Planning a brand new ED? Study up on acoustics, air quality, and patient wish-lists

Integrate patient feedback into your design plans

New systems and processes can make a big difference in trimming wait times and changing customer perceptions in the ED. However, administrators in the enviable position of being able to design a brand new ED facility have an opportunity to create patient-friendly environments that also cater to their own characteristics in terms of flow processes and volume.

When drawing up plans for a new facility, there is no better guidance than listening to the voice of the customer, stresses Gary Kusnierz, vice president of performance excellence, Affinity Health System in Menasha, WI, a regional health care system that includes St. Elizabeth Hospital in Appleton, WI. The hospital just opened a new emergency department and surgery procedure area this fall. However, at the beginning of the planning process, Kusnierz says health system administrators interviewed more than 700 patients to find out what qualities they wanted to see in the new facility.

"We collected a ton of data, and one of the things that became quite clear was that people wanted to be able to communicate [with their providers] in a private area, and not give out information in public settings, so that was at the top of the list," says Kusnierz. "So privacy was a big thing, and the connection to the nature was another big item."

People wanted to have direct sunlight coming into the building, they didn't want the ED to smell like a traditional hospital, and they wanted to see more environmentally friendly natural materials, says Kusnierz. "People are starting to recognize natural products that are used not only in the infrastructure, but also in the fixtures, furnishings, and equipment," he says.

Prioritize acoustics

Administrators worked through different simulations and modeling, and created a design that includes eight centrally located "flex" rooms that can be used either as emergency department rooms or surgery procedure areas, since the two areas have opposite peak hours of operation. The rooms have frosted, sliding glass doors to promote maximum privacy, and the walls are painted with nature-inspired murals. Lighting in the rooms can be adjusted to promote patient relaxation, and radiant heat panels are positioned over the beds to keep patients warm.

Sound control was a big priority in designing the new facility, says Kusnierz. "Every wall in the department was identified to have a certain insulating factor so that we could minimize the transmission of noise," he explains. "Also, we have used an acoustical-grade ceiling tile that has a higher [sound] absorption rate ... and all the doors are equipped with seals and sweeps, because we found through our testing that doors are a major area where noise transmits through." (Also, see "Study: Noise increases stress, interferes with communications and teaching in the ED," below.)

Even the nursing stations were equipped with sound-absorbing material, adds Kusnierz. And while administrators have not yet had time to tally results from these measures, the difference is obvious, he says. "When you are in an area that is not designed appropriately from an acoustical standpoint, everyone's voice is flared, but when you start putting these designs into place, all of a sudden you walk around and you find out that people are talking in a much calmer tone of voice," he says. "So we have been able to help change the behaviors of people working in the ED and the other areas across the system that we have designed like this."

Lower stress with effective design

A redesigned pedestrian flow pattern has had a substantial impact on the stress level as well, says Kusnierz. "In our old facility, [when people walked in the door] they would immediately be positioned in a maze of corridors," he says. "In our new facility, we have made a significant design change so that the public is routed around the perimeter of the building, and always within eyesight of the outside."

It is a good way to get people from point A to point B, says Kusnierz, but people say that it also has a calming effect. "If we can create that impact, perhaps by the time they get to where they are going for care, they are not as stressed out as they were in the old environment," he observes. "It is all connected back to the whole process of people getting around on a campus where people are seeing an external connection to nature."

Patients aren't the only ones considered in the new design, says Kusnierz. The reconfigured workflow has positioned supplies and other resources at the fingertips of clinicians, so they don't need to travel as far as they did before, and there is much less "hunting and fetching" of items that they need to care for patients, he says. Even after just two weeks of operations in the new ED, staff feedback was very positive, adds Kusnierz.

While early impressions have been auspicious, the hospital intends to gather data about the impact of the new ED, find out what features are having the biggest impact with patients, and what other improvements patients might want to see. "We have listened to patients, but we have done it in a way where we can collect data and routinely go back and measure those characteristics," says Kusnierz. "All of the acoustical changes, design features, and workflows have strong metrics behind them, so we are going to go back and verify those metrics and make sure we accomplished our goals."

Take a look at no-wait concept

Adventist GlenOaks Hospital in Glendale Heights, IL, was also in a position to build a brand new ED facility four years ago, and administrators there decided that a no-waiting room concept would appeal to patients, and it would be doable, given that the ED is a smaller-volume facility that sees about 19,000 patients a year.

To accommodate this concept, the new ED has 19 private rooms so that as soon as a patient walks into the facility, a registration clerk will announce his or her arrival while performing a quick registration, then a nurse or a tech will immediately take the patient to one of the private rooms where the triage process will commence, explains Marion Schneider, RN, MBA, CEN, the director of emergency services at Adventist GlenOaks Hospital.

