Syracuse University
SURFACE
Architecture Thesis Prep
School of Architecture Dissertations and Theses
Spring 2013
Waiting as Remedy: The Architecture of Emergent
Care
Jack McCarrick
Syracuse University
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McCarrick, Jack, "Waiting as Remedy: The Architecture of Emergent Care" (2013). Architecture Thesis Prep. Paper 224.
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WAITING AS REMEDY
THE ARCHITECTURE OF EMERGENT CARE
Jack McCarrick
M.Arch I Candidate
Robert Svetz
Primary Advisor
Brian Lonsway
Secondary Advisor
School of Architecture, Syracuse University, Spring 2013
TABLE OF CONTENTS
2
I
INTRODUCTION
3
II
THE EMERGENCY DEPARTMENT:
TOWARD A NEW LEVEL OF CRISES
5
WAITING AS REMEDY
25
Waiting Room vs. Emergency Room
Diversity of the Waiting Room
III
IV THE CLINIC REVISITED
33
V
37
Herzog & de Meuron: Rehab Basel
OMA: Maggie’s Centre
SPACES OF WAITING
The Retail Store
VI WAITING AS REMEDY REVISITED
45
VII SITE
53
VIII DOCUMENTATION
62
The Urban Hospital
The Suburban Hospital
Bibliography
Figure Credits
INTRODUCTION
Following the final phases of the Patient Protection and Affordable Care Act, an estimated
thirty-two million additional Americans will have access to health insurance in 2019. Despite theoretically having a greater opportunity for access to primary care under the new policy, many of the newly
insured will seek medical attention from emergency departments, regardless of the severity of their
issues. Without consideration for this impending influx of patients, emergency departments have seen
a rise in the volume of incoming patients, becoming overcrowded and leading to a deficiency in patient
care. The current protocol for sorting patients upon their arrival to an emergency department stratifies
patients into a range of acuities with respective wait times based on the urgency or appropriateness of
their visits. With a considerable number of visits not receiving immediate attention or care, many
patients are displaced to the waiting room, where they potentially spend a greater portion of time than
they do receiving treatment once administered to an emergency room.
Considering the discrepancy between the time spent waiting and the time spent receiving care,
the waiting room potentially has a greater impact on patient satisfaction, and in turn patient treatment,
than the emergency rooms themselves. How can the spaces of medical waiting provide care for a
range of urgencies with varying wait times? While the stark sobriety of examination and treatment
rooms has come to represent an expected level of clinical expertise, the waiting room has the potential
to operate with multiple formal and programmatic expressions to administer care accordingly to the
range of incoming cases with various biological needs and psychological desires -- from medical
education and self diagnosis to emergent care to implied care.
Between the years of 1997 and 2007, the number of emergency department visits increased by
twenty-three percent.¹ This increase in visits has led to the congestion of emergency departments, with
over ninety percent of hospitals reporting overcrowding (zero available beds, holding patients in
hallways, long waits).² Recent investigations have already considered operational improvements and
changes to emergency department layouts in order to better accommodate and fast track the different
levels of severity for incoming cases³, however the role of the waiting room has fallen to the wayside.
Contemporary investigations of high-end architecture into healthcare, such as Herzog & de Meuron’s
Rehab Basel, have primarily focused on isolated care and treatment centers, considering the role that
landscape and materiality play in the healing process. However, these projects are typically detached
from an urban context with little or no sense of urgency to the care provided.
In order to research the potential of the waiting room, the current condition of the emergency
4
department must first be examined. Patient volumes of different acuities and their respective waiting
times will be researched to determine the necessary space allocation for areas of waiting and areas of
care.
Next, past examples of waiting spaces must be examined. These spaces should not be strictly
limited to medical programs, but rather they should come from other fields where the act of waiting has
been thoroughly considered or exploited to enhance or alter the desires of the users. The various
waiting experiences of commercial spaces will be primarily researched.
Finally, the range of programs necessary for fulfilling the biological needs and psychological
desires of the various patient acuities will be determined.
While the Patient Protection and Affordable Care Act provides insured care to a much larger
group of Americans, it has the potential to reduce the quality of care provided to patients, particularly in
emergency departments. This research will argue for a reimagining of the emergency department in
which there is a definitive split between the architectural implications of spaces where technical care is
administered for biological needs (the emergency room) and spaces where primary and implied care
can satisfy the psychological desires of inappropriate patients (the waiting room) in order to better
serve appropriate patients.
