One big, unsafe bottleneck.’ Redesigning Emergency Departments for safety and flow

Even before Covid-19, many working in the health system would claim that Emergency Departments weren’t in the best of health.

The narrative in the media, and from clinicians themselves, paints a picture of overcrowded spaces, overwhelmed and unsafe for patients and staff, bottlenecked and stretched beyond capacity yet growing bigger – and bigger - but not necessarily smarter. 

Creating healthcare systems that meet the very best expectations and conditions for staff and patients should be a focus for communities and operators, and this involves examining the models of health, safety, privacy, the popularity of telehealth and the role of emerging technologies.

In the last two years, we’ve all been running on a hamster wheel, trying to figure out how to redesign our emergency departments to better serve the patients, but more importantly, to make it a safe place for the workforce.”

Mya Cubitt
Emergency Physician at the Royal Melbourne Hospital

As part of a WomenIn panel event hosted by our Melbourne studio, we invited Mya Cubitt, Emergency Physician at the Royal Melbourne Hospital; Stefano Scalzo from the Victorian Health Building Authority, as well as Health, Infrastructure and Planning Consultant Brian Stevenson, to join Hassell’s Health sector leader Leanne Guy and Managing Director Steve Coster to discuss the ever changing needs of Emergency Departments.

Even though it sometimes means having difficult conversations, core to creating the best possible and most appropriate care is ensuring that designers, health planners work, clinicians and consumers work together to understand the issues, and the challenges, and the models of care that they aspire to.

Listen to the podcast in the player below and find Hassell Talks podcast on Apple, Spotify, Google Podcasts - or wherever you get your podcasts. 


Season 3, Episode 2


Leanne Guy, Hassell


Mya Cubitt, Emergency Physician at the Royal Melbourne Hospital
Stefano Scalzo, EGM Planning and Development, Victorian Health Building Authority
Brian Stevenson, Health, Infrastructure and Planning Consultant
Steve Coster, Hassell



At some point, hospitals will need to morph. We need those command centres in hospitals - we need to think a bit like Cape Canaveral at NASA.”

Stefano Scalzo EGM Planning and Development, Victorian Health Building Authority

Leanne Guy:

From Hassell, an award-winning architecture, interior design, landscape architecture and urban design practise. This is Hassell Talks. I’m Leanne Guy. I’m a designer. I’ve been working in the health sector, designing hospitals for more than 20 years, and I’ve worked on projects such as The Royal Children’s Hospital here in Melbourne and a six-story private wing at the Great Ormond Street Children’s Hospital in London. The pandemic has brought the functioning of hospitals, the health of the health care system itself, its services and buildings into focus. And much of the commentary around restrictions and lockdowns in cities has been the idea of not overwhelming the already struggling system, facilities, and the exhausted clinicians. And the pressure on the emergency departments, in particular, on the front line of the battle has been immense. EDs have been struggling for some time growing bigger but not necessarily smarter.

There’s a real opportunity here to look again at workflows, spaces, staff safety, and wellbeing was designed helping to create positive change for our health system to adapt and to embrace new approaches. We recorded the event remotely while Melbourne was still under lockdown restrictions, and I respectfully acknowledge the traditional owners of the land that we recorded on, the people of the Kulin nation, as the traditional custodians of the land and pay my respects to elders past, present, and emerging here, and to all Aboriginal and Torres Strait Islander peoples. I’ll hand over to panel facilitator and host of previous Hassell Talks episodes, Steve Coster. Enjoy the conversation.

Steve Coster:

So we’ll get straight into it. The first of our guests is Stefano Scalzo. He’s the executive general manager of planning and development at the Victorian Health Building Authority. He oversees the service and capital planning for Victoria’s enabling health infrastructure, and leads a team of experts providing advice on the conceptualization and development phases of capital projects. And he’s particularly passionate about the role health campuses play in promoting healthy lifestyles in the renewal of our cities and towns. In 2015, Stefano was awarded a prestigious 50th year Anniversary Churchill Scholarship to research the design of high-amenity mental health facilities developed over multiple levels. Thank you very much for your time, Stefano, and we’re really interested to hear what you’ve got to say about the development of better emergency departments, in particular, for the future.

