There we go.

Thank you.

So if you look at the services on the left, and then you just look at, all of the things that actually go on with pharmacy, imaging, lab services, food services, social services, business component.

And then you look to the right side and you see that there's a lot of movement within the ad going to and from the ad, different types of transfers is basically three ways to to come into the ad.

You know, you're walking in or coming in by ambulance or care flight perhaps is the third one.

There's a lot of different types of discharges or transfers.

And so there's just a lot of activity.

And, it's a good case for an emergency department kind of being the basis for micro-hospitals, which we will talk about in just a few minutes.

So obviously there's a lot of size range with emergency departments, from small rural, centers to large academic, urban centers.

There's a lot of, different types of clinical focus.

Get on the left side.

I think you had a presentation recently where you saw a Critical care incorporated into an EDI.

There's also mental behavioral health subspecialties.

Neuro stroke, cardiovascular observation, care are amongst the most popular ones of course, there are adults and PDS, and those are always separate.

On the right hand side, when you when we're talking about the hybrid emergency departments, there's really the value proposition, about the economy of scale.

And, so we have to look at what the value of really what that is.

And it's usually, amounts to enhance care coordination, usually improve clinical outcomes.

And if you look at the different types of specialty combinations or hybrid eds, you can see the one of the most common ones right now is that any urgent care, of course, is at stroke centers, in heart centers, trauma centers, and then observation care.

And we actually recently came across one that had a specialty in ophthalmology.

So if we look at, the historical trends for patient cohort divisions and just the trends in EDS in general, in the in the about 40 years that I've been practicing, there have definitely been some trends that have come in, not completely gone, but have become popular.

And then sometimes the climate changes and other things become popular.

And so I want to start with the fact that, you know, originally the, the Ed or the emergency department used to be called the emergency room, right?

The E.R.

and it was most it was a good reason for that because it was mainly basically one room, kind of an open room with a staff center.

And then around the the staff of the room was, a lot of cubicles, and maybe they had one trauma room, but it was mainly in one big room.

And as 80s got larger and larger, that got shifted to different types of typologies.

So there was a time when we really focused on, singular domestic violence, which was basically one person coming in to maybe, perhaps do harm to another patient that was there that quickly, unfortunately, kind of overtaken by mass events.

We've seen a lot of mass events lately, which has led to the August Grady Concept Project.

Dr.. One then that kind of shifted to the infectious disease, focus with, things like Ebola and Covid.

Then we definitely saw a freestanding Ed, prototype rise and hybrid EDS.

And so really the question is on the Ed micro hospital.

So the question really is what's the next what's the next best thing?

What's next?

What's next?

Coming the cohorts.

When and that's an important discussion because when you look at the total amount of patients going in, the cohort is basically how are they going to be grouped.

And so they're different.

The main grouping is of course based on acuity, which we'll talk about in a second here.

Or it could be clinical, or specialty hybrid or an age separation, of course, between pedes and, and adults.

And then there's really a lot going on right now with the intake protocol is a whole bunch of different models out there for preclinical, and what they, what they really want to try to do is to keep the very low acuity from going back into the main clinical area, so often referred to as the front and back.

The, so some of the things that drive the patient or the, any configuration, of course, there's the theory about different prototypes and configurations.

But then when you look at the actual site, there are always physical constraints.

And so you always have to work with these physical constraints.

And they will change the theory up a little bit.

Some of the things like entrance locations, size of the facility, avenues for future expansion.

This next one is really important.

Daily and incremental, expansion and contraction.

I'll show you a, kind of a presentation curve for the Ed, in a slide or two here.

But the PD volumes ebb and flow throughout the day, and you want that configuration to be able to adjust to the ebb and flow of patients.

And that's also related to seasonal fluctuation as well.

And some of the clinical operational staffing drivers for configurations have to do with clinical work group.

How many, how many clinical work group folks will be working with in a particular area, and what that number is and what the exam room ratio is to that clinical group.