Notes
1. Congressional Budget Office, “Updated Estimates for the Insurance Coverage Provisions of the
Affordable Care Act,” (March 2012): 3.
2. Richard Niska, Farida Bhuiya, and Jianmin Xu, “National Hospital Ambulatory Medical Care Survey:
2007 Emergency Department Summary,” National Health Statistics Reports 26 (August 2010): 3.
3. Shari J. Welch, “Using Data to Drive Emergency Department Design: A Metasynthesis.” HERD :
Health Environments Research & Design Journal 5, no. 3 (2012): 26-45.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
WAITING ROOM VS. EMERGENCY ROOM
From the time a patient is taken to the emergency department to when they first receive medical attention, there is a drop in the level of care received as he/she experiences the waiting room. Due to a lack
of primary care providers, which is expected to only get worse, and an obligation to accept any incoming patient, emergency departments receive a large number of inappropriate cases daily, causing
congestion and increased waiting times for urgent and non-urgent cases alike. While both groups
(appropriate and inappropriate) seek clinical care in the emergency room, they are, more often than
not, first confined to the waiting room -- an area of medical limbo where care ceases to exist. Despite
this distinct separation between the emergency room and the waiting room, the two receive the same
formal expression of clinical sobriety. Furthermore, the waiting room provides a single waiting experience for all patients regardless of the severity of each case. It would seem that the spaces of waiting
could take a more involved role in the administration of care through various programmatic and formal
operations that address the wellness of both urgent and non-urgent cases.
6
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
8
<5% of all Physicians²
22.9% Private Insurance³
50% Other Source of Care4
28% Emergency Departments¹
51.9% Public Insurance³
30%²
354 Million
Annual Visits
for Acute Care¹
50% No Other Source of Care4
29.4% Uninsured³
42% Personal Physicians¹
Deficit of Primary Care Physicians
65%²
Current Condition 2013
Future Condition 2025
20% Specialists¹
7% Outpatient Departments¹
209,000
16,000
52,000
Notes
1. Pitts, Stephen R; Carrier, Emily R; Rich, Eugene C; Kellermann, Arthur L.
“Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's Office.”
Health Affairs 29: 9. 2010. 1620-1629.
2. Sanders, Bernard.
“Primary Care Access: 30 Million New Patients and 11 Months to Go:Who Will
Provide Their Primary Care?” Subcommittee on Primary Health and Aging.
January 29, 2013.
3. Garcia, Tamyra Carroll; Bernstein, Amy B; Bush, Mary Ann.
“Emergency Department Visitors and Visits: Who Used the Emergency Room in
2007?” NCHS Data Brief 38. 2010.
4. Gindi, Renee M; Cohen, Robin A; Kirzinger, Whitney K.
“Emergency Room Use Among Adults Aged 18–64: Early Release of Estimates
From the National Health Interview Survey, January – June 2011.” Center for
Disease Control. 2012.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
10
EMERGENCY DEPARTMENT FLOWCHART
Patient arrives by
ambulance or
helicopter
Patient arrives as
walk-in
Triage: the sorting of patients
according to the urgency of
their need for care
DIVERSITY OF THE WAITING ROOM
WAITING
IMMEDIATE
EMERGENT
URGENT
SEMIURGENT
Physician
Examination
Additional
Examination
(X-Ray, MRI)
NONURGENT
As patients come into the emergency department, they are filtered through triage (the sorting of
patients according to the urgency of their need for care) creating a stratification of patients with respective waiting times from “non-urgent” (needing to be seen between 2 and 24 hours) to “immediate”
(needing to be seen in less than one minute). With 42% of patient acuities categorized as a “semiurgent” or “non-urgent”, a significant portion of the waiting room becomes occupied by inappropriate
cases with no true need for emergency facilities or the more specialized care they offer. Conversely,
“emergent” and “urgent” cases (appropriate cases) comprise 51% of emergency department visits, with
average waiting times of 51.2 minutes and 63.3 minutes respectively.¹ While these appropriate cases
have relatively little time to spare and a true need for the emergency room, inappropriate cases have
time to wait but typically no access primary care, or they lack general medical knowledge.