"How quickly it takes from the time the patient hits the door of the ED to the time he or she sees a provider has been reduced from about 30 minutes to about 6 minutes on average," says Schneider. "What has been trimmed is that patients are not fully registered at the beginning, so that is several minutes off," she says, noting that triage takes place before registration staff come into the patient's room to complete the registration process. "By that time, patients have already been assessed by a nurse and she can even start some of the treatments based on protocols that we have already set up," adds Schneider.

Patient satisfaction scores average around the 80th percentile in Press Ganey surveys, says Schneider, and there have been no dips in the last year and a half. "They have just continued to go up," she says. However, she doesn't credit the improvement entirely to the no-wait ED concept. Schneider suggests that other customer-service initiatives have undoubtedly played a role.

For example, the day after patients have been seen in the ED, a tech or a nurse will always call to see how they are doing and ask whether they have any questions or concerns. "The overwhelming majority of patients are just completely ecstatic with the immediate attention that they get from these callbacks," says Schneider. "We hear positive comments about this every single day."

Interact with pre-hospital providers

Another area of focus for the ED is on interactions with pre-hospital providers. "We have found that they are extremely important to the care of our patients," says Schneider. "We listen to what they have to say about what they see and hear in the field, and we have also begun doing programs where we invite them in and have them participate on the team so that the whole patient flow from pre-hospital, to the ED, to inpatient is very smooth," says Schneider. "The paramedics understand what we are doing in the hospital, what kinds of services we can provide for patients, and they can be advocates for patients in the field."

With such cooperation, care is expedited for patients, says Schneider. For example, when paramedics say they have a STEMI [ST segment elevation myocardial infarction] patient, the ED will immediately call in the catheterization team. "We don't even wait for the EKG," she says. "We believe them."

With increases in both ambulance and walk-in visits, patient volume in the ED is up by about 7% over the past year. In fact, Schneider anticipates that the demand will soon support the opening of a fast-track program to handle patients with less acute needs so that they can be in and out of the ED quickly. "What we are finding is that as we are growing, we are changing our processes," she says.

Schneider is the first to admit that what works at Adventist GlenOaks is not necessarily going to work for an ED that sees 200,000 patients a year, or an ED that works in a different geographic area. She advises colleagues to look at their own processes and characteristics, be patient-focused, and evaluate how they can most efficiently move patients through the ED.


  • Gary Kusnierz, Vice President of Performance Excellence, Affinity Health System, Menasha, WI. Phone: 1-800-362-9900.
  • Marion Schneider, RN, MBA, CEN, Director of Emergency Services, Adventist GlenOaks Hospital, Glendale Heights, IL. E-mail:

Study: Noise increases stress, interferes with communications and teaching in the ED

Does noise volume have any impact on care quality? It is a question of high interest to ED managers because of all the commotion, sirens, and visible distress that are typical of high-volume EDs. However, while some research finds no impact from noise in the ED, the latest study to look at the issue suggests that, perhaps, noise does have a negative impact.

The study, conducted by researchers at Sick Kids Hospital in Toronto, Canada, measured the noise levels in the tertiary care pediatric ED, and surveyed physicians about their perceptions of the noise level and its impact. The study appears in the journal Pediatric Emergency Care.1

Using a sound-level meter, researchers found that the average noise level at the nursing station in the ED was 68.73 decibels when measured over a period of one week, a level that is akin to a running vacuum cleaner, although sound levels peaked at 110 decibels, which is more like listening to a power saw.

When queried about the sound levels, only 35% of staff physicians and 22% of residents said the noise was uncomfortable, but most perceived the background noise as stressful, and said that it impacted communications. The physicians even indicated that they feel helpless when it is too noisy, and that they don't have any effective strategies to reduce noise in the ED. The physicians rated more than half of the shifts studied as very noisy, and indicated that the noise interferes with teaching.

In reports about the research, the lead author of the study, William Mounstephen, BSc, MD, FRCPC(C), the director of Paediatric Emergency Medicine at Sick Kids Hospital, said that such noise, and the resulting stress, have the potential to create miscommunication and, therefore, to cause harm. Since the study was completed, the hospital has rebuilt its ED with sound concerns in mind, says Mounstephen. Developers installed sound barriers, lowered the ring volume on telephones, and divided the space into sections, he says.


  1. Ratnapalan S, Cieslak P, Mizzi T, et al. Physicians' perceptions of background noise in a pediatric emergency department. Pediatric Emergency Care 2011; 27:826-833.