Designed for disaster: Planners of innovative ED want it to be ready for anything

Imagine this scenario:

Terrorists attack Washington, D.C., with a combination of conventional explosives and a biological agent, killing hundreds of people while injuring and infecting thousands more. Soon emergency departments across the area are receiving more patients than they can possibly handle. Long lines of ambulances with no space to offload patients form at hospital entrances. Patients are stuck in waiting rooms and hallways when all available beds are taken. EDs become overtaxed and inaccessible.

By the time doctors realize the assault exposed some victims to a deadly communicable disease, hundreds more patients and medical personnel have been infected. Entire hospitals are declared quarantine zones.

Just when physicians think the situation couldn't possibly get worse, the terrorists launch their second wave of attacks. Using truck bombs to target emergency departments, the assailants push several facilities past the point of total loss and ensure the system's complete breakdown.

Such a situation might seem hopeless, but some physicians think at least one of the D.C. area's EDs can be modernized so it remains functional and helps hold the system together amid any disaster -- natural or man-made.

ER One would be the nation's first civilian "all-risks-ready" emergency department. Washington Hospital Center, with the leadership of its emergency department chair, Mark S. Smith, MD, is planning to build the facility on its campus about two miles from the U.S. Capitol.

During an average day, it would operate as a typical fully functioning ED. But in a disaster, it would quickly transform into a state-of-the-art facility that could take many times the normal patient load while providing specialized care and protection found nowhere else.

Planners hope ER One would not only greatly enhance the emergency preparedness of the nation's capital, but also help spur a revolution in the way the rest of the country and the world think about modern ED design.

"We have this historical approach to building hospitals that comes out of the Middle Ages," said Craig F. Feied, MD, an emergency physician and founding director of Project ER One. "This is not just an emergency room problem -- this is a hospital problem."

Project leaders have drafted designs and are ready for an official groundbreaking. Before that can happen, however, the federal government has to step in. MedStar Health, the nonprofit hospital network that runs the center, has made an initial commitment of $25 million to begin construction. The project's designers are looking for about another $75 million from the federal government to move into the building phase.

"It is arguably one of the smartest investments that Congress could make, and it deserves to be approved," former Dept. of Health and Human Services Secretary Tommy Thompson wrote in a recent editorial in the newspaper The Hill.

But in each of the last two years, ER One funding has become a casualty of congressional action to strip special projects out of budget legislation. Supporters hope 2007 is the year Congress is finally convinced of the need for a modernized emergency department in the capital.

Project leaders have outlined three core concepts: capacity and scalability, specialized capability and protection.

Capacity and scalability

ER One's ability to take a massive influx of patients is built directly into the design, its founders said.

The entrance is a concourse, modeled on an airport terminal, to allow multiple ambulances to drop off patients at multiple sites, rather than waiting for limited dock space. Patients would be processed in much the same way as airline passengers. Multiple admission stations would allow quick triage and movement into treatment areas.

Movable walls would allow medical personnel to quickly reconfigure rooms and hallways to house more patients or to serve a new specialized medical purpose. Patient beds would be fully portable and have some equipment built in so doctors could maximize available space. Power and oxygen supplies would be stored in the ceiling throughout the facility for easy access.

Many of the design concepts are aimed at moving patients as efficiently as possible out of the ED and into other treatment settings, Dr. Feied said. By doing so, ER One would be able to scale up its capacity as much as tenfold, to about 2,500 patients a day.

Specialized capability

Innovations would enable the staff to treat virtually any type of health emergency. Rooms that normally serve as equipment storage space would become mass decontamination showers in the case of widespread chemical exposure. Localized air supplies and negative air pressure would combine with dedicated purification systems to reduce the chance that a biological hazard could spread to other sections of the facility. Even doorknobs and other frequently touched surfaces would be constructed of a special silver alloy that kills pathogens.

The facility would employ the newest information technology, said Dr. Feied, who also works for Microsoft on its health care software efforts. Information and communication systems designed for locating, identifying and processing patients would be invaluable at the height of a major medical emergency.

Protection

The facility would do doctors and patients little good if it could not adequately safeguard itself, said Michael P. Pietrzak, MD, an emergency physician and the project's lead scientist.

Its proposed location is close enough to treat the victims of a disaster in Washington but far enough away from the city center to avoid becoming an immediate casualty. Dr. Pietrzak said the design would survive the collateral damage of any event short of a direct nuclear attack.

By designing building structures and roads that allow control over facility access, the architects are confident they would minimize the chances that ER One would be targeted. Temporary portals could be erected to screen vehicles and personnel before they could make a final approach. The plans call for blast barriers, shatter-resistant glass and drywall that would help stop shrapnel.

The funding question

Washington Hospital Center's Dr. Smith said that although hospitals usually depend on private capital for new construction, the special federal funding request for Project ER One is appropriate. The facility would be in a unique position to help the government continue functioning amid a natural disaster or terrorist attack. Center supporters say they cannot count on getting what they need through the current system, in which preparedness block grants are parceled out to state and local governments to handle myriad priorities.

But competition for emergency preparedness funding -- and public health care dollars in particular -- can be tight. In asking for $75 million for one medical center for new construction, the project's backers are vying for resources that could bolster numerous existing, struggling EDs.

Emergency departments nationwide say they are dealing with a combination of increasing patient loads and decreasing capacity. Disaster preparedness is suffering as a result, said Steven J. Stack, MD, an emergency physician in Lexington, Ky., and member of the AMA Board of Trustees.

"Our current health care system is marginally prepared to handle a bad flu season, let alone a real mass casualty situation," he said.

In the D.C. area, several hospitals with emergency facilities are financially strapped, and at least one is circling the drain, said American Public Health Assn. Executive Director Georges C. Benjamin, MD, the district's former top health official. If any close due to a lack of federal or local funding, patient loads would shift and the capital's preparedness level would degrade.

However, Drs. Stack, Benjamin and other physicians agreed that lawmakers should not trade off between keeping existing hospitals afloat and funding ER One. The initiative's promise for doctors is evidenced by the American College of Emergency Physicians' decision to partner with the project's directors, said ACEP President Brian F. Keaton, MD. If lawmakers grant the project's funding request, emergency departments nationwide and the doctors who work in them would benefit from lessons learned through the rollout process, he said.

That is where the ER One Institutes, the venture's educational and training component, would come in. The facility would serve as a working laboratory for physicians and hospital administrators across the country, testing the latest advances in ED design and technology.

"The real value comes a few years down the line when the techniques that we've instituted here have been proven, when people can come down here and see it, touch it, kick the tires," said Dr. Feied.

When it comes time to renovate their EDs, medical directors may be inspired to design scalable, specialized and protected all-risks-ready facilities. There may even be an ER Two one day.