Treatment
Received
Discharge
Notes
Home
Inpatient
Unit
1. Hing, Esther, M.P.H.; Bhuiya, Farida, M.P.H.
“Wait Time for Treatment in Hospital Emergency Departments: 2009”
NCHS Data Brief 102. 2010.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
MEAN EMERGENCY DEPARTMENT WAIT TIME BY URGENCY
+ PERCENTAGES OF PATIENT ACUITIES¹
PERCENTAGES OF PATIENT ACUITIES:
United States, 2009¹
41%
10%
2%
4%
7%
35%
12
1
IMMEDIATE: Needing to be seen in less than 1 minute
2
EMERGENT: Needing to be seen within 1–14 minutes
3
URGENT: Needing to be seen within 15–60 minutes
4
SEMIURGENT: Needing to be seen within 1–2 hours
5
NONURGENT: Needing to be seen between 2 and 24 hours
6
NO TRIAGE: No triage system was used
10
20
30
40
50
60
MEAN EMERGENCY DEPARTMENT WAIT TIME FOR TREATMENT,
BY URGENCY OF PATIENT CARE:
United States, 2009¹
28.9 min
IMMEDIATE
EMERGENT
51.2 min
URGENT
63.3 min
SEMIURGENT
58.7 min
53.5 min
NONURGENT
NO TRIAGE
38.2 min
Notes
1. Hing, Esther, M.P.H.; Bhuiya, Farida, M.P.H.
10
20
30
40
Mean Wait Time in Minutes
50
60
70
80
“Wait Time for Treatment in Hospital Emergency Departments: 2009”
NCHS Data Brief 102. 2010.
70 min
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
TIME FROM REGISTRATION/TRIAGE TO PHYSICIAN ASSESSMENT
vs TIME FROM PHYSICIAN ASSESSMENT TO DISCHARGE:
Canada, 2005¹
3%
14
UPSTATE MEDICAL UNIVERSITY
EMERGENCY DEPARTMENT
97%
Trauma
Exam
Exam
Exam
Treat
Immediate
Triage Exam
65%
Scan
Reception
Waiting
Room
35%
Exam
Exam Exam
Exam
Exam
Waiting
Room
Psych
Exam
Exam Exam
Scan
Exam
Exam
Exam
Exam
Exam
Exam
Urgent
UP
2012-960
UP
X-Ray
66%
X-Ray
33%
Nonurgent
Notes
1. Canadian Institute for Health Information.
Time From Registration/Triage to Physician Assessment
Time From Physician Assessment to Discharge
“Understanding Emergency Department Wait Times: Who is Using Emergency
Departments and how Long are They Waiting.”
2005.
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
16
EMERGENCY DEPARTMENT FLOWCHART
Patient arrives by
ambulance or
helicopter
Patient arrives as
walk-in
Triage: the sorting of patients
according to the urgency of
their need for care
WAITING
IMMEDIATE
EMERGENT
URGENT
SEMIURGENT
Trauma
NONURGENT
Exam
Exam
Scan
Scan
22-yo male involved in a motocycle accident brought to the hospital by ambulance. The patient
has an exposed bone, a potential severed artery, and loss of consciousness. He is rushed
immediately to the trauma room.
After stopping the bleeding, setting the bone and temporarily stabilizing him, the patient
is taken to have a CT-Scan performed to insure there is no unseen internal bleeding or other
bone trauma.
UP
2012-960
UP
The CT-Scan reveals nothing new, and the patient is relocated to the intensive care unit to be
closely monitored in order to prevent further deterioration.
CASES
1. Major trauma such as a motorcycle wreck with exposed bone and loss of consciousness
2. Respiratory failure from drug overdose or overwhelming pneumonia
3. Cardiopulmonary arrest - typically an elderly patient
4. Major bleeding from a severed artery
5. Active seizure in an epileptic
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
18
EMERGENCY DEPARTMENT FLOWCHART
Patient arrives by
ambulance or
helicopter
Patient arrives as
walk-in
Triage: the sorting of patients
according to the urgency of
their need for care
WAITING
IMMEDIATE
EMERGENT
URGENT
SEMIURGENT
Trauma
Triage Exam
NONURGENT
55-yo female is driven by a relative to the hospital and checks in with the reception desk,
complaining of chest pain, sweating and nausea.
The patient is taken to triage for clarification of symptoms and a check of vital signs. Following
the check, the patient is directed to the first waiting room, where she can be monitored by the
receptionist.
Exam
Waiting
Room
Scan
Exam Exam
Exam
Exam
Exam
Exam Exam
Exam
Exam
After waiting for 20 minutes, the patient is admitted to an examination room with a high level of
visibility. Following a physician consultation, an EKG-Test is administered to check for a
heart attack
Scan
Exam
Exam Exam Exam Exam
UP
2012-960
UP
The EKG-Test comes back negative, and the physician suspects a possible pulmonary
embolism. The patient is given a CT-Scan to check for a blood clot.