Stefano Scalzo:

Thank you, Steve. And my perspective on EDs will come from the point of view of a bureaucrat, but also a designer. And a bureaucrat, I guess, at the coalface at the moment of dealing with various government concerns around emergency departments. And EDs are very complicated areas, but they do rely on good flow. That means that clinicians can get to where they need to get to, to do the amazing work that they do in as quickly a time as possible. The other complexity, of course, is that our EDs have gotten particularly big, our populations are getting very, very large in some catchments. It’s not uncommon for ambulance ramping. A lot of our EDs are not able to meet their performance targets, and much of this can be addressed through the design of EDs. So a bit like what we found in the mental health space about seven or eight years ago was how do we introduce double level EDs into Victoria. And potentially, in some instances, we are looking at three-level EDs.

So what does that mean? What does that mean when you need to have those flows? So, expertly accounted for, it means that designers play an enormous role at how do you actually create the right adjacencies. How do you ensure that people’s safety is paramount and achievable in the design, and how do you maintain that amenity for people arriving. So they are the three things that I wanted to bring today that the amenity is absolutely important, whether it be kids with autism, or whether it be families or people with mental health in ED. That EDs have gotten incredibly big and they’re going to need to be stacked. Not by default, but in some instances, they need to be stacked. And then how do you account for the fact that people work in these environments and that need to be in these environments, and hopefully, have a productive sense of themselves and of the work that they’ve done, and how does the environment, the interior environment, support that and perhaps even landscape, and other things that can be considered.

Steve Coster:

Yeah. Thanks so much, Stefano. That’s particularly interesting perspective on things given the spotlight on systemic planning for health care services across our state, given the circumstances at the moment. So similarly, we’re extremely lucky tonight to also have with us, Mya Cubitt. Mya, you’ve had a busy year or two, it’d be fair to say, in emergency medicine, I’m sure. So we are particularly grateful for you giving us some of your time and your perspectives. Mya is a New Zealander and originally trained in New Zealand, but she then ended up in Australia where she finalised her advanced training in emergency medicine and ended up here in Victoria.

And she’s lived in Melbourne since 2011, and completed a yearlong fellowship in paediatric critical care and emergency medicine at the Royal Children’s before beginning her practise as an emergency physician at the Royal Melbourne. Mya also works in the acute medical unit improving care of injured older patients and has a master’s in trauma science focused on frailty assessments in trauma. She’s a member and a past chair of the Royal Melbourne Hospital Medical Advisory Committee, chair of the Victorian Faculty Board for ACEM, which I assume is the Australian Centre for Emergency Management.

Mya Cubitt:

Australasian College for Emergency Medicine.

Steve Coster:

Oh, that was pretty close.

Mya Cubitt:

Yeah, yeah. You did well.

Steve Coster:

And an expert advisor to the Victorian Equal Opportunity and Human Rights Commission review of Ambulance Victoria and the National COVID19 Clinical Evidence Taskforce. So as I said, a busy period. So, Mya, thank you very much for joining us in bringing an on-the-ground clinician’s perspective to the design issues in EDs.

Mya Cubitt:

Thank you. I think the thing just to take it back to is that just the basics. What is an ED? And as an emergency clinician, I have to say I’m not really sure anymore. I think that’s what the last two years have really done for me. And I think you have to think about emergency medicine before COVID and after COVID. Before COVID, Eds were in a bit of trouble, actually. And I don’t think we acknowledge that enough. And I think that goes to some of what Stefano was saying, which is they’re getting bigger and bigger, and bigger, and bigger, and bigger. Now, I personally don’t think that’s because they need to get bigger and bigger, and bigger, and bigger, and bigger. I think it’s because the capacity of our health system at some point needs to recognise… As Stefano said, it’s all about flow. And what we haven’t done is figure out how to design good patient flow, including moving people through at speed, and where the bottlenecks are, and how to relieve the bottlenecks.

