High Anxiety - Dispelled by Design

By Beth Herman

Hustled by panicked family members into Washington Hospital Center’s teeming ER One, a woman complaining of intense stomach pains is triaged and soon takes a seat. It's 5 a.m. and the programmable color kinetic lighting all around her is redolent of the subtle hues of early morning, while a skylight (rediscovered during renovation) channels mild, natural light as the sun rises. Nearby, two large tropical fish tanks sparkle, and a flat screen TV with soft programming also flashes an informational display with the first four letters of the patient’s last name, and a first initial, to let her know exactly where she is in the queue. A partial wall of translucent Corian, carved into the organic shapes of grasses, reeds and willows, is backlit withmuted, evolving LED lighting to represent a restorative environment.

With wait times in metropolitan emergency rooms averaging seven to eight hours, patients’ stress and anxiety levels are exacerbated by a lack of "positive distractions." Accordingly, 21st century health care facilities have evolved to incorporate soothing elements of nature (organic design) and substantiated methods of stress reduction, manifested in design, the results of which have been called “a bridge between neuroscience and design.”

For Huelat Parimucha Ltd. Healing Design Principal Barbara Huelat, studying the emotional needs of emergency room patients and their families was all in a day’s work, so to speak, when the firm was commissioned to augment and expand the early design they’d done on Washington Hospital Center’s ER One in 2007. Employing intricate research studies, and with elements like “evidence” and “proof” no longer just linchpins of the legal system, these factors are now the domain of architects and designers whose health care clients require tangible data in making their case to vigilant boards of directors and budget arbiters. Clients are now demanding more proof that (a design choice) works,” said Huelat. “There is a direction in the industry today called ‘evidence-based design,’ which is about wanting proof that what you’re doing makes a difference.” To that end, Huelat cited decisions in the past based on best practice models with which architects and designers have worked for years, though they lacked measurable results in the form of documented data.

Embarking on a series of studies through the Pebble Project, the California-based Center for Health Design’s (which promotes improving patient outcomes in healthcare) main research initiative, MedStar Health, owner of Washington Hospital Center, sought initially to implement emergency room infection protection and bacteria mitigation throughdesign and use of materials, and also to expedite work flow processes between site nurse’s stations. In its latest study, the implementation of “positive distractions,” or design elements that serve to mitigate and redirect stress and anxiety both patients and their families may experience during interminable wait times in busy emergency centers, was the goal. But to get there, MedStar and Huelat Parimucha had to first determine what behaviors and coping mechanisms people used to navigate the ER experience.

Panacea for pacing

“The predesign emergency room was pretty awful,” Huelat said of the hospital’s inadequate 1980s space, noting there were only two ill-placed (you had to almost hunt for them), never-lit fish tanks and a television for diversion, usually tuned to inappropriate “LAPD-type” progr

ams with violence. “One of the largest ‘activities’ was hanging out at the desk,” Huelat noted, where patients would spend a lot of time trying to determine when they would be seen, or where a family member was. Among the other two most popular activities were sleeping and pacing, because there wasn’t much else todo.

Based on the “prospect - refuge” habitat theory, which states that the ability to see but not necessarily be seen is intrinsic to many of man’s survival needs and affects his comfort levels, zoned seating was created to accommodate patients.

“There were times out on the Savannah when we wanted to observe what was out there, but we wanted a sheltered area so we wouldn’t feel vulnerable,” Huelat explained. To that end, seating choices included three distinct areas: the first, being most visible to the staff (Huelat said in follow-up studies for ER One, this area has been selected the most); the second, behind a partial wall and labeled the “social interaction zone” where patients could see the TV but not feel they were in the direct view of staff; and the third zone, most isolated of the three, totally behind a wall. “This zone had the greatest view out of the windows,” Huelat said, “and was the last to fill up. If people chose to sleep, they always slept here where they felt more secluded.” Other interventions include improved acoustics and interactive video. Projected on a wall, and similarly seen in airports and shopping centers, human interaction with it (waving of hands, for instance) can scatter fish in water or balloons in the air, creating an engaging diversion, especially for children who comprise a considerable portion of emergency room populations.

A model for mental health

Based on data acquired from the Pebble Project from three perspectives: neuroscience, design, and facilities operation, MedStar’s Ella Franklin, R.N., managing director of the Center for Building Sciences at the MedStar Institute for Innovation (MI2), determined just how ER One would integrate the findings into its space. According to Franklin, for years the knowledge base for how the built environment impacts patients and caregivers was deficient.

“We were very excited to learn of the Center for Health Design and that it was starting try and aggregate knowledge into data bases – collecting stories and experiences of different hospitals and clinics,” Franklin said of MedStar’s decision to utilize the Pebble Project beginning in 2006. In fact MedStar’s own MI2 serves as a consultancy to other health systems, so that collected data is readily shared.

Among the changes gauged at ER One after December, 2010, following implementation of the positive distractions redesign, were an 80 percent reduction in pacing, patient satisfaction with perceived wait times (the information display on the TV screen factoring in), and “remarkably improved” patient performance once they left the waiting room and presented to physicians, according to Huelat.

Citing reduced mental health benefits in the District even since December, Franklin said ER One is seeing more and more patients with psychiatric needs. As such, two rooms are currently undergoing yet another redesign to achieve the right environment to care for these individuals.

“The times that we’re living in, in terms of healthcare reform and changes in delivery model…makes for an ever-changing model of what our patients need and what regulatory agencies require of us,” Franklin said, indicating ER One’s redesign is a long term, evolving challenge.

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