The CT-Scan reveals a clot and the patient is taken to the intensive care unit to be monitored
and treated for the clot.
CASES
1. Chest pain, sweating and nausea
2. Known heart attack that needs a cardiac procedure
3. Stroke - patient suddenly loses speech or strength and needs emergent procedure
4. High fever and shakes in elderly patient
5. Floppy child who is minimally responsive and with fever
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
20
EMERGENCY DEPARTMENT FLOWCHART
Patient arrives by
ambulance or
helicopter
Patient arrives as
walk-in
Triage: the sorting of patients
according to the urgency of
their need for care
WAITING
IMMEDIATE
EMERGENT
URGENT
SEMIURGENT
Trauma
Triage Exam
NONURGENT
34-yo male arrives by car and reports to the receptionist. The patient suffered from a deep cut
to his arm from an accident at a construction site. The patient is taken into triage.
The triage nurse determines that there is no arterial bleeding. The patient’s arm is bandaged,
he is given pain medication, and he is directed to the waiting room and ordered not to wander
off.
Exam
Waiting
Room
Scan
Exam Exam
Exam
Exam
Exam
Exam Exam
Exam
Exam
Following a 1-hour wait, the patient is taken into an examination room, where his arm is further
examined by a physician. After noticing no significant complications, the arm is sutured.
Scan
Exam
Exam Exam Exam Exam
UP
2012-960
UP
The patient is sent home with a prescription for pain medication and antibiotics. He is to see
a physician after two weeks to have the sutures removed, or sooner if the cut becomes
infected.
CASES
1. Deep cut without arterial bleeding
2. Abdominal pain with nausea and vomiting
3. Migraine headache with severe head pain
4. Altered mental status from drug overdose but no current need to be on respirator
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
22
EMERGENCY DEPARTMENT FLOWCHART
Patient arrives by
ambulance or
helicopter
Patient arrives as
walk-in
Triage: the sorting of patients
according to the urgency of
their need for care
WAITING
IMMEDIATE
EMERGENT
URGENT
SEMIURGENT
Trauma
thinking that her ankle is broken from an accident in a soccer game. She is sent to triage.
Waiting
Room
After waiting for 2 hours, the patient is brought back to a larger examination space with curtain
partitions. The ankle is checked by a physician who suspects a simple sprain but calls for an
Waiting
Room
Exam
Exam
Scan
Exam Exam
Exam
Exam
The triage nurse determines that the ankle could have a minor fracture. The patient is sent
to the waiting room until an examination space opens up.
Exam
Triage Exam
NONURGENT
18-yo female is taken to the emergency department by car and checks in with the receptionist,
Exam
Exam
Exam Exam
Scan
Exam
Exam
Exam
Exam Exam Exam Exam
X-Ray to make sure.
UP
2012-960
UP
The patient is taken to the X-Ray room to have her ankle imaged.
X-Ray
The X-Ray reveals no fracture, and the patient is sent home after being told to keep weight off
of her ankle.
CASES
1. Sprained ankle or simple fracture
2. Simple cut that needs suturing
3. Pregnant patient with gynecological complaints
4. Kidney stones
X-Ray
THE EMERGENCY DEPARTMENT: TOWARD A NEW LEVEL OF CRISES
24
EMERGENCY DEPARTMENT FLOWCHART
Patient arrives by
ambulance or
helicopter
Patient arrives as
walk-in
Triage: the sorting of patients
according to the urgency of
their need for care
Trauma
Exam
Exam
Exam
Treat
WAITING
IMMEDIATE
EMERGENT
URGENT
SEMIURGENT
Triage Exam
NONURGENT
Exam
Reception
6-yo female is brought in by her father, who tells the receptionist that his daughter has strep
throat. The daughter is quickly checked in triage and then told to have a seat in the waiting
room.
Waiting
Room
Waiting
Room
Psych
Exam Exam
Exam
Exam
After waiting for 4 hours, the patient is brought to a larger examination space, divided by
curtains. A physician checks the patient and determines that the sore throat is most likely
due to allergies.
Scan
Exam
Exam Exam
Scan
Exam
Exam
Exam
Exam Exam Exam Exam
The patient is sent home and told to get rest.
