibility. We had observed this condition over years of healthcare design. Principal architect, David Souers, AIA, ACHA, ASHE discussed these same issues with the Emergency Department Director at the University of New Mexico Medical Center where their visibility was hampered.
Optimus worked with the clinical staff at HVHA to create a hybrid Ribbon ED where the radial treatment bays and concentric Nurse Stations from the Ribbon ED, in combination with a wide open circulation hall between the two large round pods maximize the openness, flexibility, and visibility within and between the pods. Each Nurse Station has a glassed in Med Room and work counters within their center, that staff can see into and through for 360 degree visibility. Circulation into and out of each treatment pod in multiple directions maximizes opportunity to get to essential services while shortening travel distances. Except for specialty bays, all other bays are similar in size and fit-up. Triage and Hyper-Track rooms near the Walk-in entrance provide flexible, fast examination and treatment for patients not requiring testing, longer observations or prolonged care. A Fast Track area is integrated into one of the Critical pods, closer to Walk-in where less acute patients can be handled by the same nurse station and staff. Fast Track and Critical can also expand and contract into each other as needed. A small sub-waiting area in Fast Track provides a location for ambulatory patients to wait for test results without occupying a treatment bay. The Behavioral Health ED is located close to the Medical ED where medical staff and support services can be quickly and conveniently available without taking the medical staff far from their principal activity. The ED staff offices are located conveniently on a rear hall near the building’s staff entrance, with close access to the hospital elevators and the treatment areas.
Our ED design makes good use of the existing and planned adjacencies. The existing Main Lobby connects immediately into the ED Walk-in Entrance providing flexible options for entrance, reception and security. Two existing elevators to the upper floors for surgery and patient units are within a few hundred feet of the ED treatment bays. We designed a new Imaging Suite that includes a dedicated ED Xray room, three new In-patient/Out-patient Xray rooms, an MRI, and two CT rooms. These are all close and convenient to the ED for transport, ED and Imaging staff. Imaging staff can efficiently service all ED and hospital imaging services without leaving the Imaging area. Optimus designed a new ICU next to Imaging, close to the ED and also close to the hospital elevators. Being on the same floor with ED allows patients to be transported efficiently among the ED, Imaging and ICU without elevator time. The clinical staff in all three departments saw this as a significant benefit.
In a Ribbon ED, there are spaces created between the rectilinear building and the curved treatment areas. These spaces initially seem wasteful. However, as we developed our design, we found good use for most of this space for structural, mechanical, electrical and support functions. Our relative compact and efficient hybrid Ribbon ED design with its operational efficiencies outweighs the space lost at these geometric intersections.
As a result of our ED design, we agree with the conclusions reached by James Harrell, FAIA, FACHA, LEEP AP and Angela Mazzi, AIA, ACHA, EDAC in their article “Evolution of the ED” in the AIA Academy of Architecture for Health | Academy Journal 2012,, “The concept of a Ribbon ED evolved out of previous models for radial design and decentralization. ……The curvilinear design allows rooms to be arrayed in direct line of sight of the nurse work area and equipment to be distributed along the path so that it is never more than a few steps away from either staff work areas or the exam rooms. The number of walls that extend to the ceiling were minimized in order to increase visualization through the department and allow staff to zone and flex the space as needed. A supertrack concept keeps less ill patients who require more than cursory treatment out of exam rooms in order to keep them free for more critical patients and decrease overall treatment times. The pivot nurse keeps the flow moving. Operational data supports the Ribbon design for the Emergency Department. The Ribbon or continuous, closed loop layout of exam rooms can keep operating costs in line by permitting minimal staffing. Decentralization of supplies and support can improve staff efficiency, and therefore improves patient care. Furthermore, open planned ED’s promote and maximize visualization throughout, enhancing patient and staff safety.”
During the 2015 ASHE & AIA Planning, Design & Construction International Conference, Optimus principal architect, David A. Souers, AIA, ACHA, ASHE, attended a presentation on Ribbon ED design showing several large ED’s as examples. A Ribbon ED design is not an improvement over rectilinear designs unless you follow through on the potential of the Ribbon design to maximize visibility, establish flexibility, facilitate staff sharing and shorten travel distances. As soon as you isolate pods, insert rooms and partitions between nurse stations and reduce circulation options, while increasing travel distances, the Ribbon ED design may end up looking and working more like the common rectilinear ED design. Not all of the Ribbon ED designs that we have seen make the operational improvements that the Ribbon design is capable of.
Community hospitals provide a wide range of care, spanning from primary to specialty acute care for smaller populations. Patient numbers cannot cost effectively support distinct specialized patient units for each level and type of care. Therefore, community hospitals must have facilities that provide staff with good visibility, maximum flexibility, fewer physical barriers, shorter travel distances to supplies, and more effective access to resources across the each department, throughout the hospital. By working closely with HVHA and their ED staff, we are pleased to have developed a hybrid Ribbon ED design that offers the operational efficiencies that HVHA and their ED staff asked for.