Everyone knows about, staff to patient sightlines, but a really, really important one that's not talked about enough is, staff to staff sightlines.

Staff really, really like to be able to see where the other staff are located and where they are, just in case they need they need backup and support.

So that's a very undervalued attribute, but it's a very important one.

So here are a couple just fundamental, organizational prototypes.

Typologies rather top left here is the classic ballroom or arena.

And that goes all the way back to the air.

That's generally good for about 16, about 16 rooms.

12 to 16 is kind of the sweet spot.

You can kind of push it to 12, push it to 20.

I'm sorry.

And then as it is, got bigger over time if you needed.

But unfortunately what happened was a CTS got bigger over time.

If you, if you needed 48 rooms or 60 rooms, you a lot of designers unfortunately would take that same archetype and just kind of stamp it and repeat it.

So if you took a a 16 room archetype and if you needed 64 rooms, you just kind of did four of those.

But there's a there's a real downside to that in terms of how it affects the staffing.

It's not very efficient and it really doesn't affect and it really doesn't well serve, rather the ebb and flow of the daily volumes, because each of those pods have to be opened or closed, not not partially opened.

So that brings us to the one on the bottom, which is kind of a linear concept, which is really my one of my buddies, Jim Lennon, who was kind of what I call a godfather for the linear design concept.

Linear concept is basically rooms on two sides with staff in the center.

And that really the optimum size for that is about, really about 40 to 50 rooms.

And so it's just a it's a, it's an architecture that allows site to site visualization and optimizes that.

And there's a two door and a single door concept on a patient room side of that, which, which is a detail for another day.

Some of the other fundamentals, the, yes, I levels when we're talking about dividing patients by, by acuity, that directly relates to the emergency severity index levels one through five.

When you go to the Ed, you always want to be a 4 or 5.

You really don't want to be a 1 or 2 to 1 or 2 or much more, critical, much more severe.

The one or twos are also called, horizontal patients because they're usually lying, and the fours and fives are referred to as vertical patients because they can often be in a recliner.

So that's very important to know.

And to know what the overall patient population, how it's broken down by the ESR levels.

The other thing is trauma designations.

The American College of Surgeons, kind of designate the ACA, levels, the child trauma levels, they're one through five.

They don't really drive the architecture very much.

It's more the one, two, five levels on trauma centers and more related to, staffing availability, staffing ratios and types of staff that that can be available on demand or on site.

So that's something to be aware of as well.

So this is that curve of distribution of patient volumes.

This is kind of very common.

It's either a single pump or sometimes it's a double hump.

But it basically reflects human activity.

So needs are they start getting busy in the early afternoon.

They start getting busier toward the late afternoon.

Sometimes after dinner they slow down a little bit and then they some in some cases they pick up a little bit later.

It also varies on the weekends, of course, it varies with seasonality, but that curve of distribution for the way patients present is really important for you to understand, because that directly relates to the ebb and flow of that configuration.

So let's talk a little bit about the different sizes again.

So if at the bottom half of this is really, ones that, relate more to the ones that I've been doing, in the last ten years, it is are getting bigger and bigger.

So this is just a chart that's published in the American College of Emergency Physicians.

Design book.

And you can see that, I'm going to kind of go all the way down the bottom line.

So 100 annual 150,000 annual visit volume, will yield anywhere between 80 treatment spaces or 110 treatment spaces.

And the overall area of that department could be as high as 80,000ft².

And so 80,000ft² is a very big head.

And I'm going to show you just how big that is here visually in a second.

But, obviously when you're dealing with something of that size, smaller typologies that you're just going to replicate is not going to work very well.

So we have to look at something different.

So here's an idea from a study a few years back, Washington Hospital Center, er one it had about it had about 60 to 80 patient treatment spaces and it was kind of in a curvilinear track.

And, they were exploring the idea of whether or not you could have multiple entrance points so that the walking distance between entering the E.D.

into the treatment room would be minimized.

And so this is kind of an airport Concorde, Concorde approach, concourse rather.

Excuse me, to an indeed.

