Designing a new Urgent & Emergency Care space

Where to start with designing a new urgent and emergency care space?

Dr Dominic Giles, Consultant and Clinical Lead Acute Medicine, and Deputy Chief Clinical Information Officer at James Paget University Hospitals NHS Foundation Trust

My two key learnings from the UEC design work I have done are: understand your process and your patient pathways at the start, and get feedback from the broadest range of team members possible. It’s so important to have an agreed clinical pathway before you design the space.

Mostly, we end up designing around the space we have and try to fit the clinical pathways into it. Instead, have a clear pathway you want patients to move through and design the space around it so it fulfils your needs. If you understand your clinical pathway, you can see where you’re going to have issues in future. The big one with all UEC areas, SDECs particularly, is overnight beds. We learnt early on that bedding has a massive operational impact on.

Next, think about how that pathway interacts with other pathways. Most of our trauma and a large portion of our ambulance attendees go through a CT scanner, so how does your workflow to and from the CT scanner function? How are staff getting to the patient? In the NHS, we traditionally move the patient to the staff; I think we need to start moving staff to the patient.

The other consideration is how that space is viewed holistically. If we put a bed in a space, everybody thinks the patient has been admitted and they start putting down roots. If it’s clearly an assessment area, the chances of discharging a patient home increase.

We’re currently redesigning our SDEC so that all medical admissions come through it and don’t go into a bed until we’ve explored all other options and have senior medical clinician input that a bedded overnight admission is required. We’re using recliner chairs more. We have several younger patients who need infusions for a period – traditionally, we’d put them in a bed, but if we do that the chances of them going home, particularly outside of normal working hours, are reduced. If we keep them in an appropriate chair space, everybody realises they may well not need to be in overnight.

For staff, needs include the ability to see patients. A big concern about the New Hospital Programme is single rooms, but we’ve observed with the Concept Ward that if you design it right, you can see patients in single rooms and mitigate many of these concerns. There are times when staff at all levels need to be able to work in privacy but still need to be accessible.

For staff, needs include the ability to see patients. A big concern about the New Hospital Programme is single rooms, but we’ve observed with the Concept Ward that if you design it right, you can see patients in single rooms and mitigate many of these concerns.

It’s also important that equipment is accessible but doesn’t clog up space. I once spoke to an architect about designing footpaths in a new housing estate and he said to leave them out initially, work out where people walk naturally and put the footpaths there.

We’d be better off taking that approach to equipment storage – my ideal would be extra-wide corridors with cupboards down the side because the functioning of the unit the following morning, so when we first designed our SDEC in 2015, we made the doors too small to physically fit a bed through. You need those ring-fenced spaces that allow you to keep moving forward operationally we store everything in corridors anyway, but that’s not feasible.

With my digital hat on, there are considerations about storage and centralised equipment stores, ‘just in time’ systems to get what you need when you need it, ideally linking to concepts around smart buildings and asset tracking. If we know we have a patient coming in who needs a specialty bariatric bed, we should be able to pre-order it for them. Currently, we’re very reactive, but there are tools out there to make things proactive.

The other important thing is that staff space looks clean, fairly new, with computers that work and stuff that isn’t falling off the walls. It’s key for staff morale.

Regarding stakeholder engagement, aim to over-do it.

Regarding stakeholder engagement, aim to over-do it. You’re better off speaking to 10 extra people to ensure you don’t miss anyone, because you can guarantee the person you miss will have highlighted something that you’d forgotten or are a key player with wider teams. However, also have a set project team of individuals who make decisions. If you have too many decision-makers, you end up with a poor design. If you have more people feeding in ideas and fewer people making decisions, you end up with a more streamlined design. Get the triumvirate of the clinician, nursing and operational side involved so you can look at it from those perspectives with the designer.

Nicola Booth, Head of Development at West Suffolk NHS Foundation Trust

When I started with the NHS, I found it unusual that there isn’t an Employer’s Requirements document for approaching new builds or refurbishments, detailing what the employer wants the works to entail and how it wants them to be carried out, such as quality, design and performance criteria; location and perimeters of the site; purpose, scope and definition of works; proposed programme of work; specification and any special obligations. Coming from a consultancy background, that’s the first thing you’d expect from a client.

