Field Notes � Visit to Emory Crawford Long ER 8/26

							Field Notes – Visit to Emory Crawford Long ER 8/26


Pre-visit objectives:
1) Observe the ER environment from the perspective of the patient--as patient advocate and designer
2) Focus on environmental design components in key areas (waiting room, Triage, Acute/Express/CDN:
using the senses to observe lighting, use of color, air circulation, furniture, design features,
ambient/environmental stressors, layout/circulation/flow
3) Identify problem areas and start thinking of potential ways to improve the quality of
experience (i.e. levels of stress and boredom, overall satisfaction of experience, sense of
privacy/dignity, aesthetic qualities, emotional and physical (dis)comfort.

Due to the weather, it was a slower day than usual at the ER, which gave us more time
for direct interaction with RN, although less time to observe the processes in real time.
(Difficult to know what to fix when not seeing the system in action.) But there were
certain residual markers that pointed to problems, and solutions.

Outside ER Entrance
Observation: I noticed a few people outside the ER entrance on cell phones giving
updates to family members.
Suggestion: Provide seating in the fresh air--a break in the monotony of the waiting
room, some additional privacy.

Primary Waiting Room
Observation: Glass partition in waiting room where patients register. No staff in this area.
No plants or vegetation, only a bizarre fish aquarium. Seating is one type of oversized
cushioned chair in loose grouping. One TV screen facing only one side.
Suggestion: Glass is likely for safety reasons, but still a physical barrier between patient
and care. Bring someone out to greet them directly? Create vignettes with variety of
furniture: less waiting room, more living room (to decrease sense of anonymity).

Waiting Area in Triage
Observation: Features a row of oversized, grey “reclining” “leather” chairs (similar style
to family waiting room) where patients receive standing orders/IV/oxygen/blood tests.
Suggestion: Chairs are too big for space, “sickly” color, crowded together, no dividers
between armrests. Do patients feel on top of one another? Do they feel loss of privacy?
Chairs cramped along corridor and can’t fully recline. Padded and comfortable looking,
but wrong scale/too many for space, partially blocking isle. More individuated space in
Express Room area available, but down the hall too far from triage.

Hallways in Acute Area
Observation: Patients on cots in hallways (loss of privacy/dignity, “no room in the inn”
feeling, dehumanizing.
Suggestion: Make-shift privacy curtains in hallways, or will that disrupt circulation?
Better yet, why not utilize some of those empty rooms and beds I saw all around the
unit?!
Acute Care Area
Observation: Heightened noise level – staff conversations, ringing phones, patients
groaning in pain/hacking coughs, sterile, medicinal smell, harsh fluorescent lighting, no
greenery, institutional linoleum flooring, very dehumanizing, frightening experience even
for healthy visitor. There are privacy curtains and doors, but patients in hallway on cots.
Suggestions: Many, but recognize certain lighting and conditions are needed to perform.

CDU (Clinical Decision Unit)
Observation: Where mainly cardiac patients are placed on observation, more cost
effective to keep them than admit as inpatient, less time required (11 hours vs 2 days). No
natural light, no greenery, no color, disorientation, visually cut off from rest of unit and
from family (only one member allowed). Individual rooms: cramped—chair wrong scale
for space, blank walls, no view, no connection to outside world.
Suggestion: Implement scenic pictures/photos, better looking/scaled chair, offer music
channels on TV, reading materials. Educational materials on TV/walls? Is there a way
patient/family can chart progress of tests – like tracking a package --so they don’t feel
like they are in the dark to give them sense of control.

Transition hall between ER and Outpatient Annex
Observation: After making circular trip around ER we walked down pleasant corridor to
exit. Startling contrast to where we just were. This hallway has carpeting, warm-tone
lighting, more pleasing colors, more warm comforting and inviting. More like a hotel
than science lab. Implies better treatment?
Suggestion: Carpeting isn’t realistic, but is there a way to soften the harshness of space?

Overall Observations:
ER is a dehumanizing experience. Everywhere you look you are reminded that you are
sick. Lack of color, limited or nonexistent design features, no individuation, cut off from
family and outside world, unless familiar with floorplan it feels like a maze with limited
signage and orientation measures. No fresh air. No natural light.

Furniture is too large for rooms (or rooms are too small) and not particularly well-
designed or pleasing to the eye. Chairs for family members are same kind as those for
sick. Uniformity tends to de-individuate.

Loss of privacy in hallways and in triage waiting area.

Lighting is often harsh with cool tones rather than a warmer natural spectrum. OK for
high performance areas, not for individual rooms?

Aside: Pediatric areas tend to be more playful, colorful and distracting environments (for
obvious reasons). Just because we are adults doesn’t mean we don’t need pleasing,
nurturing spaces, too.
According to Terra (RN who led tour): number one patient complaintis amount of time
spent waiting (although not clear if she meant for care or for test results).

Her number one complaint as a nurse: patient lack of health education and knowledge
of/access to preventative care. Patients often don’t understand severity of their (often
chronic) condition, how their medications work, or how to take care of themselves. This
corroborates my feeling that we (society) need to address the root problems within our
national health system in concert with structural or system changes/refinements in order
for real change to take effect. Good health starts with the individual, and preventative
care is the best way to help ensure this, with the added domino effect of alleviating the
burden on hospitals/ERs. This of course means contending with larger economic, social
and political forces!

Another interesting issue raised by Terra: misuse of EMS/911– people call in for
ridiculous things and clog system. How to curb?


Overall Suggestions:
More ergonomic, properly scaled, design-friendly furniture solutions.

Natural spectrum lighting with warmer tones. Similar to lighting solutions for those with
Seasonal Affective Discorder, perhaps have lighting fluctuate as if real daylight – softer
in morning and night, brightest at noon to simulate being outside?

Better use of color – on walls, on furniture, alternative to institutional linoleum flooring.

How can we get more fresh air in?? Green spaces for patient/staff restoration?

Are there ways to speed up lab result processing? Is there a time lag between lab knowing
results and nurse delivering them to patient?

Better utilization of space to promote education and self-care, rather than rely on staff to
educate and “scare” patients with info. More evidence of pamphlets, posters, take home
kits, perhaps special programming onto TVs in rooms.
Technology seemed good: color codes, everyone has access, heart rhythms on one
monitor, but are the departments talking? Feels disorienting walking through




Terra:
“Grady is like working in a prison”
When asked what patients complain about most is the amount of time spent waiting,
wanting information/updates. She said people expect drive-through service.

What nurses want: “more access to preventative care”. A frustration I’ve felt about the
healthcare system long before this class – that in order to improve the health of a system,
you have to look to and change the root causes. Everything else is just a bandaid. While
more staffing, more communication always help, no matter how efficient you make the
process you still have to contend with a population that ultimately doesn’t know how to
take care, isn’t educated properly, etc. always be competing with looming, larger social,
economic factors.