An A&E department can often feel like a hostile and stressful environment. Time spent waiting to see a clinician can seem a disproportionally large part of the time spent in A&E, so the spaces where people wait and the information provided while they wait will determine a substantial part of people’s reaction to their A&E experience.
Waiting spaces, whether they be the central space near reception or secondary areas near places like x-ray departments or paediatric treatment areas, will be used by patients and visitors at many different stages of the A&E process.
They can be designed to work as a useful tool to reinforce a positive sense of progression through the treatment system. People, particularly mental health users, are shown to be less likely to leave A&E without treatment if they are brought through to wait in a clinical space, as it is perceived as progress.
If only one waiting area is used by the department, it can be difficult for the visitor to know whether they have progressed at all. Zoning the waiting area into different waits can also aid understanding and the feeling of progression.
“A systematic review of violence in emergency departments demonstrated the association between increased violence against staff and longer waiting times.” [Reference: Warwick Medical School: Cooke, Matthew, et.al. (2005) Reducing Attendances and Waits in Emergency Departments: A systematic review of present innovations ]
Patients in A&E may be in pain and under stress, so waiting to be treated can be frustrating. Also, many visitors know that it is a key NHS target to treat people visiting A&E units within four hours, regardless of their condition and of how busy the department is. This puts stress on the department, as patient numbers steadily increase. Designers can help you shape the spaces and provide information to waiting people in order to make waiting areas feel less ad-hoc and more quality care. The secondary waiting area should be a planned and clearly identified space in which it feels like the visitor is being looked after and has a purpose in being there
Visitors can often feel neglected or forgotten while they wait to receive care, particularly if they are waiting for long periods and cannot see staff. This may cause them to feel anxious. By enabling visitors to be able to see staff, they know that they can be seen and consequently remembered, reinforcing the message of contract of care.
Clear sightlines also allows staff surveillance of the waiting area, so they can help if any patient’s condition deteriorates, if visitors are trying to access restricted areas or if their behaviour is not disrupting others around them.
Patients often arrive with friends or family, so appropriate provision should be made for this in the seating area. Furniture should be arranged in relaxed informal groupings to support the waits of both individuals and groups, enabling appropriate levels of intimacy, interaction and support. The ergonomics of the furniture should also facilitate a range of ways to wait, and be flexible enough to provide comfort for those with different injuries.
In airports pedestrian flow analysis – the study of how people move around a space - informs the layout of seating. It can be carefully planned in order to prevent confrontational situations that could lead to violence or aggression. For example, avoid seats being placed directly opposite each other and locating seats immediately outside clinical rooms, or with a view in to triage to maintain the privacy and dignity of patients being treated. Chairs too can be designed to prevent them from being used as weapons, and for JobCentres, they are designed to prevent weapons being hidden in or around them.
“Separating children and adults has the mutual benefits of keeping screaming children away from earshot and ensuring children are safe from witnessing trauma or abusive adults.”
It can be distressing for children to see adults in a very ill or intoxicated state and noisy agitated children can very quickly put those around them on edge. Parents may also react badly to drunk and abusive behaviour around their children. At St Thomas's there is a separate team of children's nurses and doctors (for children under 16) as well as a sperate children's waiting area within A&E. Creating a separate waiting space for young children helps to protect them and prevent scenes of confrontation. For departments that see more than 50,000 patients each year a separate paediatric area is recommended. Typically these projects select a theme which creates a fantasy world and enables stressed and bored children to ‘escape’ from the reality of their visit to hospital.
Lighting and sound design
Lighting levels and calm sounds can help to set the ambience of a space. While natural lighting should be used as much as possible, because it has been shown to promote feelings of wellbeing, it can be helpful to design a variety of lighting schemes for different spaces in the waiting area, so patients can choose where they felt most comfortable to wait.
A&E departments often have lots of hard reflective surfaces which cause sound to travel long distances and this can create a noisy environment. There is strong evidence that noise increases stress in adult patients, for example by quickening heart rates and increasing blood pressure. So installing high performance sound absorbing ceiling tiles and flooring can help reduce noise related stress.
Offering some form of positive distraction will help the wait to feel shorter and less frustrating. Time spent idle is perceived as longer than time spent occupied and entertainment in the form of music, radio or TV playing can help to pass the time.
Free WiFi access can help people occupy themselves with mobile web devices. At Maudsley Hospital an atmosphere of calm has been promoted through the design of the environment, in particular by installing artworks by mental health artists. Views of nature have been found to promote stress recovery, whether this is of real landscape views or through artwork, but abstract artwork should be avoided.
Visitors waiting for treatment will be in a continuous state of anxiety while waiting for their name to be called. This sense of anxiety will continue to grow as the unexpected wait seems to lengthen.
Providing information on waiting times allows the visitor to relax, at least for that period of time, and for example, frees them up to go to the toilet without fear of missing their spot. It is recommended that waiting times are given in generalised terms, for example, it will be more than 30 minutes, or it will be more than two hours.
Dehydration can lead to headaches and irritability so providing free drinking water and a vending machine in the waiting area allows people to maintain physical comfort and a reasonable frame of mind. These should be positioned slightly away from the main seating area and waste bins should also be provided – that are secured to the floor to prevent them being used as weapons.
If any cafes are available, these should also be clearly signposted, with tannoy announcements also being directed to them. Toilets should be provided in close proximity to the main seating area. Intercom links should be installed in the toilets so patients can hear if they’re being called.
Whilst every patient may have a different journey through A&E, it can be helpful to show how far they’re progressed and how much further they have to go before finishing their treatment.
Information on waiting times is delivered digitally at Southampton A&E department where software that ties in with the check-in system allows estimated waiting times to be delivered in realtime. This then has the additional benefit of acting as a prompt for staff, who may have a different perception of current waiting times. Use of real time data is more reliable than staff perceptions of when an emergency department is becoming overcrowded [Reference: Reeder et al., 2003]
It is recognised that successful organisations have the information to act on changes in real time. Live information using statistical process control enables early decisions to be made.
It has been demonstrated that perceived waiting time as opposed to actual time has an impact on visitors overall satisfaction with the service. Allowing people to wait elsewhere within the hospital (cafe, courtyards etc) can help the time to pass more quickly, as well as freeing up space in the waiting area. Visitors can then be notified that they will be seen soon via text message notification, or a vibration pager system, now commonly used by restaurants.
“The real issue in queue management is not only the actual amount of time that the customer waits in a queue, but also the customer’s perception of that wait and his or her associated level of satisfaction” [Reference: Mark M. Davis, M.D., Heineke, J. (1994) Understanding the Roles of the consumer and the operation for better queue management. International Journal of Operations & Production Management, Vol. 14 Issue 5 , p21-34]