And emergency department is just a big bottleneck. And unfortunately, as all of us know, if you make a bottleneck bigger and bigger, and bigger, and bigger, more and more people feel the bottleneck. It’s not necessarily good for patients. It doesn’t fix the system as a whole and it’s terrible for the staff. And COVID has put a really pointy peak on our brand. So the last two years have been about watching an overcrowded system compound into an infrastructure that is not fit for purpose. And when you shine an infection prevention and control lens on it, actually really unsafe. And in the last two years, we’ve all been running on a hamster wheel trying to figure out how to redesign our emergency departments to better serve the patients, but more importantly, to make it a safe place for the workforce. And that’s, I think, the biggest revelation that everybody has had in the last two years.

And I fundamentally don’t agree that increasing the size of them is the answer. We have to embed them into the system as a whole from the front end, which is actually primary care, right through to the backend, which is discharging people out of a hospital so that we can maintain the flow of people out of an emergency department, and we have to wind back the length of time that people spend in our emergency departments, and we’ve got to do it fast. And if we can’t do that, in 10 years time, we’re going to be having this discussion again. How are we going to make it a four-level ED? Because for some reason, emergency departments seem to be the only place in our health care systems where we have expanding walls. We have no nurse ratios. We just expect them to absorb, and I think all of us need to stop doing that. We just need to put the brakes on and say, Oh, no, no, no.” Maybe this isn’t about redesigning the infrastructure. Maybe it’s about redesigning the models of care and the way that we move our people through the system.

Steve Coster:

It’s so awesome to have such an on-the-ground perspective of what these spaces are like. And like lots of things that we design in architecture and design, that challenge of how you engage with the broader system beyond the bit that you are asked to design is always a really challenging thing to be able to do. So it’d be interesting to talk about that more. Brian Stevenson’s a strategic leader with a background of major infrastructure planning and delivery, and provides consulting and advisory services across government, non-government, and private sector.

His expertise and experience has been gained from a diverse career, that’s for sure. He’s worked with Court Services Victoria as the COO for assets and security, as a director of capital planning and infrastructure at Monash Health, project director at Alfred Health, and has also worked as a mental health clinician at St. Vincent’s Hospital, and was a CEO for three years with Drug Services Victoria. So, really spanning everything from some of the emerging issues in EDs all the way through to the reality of user consultation and design processes for new facilities. So, Brian, thank you. It’s lovely to have you with us. Welcome.

Brian Stevenson:

Thanks very much, Steve. Thank you. I just wanted to make a quick point about mental health. There was a lot of change in the 90s when emergency departments, unsuspectingly, had to address the arrival of mental health patients at their front door, prior to that, this was carried out at psychiatric hospitals. That was a really significant change that occurred at that time, and a lot has happened since then. The primary purpose of that change was actually really about in accepting statewide and national frameworks. It was really about providing better care. A quality of care, and to ensure that assessment and diagnosis was optimal, including being able to distinguish differential diagnosis and complex presentations. So, great deals happened in that 25 years, and a lot’s gone wrong. Care is suboptimal not because of emergency departments, because the system’s in a complete crisis and that’s official, of course, as noted by the royal commission.

I just want to note that moving forward, the way in which this particular problem is thought of in the context of EDs is going to be critical. Because the impact of not being able to provide optimal care for people with mental illness in EDs has significant ramifications for people’s health and for the staff working in these areas. I think the challenge for designers relates to, firstly, the existing conditions, and associated challenges and constraints which is quite unique to emergency departments. Being clear about the scale of services that need to be provided for based on the clinical service planning.

The functional relationship associated flows and efficiencies, and how care can best be provided through care pathways and processes. Core to this is how designers, health planners work with clinicians and consumers to design buildings that are about the best possible and most appropriate care. It can only be done by ensuring that designers work in collaborative ways to understand clinicians the work they do, the issues and the challenges, and the models of care that they aspire to. This is really about building effective teams and effective collaboration. I really do believe you can’t achieve good outcomes without this. Teams really made up of health planners, designers, clinician, service users, the success of the team enhances the success of the project.

