Doctor Reveals How ERs Are Designed to Save Lives | WSJ Pro Perfected

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- It's kind of funny when ER first came out. - You've got an unwashed, undomiciled male with a laceration to the forehead at two. - That was my first experience to like ER before I became an ER doctor.

It's definitely not accurate now. - Today, emergency departments in the U.S. are often bursting at the seams, and the physical layout of the space can have a big impact on patients' experience. - There are places in the United

States where people have died in emergency department waiting rooms waiting for care. - Everything from the placement of the bed to the X-ray machines can be optimized to help get the right person the right care at the right

time. So we asked the doctor to engineer a better solution. - I'm a doctor, not an artist. Well, my name's Ben Bassin. I'm a physician. I've been practicing emergency medicine for almost 20 years now. - The first thing

to note is that ER is a pretty outdated term. - Actually, some people will get a little irritated if you use that term, even though everybody does and it's common. It stands for emergency room, and that's where it

started back in the '50s and '60s. It literally was a room. It was sort of an afterthought on hospitals as EMS and ambulances were becoming more popular in the United States. And now, we call it an ED or

emergency department, 'cause it really is much more advanced and complex than it was when it first started, you know, 50, 60 years ago. - Today, many EDs operate out of those same fixed spaces, only they're seeing a lot

more people. - Our house is always packed, and our department is mostly clogged up with boarders. Those are admitted patients waiting for a room upstairs, sometimes for days. - And the pit is actually very realistic. So this is

the ED and everything that happens inside of it. - Think of these chips like different types of patients who show up to the ED. Green are the ones who could be managed by a primary care provider. - People

may be uninsured. There may not be access for primary care in a timely way. And so now, all these green people show up needing to be seen in the ED. - The blue chips are people who need behavioral

or mental health care. - Across the country, we have closed hospitals and systems and clinics for behavioral and mental health care. And so now, all the blue patients have now shown up in our waiting room. - Yellow represents

patients who would've been better served by urgent care, but either don't have access to it or didn't know it was the better choice. - And then there's the patients that the ED is actually designed for, and these are

the patients who truly need emergent care. And so really quickly, we've now, as you can see, we have now been the recipients of care for everybody. And this is sort of the state of healthcare in America, and this

is why the EDs are sort of overrun. - To sort through all those people coming through the door, EDs use a triage system. - We're very much a commodity-based system in America, and it's based on first in, first

out. If you're first in line, you get the thing first. The ED is not designed that way. We are designed on priority of need. And the way we do it is actually something called ESI, or Emergency Severity Index.

- Each patient is assigned a number one to five. A one means you're at risk of dying and need to be cared for right away. And a five is someone who doesn't have an emergent condition but will still

be treated. How fast you get seen all depends on that ESI number you're assigned on arrival. - And so you may have showed up 12 hours ago and are still waiting and somebody showed up three minutes ago is

getting care all of a sudden. And that may seem very unfair, but that person has a much higher risk of having something really bad happen to them or a bad outcome than you do. - Sometimes, that triage process

could happen before you even enter the building, like at the University of Cincinnati. - These are actually outdoor heat lamps and showers. So this is if there is sort of a mass casualty or a huge amount of patients

who show up from a disaster. These are privacy screens or curtains that come down that we can manage patients even in Cincinnati in the winter. - Ideally, waiting rooms are divided into different zones, like immunocompromised versus pediatrics or

behavioral health patients, but not everywhere follows this approach yet. - We don't want you leaving sick if you weren't to begin with. So I think the first thing is to sort of create some divider among sort of sick

and not sick. - From there, patients can be triaged and put through a split-flow process, with one route for patients who will likely be admitted and another fast track for those who need fewer resources and can likely be

discharged sooner. Sometimes, that means swapping horizontal beds for vertical chairs, which take up less space and typically result in patients getting discharged faster. - You're set in a recliner because that's safe for you to be in. Your average

length of stay is about two hours less than as soon as you were made horizontal and put in a bed. - The waiting room is just one building block of the puzzle that is any ED layout. - Yeah,

so when we think about designing ED, architects and designers traditionally use a few different layouts that are sort of reproduced all over the country over and over. - In the traditional model, the ED is packed full of rooms.