And this was a study that we did for, on a hill, Washington, DC.

And, I think it's a great idea.

We, if you take the intake and just in subdivided into the entrances and have that electronically controlled, I think you can do this kind of thing.

I haven't yet seen it, executed, but it's.

I think it's a great concept.

I also want to point out that, so, you know, hospitals in general are loaded with vulnerable people, right?

And particularly people in the Ed, they're very vulnerable.

So we want to make sure that at the entrance to the Ed, there's always some type of secure control.

It doesn't make any sense for someone to be able to just walk into the emergency department unchecked in any way.

So, there's a variety of different, different entry concepts that you can look at, but, be sure that you address, safety and security, which is starts at the entrance of the Ed.

Just some, some images of some, less a less obtrusive technology for metal detection.

So this gets this here, drives back to that linear concept that I spoke about earlier, how it's basically rooms on two sides.

I mean, of a central track with a core is.

So one of the best reasons for a linear concept is the way it loads.

If you patients come in on one side to the left side, in this case, and as volumes increase, you can load that just just like a thermometer as it goes up and down.

And so this is the trick of the day.

You ready.

So as it gets busy, you know you just go in that direction as as volume start contracting.

It just comes back down.

So it's a nice clean incremental response to your daily flow and your daily your daily fluctuations of flow.

So here's a one concept that we developed.

This is about it's about 60 rooms and the staffs all in the center.

It's just very straight linear track.

You can see the observation component down in the lower right, which is nearby.

So this is really kind of an intake to the top side for the walk ins where the yellow is, they come through the intake and then to the track, they get into the track at each third point.

So the walking distance are pretty reasonable to get into the track.

And then on that south quarter, running left to right is, the trauma component all the way over to the right.

On this side over here is where the trauma rooms, this is an open body trauma area.

As opposed to some individual closed rooms.

I see you see it on both ways.

A lot of times if you have trauma surgeons that you're working for, they like the open bay for trauma.

Where we do a lot of private rooms as well.

And imaging is down here as well.

So very clean.

60, 60 exam treatment room, track.

Here's another one image.

The walk in is over on this side.

The ambulance entrance is on this side.

Here are the trauma rooms.

Single track.

This one's about 50 rooms.

And the imaging over here.

So again, very clean.

All the staff in the center, they can they can look down, look, step out onto the hall, look down and see each other.

We find that that's been a very successful concept.

So now I'm going to go to another project here that's what I, what I really call a kind of a huge emergency department.

It's got 144 rooms.

And, this case is a large 118 adult for the Ed, 26 for pedes.

And then they have 55 observation on level two.

So we're getting into this organization here.

So the interesting thing about this graphically here's the level 255 bed observation unit.

So graphically that that green area is basically what was that look like Kyle Field.

It's a football field.

So that's the scale of this emergency department relative to a football field does include end zones.

I didn't I didn't pick the end zone.

So if it does include the end zones, we didn't want to cheat.

So that again, that's just the scale.

This is, in the order of approaching 80,000ft².

And so how do we how do we achieve.

A kind of a unified EDI and at the same time, work with the special clusters and component parts.

This this was so large that, on the north side of the site, to the top of the page is the walk in for the adult side, and the south side is the working from the pediatric side.

But it's very difficult to get by car around the other buildings on campus to get to either side.

So one of the requirements that the client definitely needed to maintain was to be able to if someone came in on the wrong side, they can end up North side with kids, but they needed to be on the other side to be able to at least get through the building instead of having to go back in the car and go all the way around, which was really going to be time consuming.

So we had to make sure that we we maintained that circulation.

That was a very key circulation.

So this is organized with three tracks going left to right, see to one, two, three.

The adult intake is to the top right over here, three horizontal tracks.

Now this part of this track you'll see here in a second is a low acuity area.

So the low acuity areas kept typically adjacent to the adult walking side, because you want the low acuity to not have to go very far into the Ed to, to, you know, to be treated.

So they have to have something very quick and simple.