We must provide a good level of information to ensure the design team create something that’s fit for purpose that meets our long-term goals. Trusts rely on the HTMs and HBNs to define what that means, but when you drill down into it, Trusts have their own specific requirements that aren’t defined in the HTMs.

There are also conflicting paragraphs and clauses within the HTMs and HBNs, which need clarifying. For example, between HTM 03 and HTM 05 there’s a conflict in terms of the ventilation system’s operation and design in the event of a fire. Many consultants
perceive that if one zone catches fire, you shut your air handling systems down. However, infection control requires good ventilation in occupied and operational spaces. The design of the ductwork systems should be reviewed alongside the fire dampers and the control to ensure your system operates effectively if one compartment is on fire, allowing adjoining spaces served by that same system to continue to operate.

I’ve started to build an Employer’s Requirements document with input from our stakeholders within the Trust so that when we engage consultants on a design journey, they have clear guidance. It’s about getting it right first time to ensure those costs don’t spiral during construction because you have to change or retrofit something. Within the document, I consider all our requirements. For example, you might ban the use of PIR products because they can create a pathway of flame (not a legal requirement). You could outline your preference for structure – volumetric modular, steel-framed SIP construction or traditional bricks and mortar. You might consider using timber products because exposed wood is good for wellbeing. After structural, look at civils requirements, surveying the below-ground drainage to ensure that new load can be supported, avoiding things like submerged pumping chambers, which are costly and time consuming for maintenance. Then look at architectural and internal finishes, furniture requirements to suit a variety of needs, sanitaryware – there’s a ‘shopping list’ of equipment and brands we have as standard on site to streamline maintenance and spares. We discuss the contrast of colours, designing for EDI wellbeing and landscape requirements in adherence with biodiversity laws. We break the document down into system subsections for all disciplines in order to clarify the requirements for each. For example, the mechanical services includes sections for ventilation, water, heating, renewable energy, etc.

To comply with NHS Net Zero Building Standard, if it’s a new build with construction value of £25m or more, it must be net zero, including the embodied carbon, but it is good practice to apply this ethos to all projects. We do overheating assessments too (not a requirement of the HTMs) to ensure optimal sizing of chiller plant and to address the increasing climate temperature impact on our occupants.

The most important thing is to carry out internal stakeholder and user engagement to create a well-thought-out layout that meets legislation requirements, and that we have identified any areas we would struggle to meet in terms of derogations and that these have been approved through the appropriate channels (HTM safety groups, for example). Get everyone together to take them on the journey of the design process – talk about your intention and explain the users’ needs so they understand why we’ve done things how we have.

It’s important to engage the right experts within the Trust to look over the Employer’s Requirements document, ask questions and suggest their thoughts, which enables all to contribute to the project-specific brief. We also use a design tracker where stakeholders add comments to a document or drawing. The design team can respond using that tracker so we can monitor decision-making throughout the process.

By the end of 2024, I want to complete an Employer’s Requirements template, which I am happy to share with other Trusts.

Ask the experts – designing new urgent and emergency care spaces 

Dominic graduated from the University of East Anglia and completed post-graduate training in East Anglia and the North East. He joined James Paget as a consultant in 2019 before taking up the role of Clinical Lead Acute Medicine three years ago. He is also Deputy Chief Clinical Information Officer. He has been involved in the evolution of the hospital’s UEC space, from ambulatory unit to SDEC to the current redesign work.

Nicola is an MCIBSE accredited Mechanical Engineer with 20 years’ experience in the construction industry. Nicola has delivered projects within the commercial, education, healthcare, residential and leisure sectors. She’s the immediate past Chair of the Chartered Institution of Building Services Engineers (CIBSE) East Anglia Region and immediate past Chair of the Suffolk Joint Construction Committee alongside her NHS role. She joined the NHS in March 2022 to give something back following the pandemic. Nicola oversees and manages the capital works programme for the Trust and develops the brief with her team, so that it meets the needs of stakeholders. 

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This article was taken from the November 2024 edition of FORTIS magazine.

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