A recent report from House Democrats on the Committee on Oversight and Government Reform surveyed trauma centers in the country’s top cities and found them all lacking the capability to deal with the aftermath of “predictable surprises” such as terrorist attacks. The Washington, D.C., area is at high risk for such events, and Washington Hospital Center (WHC), the region’s biggest provider of acute care, was the single most crowded facility of the 34 hospitals surveyed. In spite of this, WHC is a national leader in emergency preparedness and has spearheaded efforts to improve the national capitol region’s ability to respond to mass casualty incidents.

Project ER One is a federally funded initiative at WHC to develop the design concepts, features, and specifications for an all-risks-ready emergency care facility. It will be optimized to have the capability to provide emergency medical care during acts of terrorism and epidemics and built to function fully as a hospital emergency department during daily operations. The ER One concept was developed in 1999 by a team led by Dr. Mark Smith, chairman of Emergency Medicine at WHC. After the events of 9/11 and the anthrax attacks of 2001, the project took on a greater sense of urgency since WHC was one of the few hospitals in the country to play a major role in response to both of those events.

ER One is projected to cost $100 million. Washington Hospital Center is seeking federal support of $75 million towards the overall cost. Concepts of ER One were presented to the Senate and Congress over the last three years to receive funding for continuation of each phase. Washington Hospital Center will be responsible for obtaining the remaining $25 million from other sources (internal capital, philanthropy, etc.).

In this Pebble Project update, Natalie Zensius of The Center for Health Design, interviews Barbara J. Huelat, AAHID, FASID, IIDA, of Huelat Parimucha Healthcare Design, based in Alexandria, Virginia. Barbara is one of the designers on the Bridge to ER One project.

Natalie Zensius: Tell us about this Pebble Project.

Barbara J. Huelat, AAHID, ASID, IIDA: ER One is a model for the emergency room of the future—it’s designed to handle mass casualties for the nation’s capital; mass casualty situations caused by events such as terrorism, bioterrorism or natural disasters. Bridge to ER One, is a simulation and training environmental lab that will test new concepts to be introduced in ER One when it is completed. It’s a prototype designed to establish research in the areas that are being investigated to develop a set of criteria that will inform the ER One project when we receive federal funding to build it. It also includes a 10-bed addition to the existing emergency department at Washington Hospital Center, point-of-care clinical lab, and a central staffing core. Bridge to ER One is a part of The Center’s Pebble Project.

Zensius: So, just to clarify, ER One isn’t actually built yet?

Huelat: No, as the name suggests, this is a bridge. We haven’t received funding for ER One yet but we hope it will be completed within the next six to ten years. The project is moving along in phases; Bridge to ER One, which was completed and opened in January of this year was phase 1. Congress needs to find the money for this. It would go a long way toward improving disaster preparedness for the high-risk Washington region. Until then, we hope that Bridge to ER One will be a significant step towards helping us understand ways to improving patient safety, comfort, and the speed with which care is delivered.

Zensius: What makes ER One unique?

Huelat: The fact that it’s designed for dual-use. It will be a daily Emergency Department that will function as the everyday emergency room of the city’s trauma center, but it will also be able to flex up for any unusual contingent situation, including large surges in patient load. From a design perspective, this poses several challenges because one needs to keep functionality in mind: How do you design a single room that may suddenly have two to four people and their family members in it in times of crisis? How do you store, move, and clean things? What materials will mitigate bacteria, especially with dramatic changes in intensity of usage?

Zensius: What were the design goals for this project?

Huelat: There were three main goals: a capacity to manage 10 times the normal intake rate immediately after an event and four times the normal daily patient volume for the facility; the capability to manage the medical consequences specific to terrorist threats (infectious, toxic, radioactive, incendiary, and blast-related) and the additional threat posed by emerging diseases, and finally, protection—safeguards to prevent the loss of critical medial resources whether from collateral damage or from a direct attack.

Zensius: Can you explain some of the features?

Huelat: The new features include negative pressure isolation rooms to prevent spread of infectious agents, oversized rooms that can be used for up to three patients, and clinical lab space in the Emergency Department to expedite blood tests. Infection control features will include rooms that can be sterilized with vaporized hydrogen peroxide, walls made of Corian to provide a cleaner environment, and surfaces coated with antimicrobial material to reduce infections. Newly designed nursing stations will help improve work flow. There will also be ultra wide band tracking technology for easy location of equipment, a communications system to provide better relay of patient data, and technology that provides staff with faster access to patient information.

Zensius: What evidence-based design research most influenced you on this project?