So we try to optimize that being adjacent to the walk in area.

Any imaging is a block here that's actually just for EDI.

This is not the main imaging department.

This is the EDI imaging department.

It has MRI, CTS, you know, X-ray, ultrasound with this many rooms that they can justify having a dedicated imaging imaging component, the size to the right over here, is a crisis intervention suite.

Down here is the, just kind of some admin for the side.

Here's the PGD and then the walk in intake on a side, the trauma for the adult is over here, and trauma for the pedes and for the, crisis intervention suite is on the side over here.

So they directly can get quickly into the crisis intervention suite.

Again, low acuity over here adjacent to the admin.

This is not really an empath in this case.

This is really a crisis intervention because this does not have an open milieu.

And the staff is protected at the nurse station.

So that's, that's mislabeled.

That should be a crisis intervention or a crisis, psychiatric assessment.

And this is how the volumes are broken out.

In terms of numbers of exam rooms.

And so we generally find, in terms of the room sizes, you know, you hear a lot about, universal rooms and emergency department, universal rooms can get you most of the way down the road, you know, probably 90% of of lot of all the rooms can be universal.

However, on each end where the lower communities are and actually can be quite, a, quite a percent of low acuity as well, but lower to low acuity.

So now we can now do in a space that's about 50ft².

So because it's so efficient, I'll show you a picture of what what what we see coming on the industry.

It makes sense to use it does make sense to use a small space for lower queries.

And of course, on the high acuity on the trauma side, you definitely need a larger room than just a standard, universal exam room.

So I generally see three room types, a low acuity kind of a universal treatment, and then, an exam or, you know, trauma resuscitation.

In this case, the four trauma rooms, they really wanted to try to, what we call load level with that work.

So, this was intended to take these three, these four trauma rooms and have them, split across the three tracks so that the staff in each track would kind of be responsible for 1 or 2 of those trauma rooms so that it wasn't just a dedicated trauma staff, it was it was load level so that, it could just be split between the three, the three staffing clusters.

Here is the, crisis intervention.

This particular facility also took the, community, crisis.

I mean, the community, corrections patients as well, when they got sick and needed to come to the hospital.

So there was a corrections component, incorporated with the behavioral health crisis.

And then that's the pedes on the south side, the imaging suite and the pizza walk in area.

So this one really had four entries adult, ambulance and walk in and pedes ambulance walk in and, well, actually the fifth one being the, crisis intervention and corrections patients.

So this is a concept, for the low acuity.

This is something that, we have been involved with over the last ten years.

Jim Lennon, won a National Air Innovation Award for this, I believe, in 2013.

And this is now a concept, that, this particular one is, by dirt.

If you guys are familiar with their modular, prefabricated, and, this this takes about 50ft².

And, it's really a nice little small space that you can customize with your own lighting.

And it's basically a vertical space, you know, with a recliner and very, very efficient.

So staff friendly staff don't have to cover as many steps to get to the same number of patients in a 50 square foot, low acuity space.

So just some of the things about some of the psychiatric space, I know there's a lot of talk right now about open milieu, and crisis type spaces and the staff not necessarily being behind, protective polycarbonate, but, the ones that I've been doing with the EDS, just the ones that I've been doing have been more of the protective type.

This is one inch thick polycarbonate glazing at the nurse counter.

Nobody can get through that with, channels that the ceiling and at the at the top of the casework, the one on the right is basically kind of a classic, behavioral health treatment room that has the roll down shutters that you can roll down and protect the head wall to get, to to remove all those, ligature points, potential to ligature points.

So that helps to reduce, that exposure.

So case study two here is another facility that has, 98 rooms, 24 observation and 20 urgent care all on the same level.

So.

Be interested in capturing your opinion.

If you had the opportunity to do an 80,000 square foot hybrid with a variety of component parts, like I just showed, and you think you're you think the clinicians prefer 80,000ft² on one floor, but do you think they prefer two floor plates at 40,000ft²?