UP
2012-960
UP
X-Ray
CASES
1. Child with "strep throat" or ear infection
2. Anyone who just feels bad
3. Dental problems such as infection or broken tooth
4. Psych case threatening something
X-Ray
WAITING AS REMEDY
Trauma
Exam
26
Exam
Exam
Treat
Triage Exam
Waiting
Room
Scan
Psych
Exam Exam
Exam
Exam
Waiting
Room
Exam
Exam
Exam Exam
Scan
Exam
Exam
Exam
Exam Exam Exam Exam
X-Ray
X-Ray
Despite having a relatvely large amount of square footage devoted to a relatively small portion of
patients in the emergency department who are categorized as either immediate or urgent, these groups
still experience longer wait times than the Center for Disease Control deems appropriate, putting them
at great risk. Conversely, semiurgent and nonurgent patients are seemingly better-served than moreemergent cases in the emergency department, experiencing average wait times that are less than their
appropraite wait times. Considering the lack of need for emergency facilities by such a significant
portion of the waiting population, it would seem that the waiting room could be expanded to facilitate
needs for primary care or general medical education (promoting self diagnosis). While inappropriate
cases seek a waiting space that would make them more aware or knowledgeable of their current
medical condition, truly emergent cases desire a space that could imply care and assurance in the
absence of the emergent treatment they need.
WAITING AS REMEDY
28
MEAN EMERGENCY DEPARTMENT WAIT TIME FOR TREATMENT,
BY URGENCY OF PATIENT CARE:
United States, 2009¹
Scan
Exam
Trauma
831 sq ft 11.7%
Exam
IMMEDIATE
27.9 min
28.9 min
37.2 min
EMERGENT
Scan
51.2 min
3.3 min
URGENT
SEMIURGENT
Exam
63.3 min
Waiting
Room
Exam
58.7 min
468 sq ft 6.6%
53.5 min
NONURGENT
664 sq ft 9.4%
Exam Exam
Waiting
Room
Exam
10
20
30
40
50
60
70
80
Exam Exam
Mean Wait Time in Minutes
Exam
740 sq ft 10.4%
Exam
Exam
Exam Exam Exam Exam
PERCENTAGES OF PATIENT ACUITIES:
United States, 2009¹
X-Ray
X-Ray
1398 sq ft 19.7%
1
IMMEDIATE: Needing to be seen in less than 1 minute
Exam
809 sq ft 11.4%
Exam
Treat
2%
(21.1%)
7%
(35.8%)
10%
(40.2%)
41%
(24.9%)
4%
35%
(43.1%)
2
EMERGENT: Needing to be seen within 1–14 minutes
Psych
3
URGENT: Needing to be seen within 15–60 minutes
4
SEMIURGENT: Needing to be seen within 1–2 hours
5
NONURGENT: Needing to be seen between 2 and 24 hours
Exam
294 sq ft 4.1%
Notes
1881 sq ft 26.5%
Total = 7088 sq ft
1. Hing, Esther, M.P.H.; Bhuiya, Farida, M.P.H.
6
“Wait Time for Treatment in Hospital Emergency Departments: 2009”
NO TRIAGE: No triage system was used
NCHS Data Brief 102. 2010.
WAITING AS REMEDY
Trauma
30
Scan
Exam
Trauma
Scan
Exam
Scan
Scan
Exam
Exam
Exam Exam
Exam Exam
Exam
Exam
Waiting
Room
Exam
Waiting
Room
Exam
EMERGENT
CARE
EMERGENT
CARE
Exam
Exam Exam
Exam
Exam
Exam Exam
Exam
Exam
Exam
Waiting
Room
Exam
Exam
Exam Exam Exam Exam
Exam
Exam
Exam Exam Exam Exam
Exam
Exam
Exam
Treat
X-Ray
Psych
X-Ray
Exam
NON-EMERGENT
CARE
Treat
WAITING
ROOM
X-Ray
NON-EMERGENT
CARE
Psych
WAITING AS REMEDY
IMMEDIATE
32
EMERGENT
BIOLOGICAL
NEED
URGENT
SEMIURGENT
NONURGENT
PSYCHOLOGICAL
DESIRE
THE CLINIC REVISITED
34
HERZOG & de MEURON: REHAB BASEL
Clinic Type: Center for Spinal Cord and Brain Injury
Location: Basel, Switzerland
Year: 2002
SENSORIAL TREATMENT
CLINICAL TREATMENT
The rehabilitation center aims to create a distinct split between spaces where clinical, more technical
care is administered and those where sensorial treatment is provided. Shifts in materiality and form
distinguish between these two zones, allowing for patients to escape the clinical feel typical of
rehabilitation centers. Wood in the patient rooms is contrasted with zones of greenery interspersed in
plan and a concrete pyramid, celebrating the rehabilitation pool -- where freedom of movement is given
back to the patients.
