'ED of the future' girded for disasters

Boost capacity and limit contamination

In 1999, "ER One," a high-tech ED designed for optimal response to mass casualty events, was just a gleam in the eye of Mark Smith, MD, FACEP, chairman of the Department of Emergency Medicine at Washington (DC) Hospital Center. While the $300 million facility, targeted for another part of the campus, has yet to be built, 10 patient rooms in the ED have been transformed to the specifications of the ER One as part of an initiative Smith calls "Bridge to ER One."

Here are some of the ways in which the "Bridge to ER One" rooms differ from typical ED rooms:

  • The oversized rooms can readily be converted to two-patient rooms should the need arise.
  • The corridor is slightly wider, to allow for more stretchers.
  • All 10 rooms can be turned into negative pressure isolation areas.
  • There is no recirculated air, so the risk of infection is reduced.
  • The walls are made of a nonporous surface also designed to limit the spread of infection.
  • Rubber flooring, which is antimicrobial, also reduces the pressure on caregivers' feet and legs.
  • Surfaces are coated with natural antimicrobial materials such as silver.
  • Each room has a bathroom and shower, to eliminate shared bathrooms as a potential source of infection spread.

"Our ultimate goal is to build a full ER One on our campus to serve as a resource on a day-to-day basis as a demonstration facility — a national test bed for other EDs to [observe] and see how their departments should be enhanced or retrofitted," Smith says.

While in pursuit of funding for ER One, however, Smith realized his own ED had grown at a very rapid rate and needed to add incremental space. "Over the last year and a half, we have expanded into contiguous space that was a step-down ICU and renovated it into what we call our "Bridge to ER One," he explains.

As with "ER One" when it is built, the evaluation of "Bridge to ER One" never will be completed, says Smith, because new elements will be added as they are developed. However, he adds, the patients already are having a better experience. "We had had [a negative] experience with boarding patients, and this relieves that," he says.

The original ER One concept, created by Smith and his colleague Craig Feied, MD, also an ED physician, was based on several guiding principles, including capacity, capability, and flexibility.

In terms of capacity you need scalability, which is being able to go bigger without gridlock, Smith says. "In terms of capability, you've got to consider how you would manage highly contagious patients and keep operating when you yourself could be the target of direct attack, suffer collateral damage, or suffer major outages," he says.

The ER One concept calls for a 15% premium in room space. "That's very nice [space] for one family and patient, but easily used for two, allowing for 'graceful degradation' as opposed to catastrophic failure" when four or five patients would be crammed into one room, says Smith.

In ER One, the public or waiting space will be gridded with water and power and be rapidly convertible to patient care space. "We pay strict attention to the way infection is transmitted," adds Smith, noting that the typical ED may have one or two negative pressure rooms. "We think every room should be negative," he says.

Not every one of the 10 rooms is receiving full 'ER One' treatment, explains Ella Franklin, RN, CRC, an ED nurse manager and director of external partnership relations, research, and development for "Bridge to ER One."

Four patient rooms are designed to the best standards, while four others look like standard ED rooms, she explains. The other two rooms are set up for a concept called "healing design," which, she says, has been proven in pediatrics. "Certain design elements, like natural colors and tree patterns, can improve healing," she says. All 10 rooms have negative pressure.

"We will trial in this space so when we move to ER One, we will have hard evidence about which of our ideas bear out," says Franklin. He says environmental samples will be taken to see if the microbial load is lowered, and staff and patients in the 'healing design' rooms will be surveyed about fatigue at the end of the day.

Smith and his team have been seeking $75 million in federal funding to build ER One. Meanwhile, several corporate partners are supporting the cost of the ED space that already has been transformed. For example, notes Smith, DuPont contributed the nonporous solid surfacing material, and Agion Technologies provided the silver coating. Steris Corp. just received Environmental Protection Agency approval for vaprosure, which is vaporized hydrogen peroxide that "kills everything," he says, In addition, Herman Miller took one of its office furniture lines and created a central workstation that adheres to ER One design for staff collaboration. Designed for three workers, it can comfortably expand to five during a disaster, with additional outlets for phones and equipment built in to the work station. Microsoft Corp. has contributed Azyxxi, its new clinical information system. Cisco is providing its new voice-over Internet protocol, and Parco is offering an ultra-wideband tracking system.

"These are very forward-thinking companies who recognize some serious problems that have resisted solution, and realize that nothing beats trying solutions out in a real-life medical setting," Smith concludes.


For more information on ER ONE, contact:

  • Mark Smith, MD, FACEP, Chairman, Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Phone: (202) 877-7000.