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Glimpsing into the ER of the future

Like every U.S. hospital emergency room, the one at Washington Hospital Center is overwhelmed -- on any day patients lie on gurneys in the corridor, hooked up to monitors. Others wait for hours to see a doctor.
/ Source: Reuters

Like every U.S. hospital emergency room, the one at Washington Hospital Center is overwhelmed — on any day patients lie on gurneys in the corridor, hooked up to monitors. Others wait for hours to see a doctor.

But next door to the old and crowded emergency department is a bright oasis of calm. Backed by a $2.2 million federal grant and drawing on 600 different ideas from a task force of experts, the hospital is putting in what emergency department chairman Dr. Mark Smith hopes will be a first draft of the emergency department of the future.

It is designed to handle a sudden influx of mass casualties from a natural disaster, biological attack or a pandemic, and at the same time prevent the ongoing disaster of hospital-acquired infections.

"Our goal is to build a center as a demonstration facility — a model test bed for the rest of the country," Smith said in an interview.

Preparing for the worst
"The risk of terrorism is real. The likely targets are going to be New York City and Washington."

On September 11, 2001, all the people injured in the Pentagon when a hijacked jet crashed through its walls were treated at Washington Hospital Center, the largest trauma center in the area and the region's specialty burn center.

"We recognized that we have a very, very special responsibility. We are a national security asset," Smith said as he gave a tour of the unfinished section. The hospital is owned by nonprofit MedStar Health.

The new facility must work as an emergency room day-to-day, but must quickly accommodate three to five times the usual number of patients. It must resist an invasion of germs from inside, and withstand attacks from the outside.

More than 115 million people visited emergency rooms across the United States in 2005, according to the U.S. Centers for Disease Control and Prevention — a 20 percent increase over the previous decade.

But between 1995 and 2005, the number of ERs dropped by 9 percent, from 3,795 from 4,176.

Several reports show there is no surge capacity in U.S. hospitals, and predict that even a bad flu season, let alone a pandemic of avian influenza, will completely overwhelm them.

With 10 new patient bays and two movable nurses' stations, this new ER will fill an immediate need, as well as having a built-in capacity to deal with surges.

Unlike like most emergency department treatment bays, which are usually barely larger than a closet, these are spacious and airy. Each has three beds, but in daily use a patient will ideally be alone.

Sliding glass doors can convert each bay into a sealed isolation unit, with negative pressure systems to keep infections from spreading, and outfitted with a hydrogen peroxide gas disinfection system.

Providing some breathing room
The doors can rotate out to make the bay fit two more beds, accommodating five patients at once, although not under sealed conditions.

That means this section of the emergency department can accommodate 50 patients without anyone being in a corridor.

The air pumped into and out of the rooms can be filtered and sterilized using ultraviolet light. A typical 30-bed emergency department has two negative pressure rooms. This one will have 10, Smith said.

"What is going to work for smallpox and plague is going to work for pandemic flu," Smith said.

The air comes in from above, flows across the patient beds and is sucked out near ground level in a corner, to protect staff by swooping germs away from them.

A typical hospital room has eight to 10 air changes an hour. These fill with fresh air 15 to 18 times an hour and can be ramped up to 25 exchanges an hour under negative pressure conditions to foil airborne viruses and bacteria.

Such measures can be used when patients are being treated for highly infectious respiratory diseases such as severe acute respiratory syndrome, which infected 8,000 people globally and killed 800 after it emerged suddenly in China in 2003.

Many casualties were hospital workers.

Improving infection control
But a second experiment is under way at the same time.

"Hospitals haven't improved infection control," says Ella Franklin, a registered nurse with a degree in public health who is the project manager.

The CDC reports that staphylococcus and other bugs that thrive in hospitals kill 90,000 people a year at a cost of $4.5 billion.

Franklin has turned the new ER into an experiment testing design, procedures and new materials to see if they can do better.

"We have the knowledge in other industries and we haven't done it in healthcare," she said. "We know from the food industry that a non-porous Corian surface doesn't support microbial growth."

She runs her hand along a blue-green strip of Corian, made by DuPont Co, just above waist level on the wall. "This is where people will put their hands to steady themselves," she said.

Every time a hand touches a wall, germs can transfer and the oils on a human hand help them stick. They can burrow into tiny crevices and create biofilms -- living colonies than are maddeningly hard to eradicate.

"I can tell my environmental services staff 'make sure you get this strip' because we know that is where people put their hands," Franklin said.

Control panels on the monitors in the rooms will be coated with a clear plastic antimicrobial film.

Franklin hopes each room will be cleaned at least daily and optimally between patients, but years of experience have told her this often does not happen in a busy emergency department.

Silver ion technology from Massachusetts-based Agion Technologies Inc. has been used to make door frames and handles.

"I will be doing microbial swabbing to make sure this works," Franklin said.

Acoustic tiles will absorb noise as part of an experiment to see if quieter working conditions help prevent the distractions that cause harried workers to make mistakes.

Sinks are right by the door and will be fitted with sensors, so that they are lit up as someone walks by to entice staffers to wash their hands as they enter and exit.

"We have seen in the military, we have seen in aerospace engineering, that you can design a space to lead a person to do the right thing," Franklin said.

Computer keyboards pose a special challenge. "Like everyone else's keyboards, they are contaminated." A keyboard designed to survive dunking in a bleach solution did not work well, so Franklin is trying an antimicrobial shrink-wrap cover instead.