THE CLINIC REVISITED
36
OMA: MAGGIE’S CENTRE
Clinic Type: Cancer Care Center
Location: Glasgow, Scotland
Year: 2008
The cancer care center acknowledges the various needs and social desires of patients coping with
cancer by creating a series of continuous spaces ringed around a central garden. Each space is
kinked off access from the next to create distinct zones for the different desires of the patients while
preserving continuity. Furthermore, material (concrete and glass to wood) and formal changes
(rectilinear to curvilinear) create a distinct space of isolation that offers a phenomenological escape.
SPACES OF WAITING
38
THE RETAIL STORE
The act of waiting is manifested in various spatial layouts dependent on a particular retail store’s target
audience and their respective desires. Ranging from the generic big box store to the apple store,
waiting can be seen as an opportunity to increase desire and consumption, or it is eliminated
altogether, viewed as a suppressant to desire. Big box retail creates a distinct zone for acquiring
particular items of desire separate from the zone of waiting, the checkout. Alternatively, IKEA combines
waiting with desire, forcing the customer to walk through all mock-up rooms before finally being able to
select their item of choice, constantly driving desire up through the act of waiting to leave. Apple
replaces zones of waiting with mobile employees, filling a single space with overlapping nodes of
desire, increasing consumer interest until they leave, never allowing for a drop in desire.
CONSTRUCTED FACTORS
CONSUMER DESIRE
TIME SPENT SHOPPING
INTERCEPTION
SIGNAGE
PHYSICAL INTERACTION WITH PRODUCT
Notes
TIME SPENT WAITING
¹
1. Underhill, Paco
Why We Buy: The Science of Shopping. 36-39, 58-59.
Simon & Schuster. New York: 1999.
SPACES OF WAITING
40
BIG BOX STORE:
Consumers enter the big box store with desire at its maximum level, already aware of the items they
will purchase. Signage distributes these items of desire in space, determing the path of the customer.
Initial consumer desire decreases incrementally as each item is acquired, while the aisles of the store
create constructed zones of desire for the consumer to pass through, creating a new list of desires.
The process ends in the checkout line, a distinct zone of waiting where desire drops.
4
3
4
5
3
5
6
6
2
2
8
8
1
1
7
DESIRES
7
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
SIGNAGE
TIME SPENT SHOPPING
TIME SPENT WAITING
Initial Consumer Desire
Constructed Desire
Waiting
Service
SPACES OF WAITING
42
IKEA
Upon entering IKEA, customers are directed to the second floor, where they occupy rooms of desire.
Any individual items of desire are showcased with complementary items, creating variations on
complete rooms. Regardless of the customer’s need to view other rooms, he/she is required to
progress through all rooms, increasing desire through the act of waiting to leave and checkout.
PHYSICAL INTERACTION WITH PRODUCT
TIME SPENT SHOPPING
TIME SPENT WAITING
Initial Consumer Desire
Constructed Desire
Waiting
Service
SPACES OF WAITING
44
APPLE STORE
Apple’s transparent facade forces desire on passersby, drawing them in regardless of their intention to
purchase. Products are distributed across an open space, creating overlapping nodes of desire.
Waiting is replaced by mobile employees, eliminating any space or period of downtime, allowing desire
to never fall.