- How do I get the absolute most space to take care of patients, regardless of how it's oriented or how things are laid out next to each other into the box? And maybe there's something over here, over here,

but at the end of the day, the box is full. That's sort of the mentality of traditional. - But in this layout, the staff don't have a direct line of sight to all of the treatment rooms. - I

can't see them. I can't hear them. To get to them, I have to walk sort of all the way around to get there. It's really inefficient. So let's talk about different layouts. Some people will call it the Disney

model. - In this layout, each room has two doors, one for the staff and one for the patient. - And so what happens is somebody comes from, I'll use this as my person, this person comes to the waiting

room, they get triaged, and then they get routed to the patient side. The staff are all here in the middle, and there, this is where all the machinery is, right? This is where all sort of the chaos, the

machinery and other stuff is that you see from an ED. It's all being sort of contained. And that's why it's sort of called the Disney model. It's what the patient sees as sort of what you want them to

see. - This design can be better for the patient experience, but the extra hallways take up what could be more treatment rooms, all of which are designed exactly the same inside. - I'm not looking around the room like,

where's the hand sanitizer? Where's the sink? And it's just the sort of the same motor memory every time, and that's why we design it into zone. - Every treatment room can be split up into three zones: family, patient,

and healthcare. - So you're gonna have a bed with a patient, and that's what they look like in real life. And then, so I'm gonna put my bed there. - The bed always goes in the middle, so the

physicians can walk around and examine the patient from both sides. One side is reserved for medical care, like the IV drip and the computer. - At the top here is also usually a headwall, and the headwall is sort

of where all the gases come in, like oxygen and medical air, and all the devices and the data feeds and the information stuff that comes into the patient to connect them to the bigger system of care delivery. -

The Family Zone will typically serve as more of a lounge area for people to wait with the patient, but these rooms still need to make sense within a larger ward layout, which brings us to Dr. Bassin's favorite. -

This is called the racetrack, and it's called that 'cause it literally is like a track around the ER. So again, if we take our box, it's our ED box. So our waiting room again is somewhere here, maybe at

the front, and triage, which I think is purple, is somewhere in here. Our core functions, our staff are in the middle. - High-risk patients will go near where the ambulances come in. - And then we're gonna put imaging

here, and it might seem like, oh, that's like right smack in the middle, and why would you do that? Both of these patient populations need imaging, and we don't want them to go very far from the area they

get their care, 'cause they're sick and sometimes unstable. - Not only does this design keep people closer to the services they may need, it gives staff clear sight lines of everything happening in the ward. - You wanna know,

like, are my staff okay? Is the nurse in that room okay? Is the patient in that room okay? Are they calling out for help? And you don't want it to be in the back corner somewhere over here where

nobody can see and nobody knows they're there. - The trade-off is that you can probably hear everything happening right next to you, and infections aren't isolated to a room. - All of this stuff is on wheels. And the

reason again is that in the future, we have no idea what care delivery will look like. These buildings might be there for 30 or 50 years. 10 years from now, I have no idea what healthcare is gonna look

like. It might be done by robots and I may just be on a screen in the room and not even physically in the room. Who knows? But we wanna take this box and make it incredibly flexible for the

future. - Dr. Bassin is already helping design the EDs of the future, complete with outdoor gardens, multiple types of waiting space, and more privacy for people receiving care in the waiting room. - Despite maybe hearing me bring up

some of the things that are big challenges, and they are, I think we are also in an era of sort of unprecedented capability. The system in America is designed around sick care, and it has been for a long

time. Like we are designed to react to when people are already ill and sick, and then we bring them to the hospital and we do a bunch of things. The goal now is to be so far upstream that

we keep people healthy that they don't need the hospital.