Leanne Guy:

Household actually has done some research into emergency departments. We’ve specifically looked at the various models for mental health. We’ve touched on telehealth and what that might mean to all spaces within a hospital. And in 2017, we looked at how we can improve and enhance communication within the emergency department. And some of the things that was found in that piece of research, I think, is really relevant to this conversation. It’s about safety, and I think that that is an overriding, I guess, or an overarching element that we need to consider is the staff safety, it’s the patient’s safety. It includes infection prevention strategies, reducing violence and aggression, but it also is about wellbeing, and how can we promote wellbeing right from that front-door experience for our patients without making it a hotel model, because it’s found that the staff and the patients aren’t after a hotel or a home-like model.

A clinical environment is absolutely fine for an ED. It provides that element of safety and standardisation for the clinical staff, which is really important. But I think also, it provides assurance for the patients that they’re in the best possible place to receive their care. The last two years have really proven that looking after the staff wellbeing is so critically important. Previously, we used to put the staff tearoom right in the middle of the ED department so everyone could be close at hand if a trauma case came in. But now, we’re finding that a lot of the staff spaces actually need to be a little bit separate from the ED to give staff respite and time to break from the demands of their time, actually, on the floor, which are often double shifts at the moment as well. One of the other big things is privacy. How do we provide that patient privacy within the ED that’s providing spaces for staff to be able to have confidential conversations, as well as really looking after the patient holistically. And then connection, and what does it mean by connecting our staff and our patients.

Steve Coster:

One of the things that we haven’t talked about too much apart from a comment you made, Leanne, was the potential role of technology in the future and how that might change the way these places work, about how technology might be able to be a new lever maybe for releasing some of these pressures either internally in terms of managing flow and process, or externally in terms of being a different new interface through telehealth or different modes of accessing the emergency department in the first place. Do you have a view about how significantly technology will change the way these places work?

Mya Cubitt:

So I think of emergency medicine as five things. Number one, the workforce. Number two, the infrastructure. Three, the models of care for how you communicate across that. And five, how you use the data. So clearly, the IT fits in a number of those parts. And it’s not rocket science, an emergency department, everyone keeps going on about the demand rising. It’s all completely predictable on either a day-by-day level, an hour-by-hour level, or across years. If you use artificial intelligence, you’d be able to predict your need very, very accurately, actually. Most of us will be able to tell you what’s going to happen in an ED on any given day, and it’s always baffled me that we have these conversations around demand. If you look at the demand that we are facing at the moment, it was entirely predictable even before COVID.

So, artificial intelligence is a little bit underused. We live in the Dark Ages in emergency medicine. I still use a fax machine to communicate with all of my colleagues across the system, which is just ludicrous, really. That’s the only way I can find out information about my patients. So when you talk about communication, that’s the obvious one to give you an example of. One is using the data in the dashboards for visibility so that you can increase efficiency. Within the data space, we’ve been working on a big project across the state trying to build a dashboard. It’s a model where we can actually see each other, and then the ambulance can see us, we can see them, and the inside of a hospital can see us and we can see them, so that we all start to work together in a way that helps our patients move through that journey.

Steve Coster:

Stefano, how does that technology play into that already difficult task of thinking about how a particular facility exists in this very complex larger system?

Stefano Scalzo:

At some point, hospitals need to morph and we need to… And I know Leanne and I are working on this at the moment. We need those command centres in hospitals. We need to think a bit like Cape Canaveral at NASA. We need spaces where clinicians… Their shift might be just monitoring, bringing the spec rather than be constantly reactive, be a bit more predictive about… Once again, you’re saying you can almost tell what’s going to happen on a Thursday evening, that if somehow there was some interconnection between wearable devices, command centres in hospitals, a slightly different way of thinking about how you curate your workforce, that there may be some incredibly innovative ways of tweaking the whole system with this type of technology. I think we’re seeing the infancy of that. I think we’re seeing in some jurisdictions around the world, they’ve moved way ahead from us even in some other states in some of these command centres. And I think what we’re planning for at the Royal Melbourne, certainly what we’re planning for at the Alfred, has to start baking in some of this thinking in the infrastructure.

Steve Coster:

Yeah, thank you. Brian, I might ask you about that because as you talked about before, how you bring together all those different stakeholder groups and get them all on the same page about what that forward-looking new design standard should be is part of the challenge. How do you build that into the process of bringing together the stakeholders, and how can we as designers help facilitate that happening and bring everyone together on these projects so that everyone’s priorities are being met?