SIGNAGE
SIGNAGE
PHYSICAL INTERACTION WITH PRODUCT
TIME SPENT SHOPPING
INTERCEPTION
Initial Consumer Desire
Constructed Desire
Waiting
Service
WAITING AS REMEDY REVISITED
46
4
3
5
6
2
8
1
7
IMMEDIATE
Biological Need: Emergent Care / Treatment
Psychological Desire: Reassurance in the waiting room
Ability to Wait: Low
EMERGENT
URGENT
SEMIURGENT
Biological Need: Urgent Care
Psychological Desire: Comfort / Reassurance in the waiting room
Ability to Wait: Medium
Biological Need: Primary Care
Psychological Desire: Medical Knowledge + Attention
Ability to Wait: High
NONURGENT
WAITING AS REMEDY REVISITED
48
NONURGENT
SEMIURGENT
URGENT
DECREASING URGENCY
EMERGENT
IMMEDIATE
Biological Need
Psychological Desire
Waiting
WAITING AS REMEDY REVISITED
50
NONURGENT
SEMIURGENT
URGENT
DECREASING URGENCY
EMERGENT
IMMEDIATE
Biological Need
Psychological Desire
Waiting
WAITING AS REMEDY REVISITED
52
WAITING AS PURE DESIRE / DISTRACTION
GALLERY OF MEDICAL KNOWLEDGE + SELF DIAGNOSIS
IKEA OF WAITING ROOMS + URGENT + PRIMARY CARE
WAITING ROOM + EMERGENCY CARE
Biological Need
Psychological Desire
Waiting
The emergency department is reimagined as a stratified system that progresses from the highest level
of biological need for immediate and emerg``ent patients to the lowest level of biological need and the
highest level of psychological desire for nonurgent and semiurgent patients. At each level, the act of
waiting is altered to accomodate the desires of the level’s corresponding patients. At one level, desire
is manifested in various waiting rooms, providing comfort or reassurance to a range of patients through
differences in materiality or form. At the next level, desire is dispersed into a field of nodes to create a
gallery of medical knowledge and assisted self diagnosis, to assuage the psychological uncertainty of
inappropriate patients who come to the emergency department. At the highest level, waiting is transformed into pure desire or distraction, in an attempt to completely remove a patient from the medical
setting as they wait to be seen by a health professional.
SITE
54
ST. LUKE’S HOSPITAL¹
1. 76 Minutes
2. 6% of Patients Left
MOUNT SINAI HOSPITAL¹
1. 46 Minutes
2. 3% of Patients Left
METROPOLITAN
HOSPITAL CENTER¹
1. 44 Minutes
2. 5% of Patients Left
LENOX HILL HOSPITAL¹
1. 56 Minutes
2. 0% of Patients Left
NEW YORK
PRESBYTERIAN HOSPITAL¹
BETH ISRAEL
MEDICAL CENTER¹
1. 93 Minutes
THE URBAN HOSPITAL
The urban hospital provides the possibility for waiting to take place outside of the waiting room if a
patient is in the condition to leave and return at a later time. In Manhattan, individual hospitals can be
identified for an intervention based on their average wait times. Hospitals in urban conditions, typically
take the form of towers that occupy an entire block, with a significant portion of the ground floor
devoted to the emergency department. A reimagining of an urban emergency department would
require a sectional reorganization of space, in which the ground floor would still be devoted to emergent cases, while other hospital functions would be shifted upwards to create space for nonemergent,
inappropriate cases.
2. 6% of Patients Left
1. 76 Minutes
2. 6% of Patients Left
NYU HOSPITALS CENTER¹
1. 46 Minutes
2. 1% of Patients Left
NEW YORK DOWNTOWN HOSPITAL¹
1. 32 Minutes
2. 1% of Patients Left
1. Average time patients spent in the emergency department
before they were seen by a healthcare professional
2. Percentage of patients who left the emergency department
before being seen
Notes
1. Medicare.gov
Hospital Compare Data: Timely Emergency Department Care
2013.
SITE
56
ASHEVILLE, NC
THE SUBURBAN HOSPITAL
As suburban hospitals typically develop piecemeal through the addition of appendages, they would
likely be the suitable testing ground for a new type of emergency department. Furthermore, the availability of neighboring land to the campus allows for the consideration for a reorganization in plan as
well as in section. The suburban hospital typically lacks neighboring attractions, requiring all waiting to
take place within the hospital itself, however, this could motivate the design to more critically engage
the act of waiting within a hospital.
MISSION HEALTH SYSTEM
SITE
58
ST. JOSEPH CAMPUS
CANCER CENTER
MEMORIAL CAMPUS
VE
EA
ST
LL
WE
R
MO
LT
BI
DO
Mc
PROPOSED
SITE
60
SITE
EXISTING
EMERGENCY
DEPARTMENT
SOUND
#3
RAD
#1
SOUND
#2
RAD
#2
RAD
#3
RAD
#5
E RM
RESOURC
#6
CT #3
OR.#3
OR.#2
CT #1
CT #2
G265.02
G265.03
OR.#1
RAD
#13
RAD
PACS
#15
ROOM
RAD
#16
NTIONAL
INTERVE
#2
NTIONAL
INTERVE
UP
#4
NTIONAL
INTERVE
#1
PLTTS
SHAFT
TUBE
DOCUMENTATION
62
BIBLIOGRAPHY
FIGURE CREDITS
Canadian Institute for Health Information. “Understanding Emergency Department Wait Times: Who is
5, 31, 32, 61 - Gim, Gabriel. Gabe's Doctrine of Atheistic Philosophy (blog).