Huelat: The decisions we made about color and light design were based on Roger Ulrich’s studies of nature and art. We’ve received various comments and feedback on how beautiful the color palette is, which happen to be aspects of nature and a balanced color spectrum that was intentionally integrated into the design.

Zensius: What types of finish materials were used?

Huelat: We designed a 10-bedroom unit that we divided into three different types of rooms: a standard room, typical of an urban city hospital; a protected room; and an enhanced image room, which is very unusual in that it uses a lot of experimental materials not typically put in an emergency room, such as paint that has silver ions in it so that bacteria cannot live, Corian walls that can be easily cleaned, and poured rubber floors—all materials that can mitigate bacteria. The materials we recommended were monolithic and could be cleaned easily in cracks and crevices. This is all an experiment of sorts to see if it makes a difference in bacteria count.

Additionally, we are looking at acoustics. The best materials for cleaning aren’t usually the best for acoustics; you can clean hard surfaces, but they have poor acoustic values. We’re paying attention to acoustics by evaluating the sound of cubicle tracks in the different rooms; and hopefully all of this will give us information to be used in the ER One project.

I want to make clear that all of this is a starting point. We don’t really know yet whether using the materials we chose will impact outcomes in this particular setting.

Zensius: Were there any materials that you used along the way that didn’t work out?

Huelat: We re-examined the contractor’s detail work and the joining of materials that had never been used together before, like the Corian finishes and rubber flooring. We found that bacteria collection in the crevices might be a problem, so we’re changing some of those details before it actually comes time to collect data.

Zensius: Any other lessons learned?

Huelat: After it was built, some areas like the nurses’ stations didn’t work out visually and functionally, so we’re making some of those fine-tune changes.

Zensius: Was there any thought given to improving the staff’s perception of their work environment?

Huelat: We’ve partnered with Herman Miller to evaluate workflow of the nurses and staff, and the care teams in developing a nurses’ station that supports both the technology and workflow. We’ve used some of the studies Herman Miller has conducted in the corporate world and adapted them to workflow in the emergency room environment and revised it to fit the nurses’ needs.

In terms of the staff, there is a strong culture of the high-stress environment of an inner-city emergency room. Staff are there to save lives and don’t really have time to stop and notice their surroundings. While it was taken into consideration, staff respite wasn’t a significant factor in designing this project. In fact, when we talked to the staff about it, they almost became insulted; their mentality was that this is their job, and they were going to be there no matter what, even if it felt like a battleground.

The people who do notice what’s around them are the patients and in particular the families. They are much more inclined to be emotionally affected by their surroundings in an emergency room, since they often spend time waiting and are in shock or stress.

Zensius: What will you be studying as part of The Pebble Project?

Huelat: As I mentioned earlier, the Bridge to ER One was conceived as an experimental laboratory setting. One of the key projects that Director of External Partnership Relations, Research, and Development at the ER One Institute Ella Franklin is planning to undertake is a comparison of the standard rooms and protected rooms in the Bridge project with regard to bacterial loads and cleanability. The hypothesis is that the protected rooms will have lower pathogen levels because of their easy-to-clean and pathogen-resistant finishes. Furthermore, the new ED expansion is adjacent to an existing ED, and staff and patients are randomly assigned to either setting. The two environments are very different and offer multiple opportunities for comparison. Though topics and funding have not been finalized, here are some additional studies that Ella and her team are considering:

  • Hand-washing compliance between Bridge and the existing ED

  • Housekeeping behaviors/practices between Bridge and the existing ED

  • Staff fatigue/influence of Healing Environment in Bridge versus the existing ED

  • Migration of staff from existing ED into Bridge for respite during shift (subliminal effect of healing environment)

  • Relationship of unit design (bays versus rooms) to situational awareness (clinician awareness of patient status)

  • Impact of ergonomic nurse station design on operational efficiency and staff satisfaction

  • Resource utilization—Effect of Bridge design on patient throughput as compared to the existing ED

Zensius: Do you know of any other facilities like this?

Huelat: No, this is the first of its kind. Building this project itself was an experiment, since a lot of the materials had never been used before in an emergency room. We believe that ER One when built, will serve as a model on which ER Two, ER Three, and all future Emergency Departments will be based. HD

Barbara J. Huelat, AAHID, FASID, IIDA, is nationally recognized for work in evidence-based healthcare design and serves as a healing environment interior design consultant to healthcare facilities, product manufacturers, academia, institutions, and the architectural design community. She is currently president of the American Academy of Healthcare Interior Designers (AAHID), a credentialing organization to qualify healthcare interior designers.

For further information on ER One, visit http://www.eroneinstitute.org.


The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at mgoodman@healthdesign.org.


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