Brian Stevenson:

I think you need champions. Clinician champions are really important in developing new clinical models. If you’re reliant on someone rushing into a meeting who’s busy doing work elsewhere as the key means of input into how you are designing around the model of care, that’s not enough. It’s not enough. I think you really need to invest in people, people with expertise, build the capability, and draw that leadership in to the processes of planning and design. I think the research and the new thinking is really important. For me, anytime I’ve been involved in a project, I want to know what other people are doing. That’s not for want of being lazy or trying to build up the thinking with myself or with the teams that I may be working with. It’s because there’s lots to learn from other places.

Leanne Guy:

Often when designers and the architects come on board, the strategic plan, the model of care, the functional design brief has already been done. And so a lot of that framework’s already been established. What’s really exciting is getting involved early on, and we’re doing that with a couple of our projects now where we can be part of that conversation, and we can bring in that, I guess, experience from other work that we might have done. As designers, we’re working on multiple sites, multiple different areas within a hospital, but you really need to listen to the people who are on the ground. We find that the clinicians are often talking to other clinicians internationally and around Australia, for example, hearing what’s working, what’s not working well.

Steve Coster:

There’s also, though, the potential to learn from other fields outside medicine altogether. And that’s certainly something that I really enjoy about being in a firm like Hassell where we’re designing very diverse types of projects across all sorts of things, and the lessons you might draw from the logistics, the designing of logistics systems in an airport, for example, to complex logistics systems in a hospital, or we talked to the other day about information flow in designing a newsroom for a large news media organisation, how that might relate to information flow in an ED. We’ve designed spaces for remote control centres for minds in the Pilbara that are sitting in a building in Perth, operating the mind 100% remotely using technology, for example. Now I’m not saying any of those are perfectly relevant, but there’s all sorts of models from other things that could potentially be part of unlocking thinking that could help relieve some of the pressure points. Do you think that there’s scope for that?

Mya Cubitt:

Yeah, absolutely. And look, I don’t think that there’s a block from clinicians here, quite frankly. But at some point, you actually need to all work together as a system, and that’s the real problem we have. And I’ve spent the last three months in a project with the Department of Health, with PricewaterhouseCoopers, trying to get people to understand that a lot of the problems we have in EDs actually require people outside of EDs to solve. So you can’t fix patient flow in an emergency department if you’re not asking all those other people over there to do their work on their models of care.

And unfortunately, it’s really easy to ignore patient flow if you don’t have a system level view, you don’t have a command centre, and you haven’t got somebody sitting in the command centre accountable to moving the Tetris pieces around the deck chairs. Because ultimately, that’s what it is at a base level. It’s numbers of people across a very, very large system that currently don’t interlink very well. And until we fix that, we’ve got some real problems, quite frankly. We can make EDs as beautiful as we like. We can make them infection prevention control much more suitable, but we won’t solve the actual problem, which is flow. And so we have to look at some of the governance structures fundamentally, and clinicians would love that.

Leanne Guy:

Thank you to our generous guests, Mya, Stefano, and Brian for their insights and contributions, and to Steve for facilitating. As a show of our appreciation, we contributed to the Women’s Health Victoria on behalf of our panellists. Women’s Health Victoria is a not-for-profit organisation doing great work in the women’s health space, together with health professionals, researchers, policymakers, service providers, and community organisations to provide advocacy and to reduce inequalities, and improve women’s health outcomes.

Please do keep an eye out for more episodes coming your way soon covering some of the density challenges, Facing Island cities, why university campuses need to rethink how they cater for the future, and putting perceptions of safety at the centre of design. We’ve had some terrific reviews being left for the podcast. Thank you to you, our listeners, for those. Subscribing and leaving us a review or rating helps us get into the ears of more people and shares the fantastic insights we gather from our network of designers, researchers, and strategists. Don’t forget, you can find more about our work and insights at has​sell​stu​dio​.com. This episode was produced by Annie Scapetis and Prue Vincent. Thanks for listening.