Using Emergency Departments and how Long are They Waiting.” (2005).
Congressional Budget Office. “Updated Estimates for the Insurance Coverage Provisions of the
Affordable Care Act.” (March 2012): 3.
Garcia, Tamyra Carroll, Amy B Bernstein, and Mary Ann Bush. “Emergency Department Visitors and
Visits: Who Used the Emergency Room in 2007?” NCHS Data Brief 38. (2010).
Gindi, Renee M, Robin A Cohen, and Whitney K. Kirzinger. “Emergency Room Use Among Adults Aged
18–64: Early Release of Estimates From the National Health Interview Survey, January – June
2011.” Center for Disease Control. (2012).
Hing, Esther and Farida Bhuiya. “Wait Time for Treatment in Hospital Emergency Departments: 2009.”
NCHS Data Brief 102. (2010).
Medicare. Hospital Compare Data: Timely Emergency Department Care.
http://gabrielgim.blogspot.com/2010/09/island-hospital.html#
5, 31, 32, 61 - Destiny Surgical Prodcuts. http://www.destinysurgical.com/product-installs/er/
33, 51 - Naomi, Shibata. Herzog & de Meuron, 2002-2006. Tokyo: A+U Publishing Co, 2006.
35, 51 - Designboom. “OMA: Maggie’s Gartnavel.” http://www.designboom.com/architecture/omamaggies-gartnavel/.
37, 40 - Speicher, Susan. Hugs and Money (blog). http://susieecoolmarketing.blogspot.com/
39 - NBC News. “Home Depot hopes price cuts repair image.”
http://www.nbcnews.com/id/26744120/ns/business- retail/t/homedepot-hopes-price-cuts-repairimage/#.UYINvMo4FWc
40 - Target Addict (blog). http://target-addict.blogspot.com/2010_02_01_archive.html
41, 42 - Yiu, Betty. 360 Design Inspiration. http://bettyiu.wordpress.com/
http://www.medicare.gov/hospitalcompare/results.aspx#loc=NEW%20YORK%20CITY%2C%
41 - Miletieva, Kristina. flickr. http://www.flickr.com/photos/kpucu/776775341/
20NY&lat=40.7143528&lng=-74.0059731. 2013.
41 - Lovin' Life (blog). http://www.lovelifeblog.info/p/about-me.html
Niska, Richard, Farida Bhuiya, and Jianmin Xu. “National Hospital Ambulatory Medical Care Survey:
2007 Emergency Department Summary.” National Health Statistics Reports 26 (August 2010):3.
Pitts, Stephen R et al. “Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's
Office.” Health Affairs 29, no. 9. (2010): 1620-1629.
Sanders, Bernard. “Primary Care Access: 30 Million New Patients and 11 Months to Go: Who Will
Provide Their Primary Care?” Subcommittee on Primary Health and Aging. January 29, 2013.
Underhill, Paco. Why We Buy: The Science of Shopping. New York: Simon & Schuster, 1999.
Welch, Shari J. “Using Data to Drive Emergency Department Design: A Metasynthesis.” HERD : Health
Environments Research & Design Journal 5, no. 3 (2012): 26-45.
42 - IKEA Inside (blog). http://ikeainside.blogspot.com/
42 - Serenity Now (blog). http://www.serenitynowblog.com/2012/01/ikea-decorating-inspiration-our.html
42 - Exploring Asia Since 2003 (blog). http://randomwire.com/ikea-shenzhen
42 - Mom in Chapel Hill (blog). http://www.mominchapelhillnc.com/category/shopping-boutiques/page/4
43, 44- Sortol. http://www.sortol.com/gg/109738.htm
44, 51 - Applefobia (blog). http://applefobia.blogspot.com/2013_01_01_archive.html
44 - House Sensation. http://www.housesensation.it/sense/2012/11/qual-e-il-peggior-nomedipendente-della-apple-eccolo-svelato/
44 - Architetto Digitale. http://www.architettodigitale.it/negozi/50-architettura-negozi-apple.html
51 - The Spotted Pig. http://thespottedpig.com/?page_id=236
51 - Hashtag NYC (blog). http://hashtagnyc.wordpress.com/