You know, one right on top of the other one's on the second floor, one's on a first floor.

240 is the one we think most clinicians prefer.

240 no.

Even though so the interesting thing is, is you can sometimes make the case that your travel distance is going to be less if you had to go vertical, because you can get off that elevator on a second floor, and you can be where you need to be, as opposed to going, you know, 50 yards or 60 or 80 yards down the quarter.

But clinicians really don't like bringing patients in elevators.

And they always have horror stories when it comes to you having to utilize elevators.

And they don't like the fact that their staff is split on two levels.

So back to that point I was making earlier about the staff to staff visualization.

Even though there's more steps, I my experience has found that they like more space on one floor, that they can go down the corridor and or look down the corridor and see other staff where you just can't do that.

If the other, you know, the other piece is on the second floor.

So it's my experience that they like more on one floor, as opposed to split it up into multiple floors.

I have one minute.

Wow.

That was quick.

So this one here, so I'll just go through these slides real quick.

This one is got an urgent care center and a front read and an observation on the back side.

Here's your call field again.

This looks even larger, right?

Three, parallel tracks.

And walk in the entrance to the left side with the patient intake.

Urgent care has a separate intake, I find.

I know there are models out there where you have combined urgent care and any walk ins, but, this particular client really wanted to have separate.

They wanted the patient to make their separate decision point before coming into the building.

We also have an infectious disease suite on the top right.

And this is how they distributed these specialty rooms.

The trauma rooms are kind of in the north center over here.

Over here.

And they distributed their, the mental behavioral health rooms.

They kind of distributed those.

And it's like green across two different tracks over here and over here.

They wanted those distributed.

We have dedicated infectious disease rooms.

We have protective environment rooms which some people call positive rooms, which is only one eighth of what you need for a protective environment room.

Some people call the infectious isolation rooms the negative rooms, and that's only about one eighth of what you need.

You need, you know, recycled or not recycled.

They're outside of air, Hepa filtered, you know, high number of room changes per hour and things like that.

So, this is a nice clean grid circulation plan.

And that's.

I'm on my last 30s.

Roxana, this is just, enlargement of the urgent care and the observation component.

I won't talk too much about this.

This is a highly infectious disease suite, which is which also uses infectious isolation, air quality, but at the same time follows the protocol for decontamination.

One way in and one way out.

That's a unit directional flow.

Very, very important for a highly infectious disease suite.

This is just that er chart that I don't have to get into right now.

What I have found over my 40 years or so and planning of these that you really want to try to allow for operational flexibility over time because, their clinical models change.

And so you really I want to come up with a typology that is flexible.

I, I have found the, the linear track to be, best suited for that, particularly for large, large eddies, two great resources, of course.

The FDA guidelines and, the American College of Emergency Physicians EDI design book and say to a definitely that's it.

Thank you.

So I think we can have one question.

Do you have any questions for the students?

Walk over there.

I can even hand you the mic.

Grace.

Um, my question is... how would you edit or change or keep it the same at all the linear track, uh, design method specifically behavioral health units, um, that need that level of protection for the staff?

Yeah.

So I think we're still in the middle of trying to figure out with behavioral health if if the staff and the patients should be more isolated from each other or less isolated, you could simply use those track rooms and just designate, and that track at one end of the track, you could designate those rooms.

The the amount of protection really is up to the client.

You could also see that, in that second case study, the second large one, they actually distribute their behavioral health rooms, because when you when you group the behavioral health rooms and you specialize them, it takes away flexibility to use those other things so clients lose capacity.

And so some clients don't want to lose that capacity.

So they rather just distribute those rooms and have those rooms be used for regular treatment, acute care when they're not behavioral health.

So there's kind of pros and cons to the capacity issue.

I don't know that there's there's just one one answer to that question though.

Variable is so much data that supports 40 few minutes.

And we're going to have to take some of these into sculpture.

And there's going to be more informal Q&A after this session.

So thank you again for joining us.

We really appreciate it.

Thank you.

You're welcome.

Welcome.