Emergency Department Design Layout

As per guidance in The new normal ED – living with COVID-19 and Triage and reception of patients sectoins sections, we recommend that all waiting areas:

1. Are of sufficient size to ensure appropriate physical distancing between all patients and support people, including 1.5m or greater between people and a maximum of 1 person per 4 square metres.
2. Include appropriate signage and seating arrangements in support of physical distancing.
3. Are regularly cleaned and disinfected, with particular attention to high touch surfaces.

Depending on the physical infrastructure of the ED, it may be desirable to have a separate waiting area for patients with confirmed disease and those who meet COVID-19 case definition criteria and will subsequently be allocated to a high-risk zone (see below).

Allocating surgical masks to patients will further mitigate risk. Of transmission in unrecognised cases. In the interests of patient safety, all patients in the waiting area should remain within view of the triage nurse.The ratio of triage nurses to patients awaiting assessment also should be monitored. As the number of patients in the waiting room increases and/or the number of segregated waiting areas increases, additional triage staff may be required.

Principles for ambulance reception areas are discussed in the ED–ambulance interface.

Depending on local epidemiology, it may be necessary for the ED to establish a ‘high-risk’ treatment zone, which separates patients with confirmed or suspected COVID-19 (as per Figure 1) from very low risk patients.

We recommend that any high-risk zone is:

1. Clearly demarcated, with a minimum number of entry and exit points and designated areas for staff to don and doff PPE.
2. Described using neutral language, such as a ‘hot’ or ‘red’ zone.
3. Staffed by a team of dedicated clinicians separate from those looking after low-risk patients, unless the model of care allows for clinicians to safely don and doff PPE after each patient encounter.
4. Assessed for adequacy of ventilation, including air flow and filtration arrangements.
5. Temperature controlled to maintain staff comfort, given the PPE requirements that will apply.

We recommend that staff working in this high-risk zone:

1. Wear appropriate PPE at all times (see specific recommendations in Section 6).
2. Are not permitted to bring food into this or any other clinical area.

Are supported to take regular, planned breaks, as per the workforce and wellbeing section of this guideline

Design of the high-risk zone will depend on the available infrastructure, ventilation arrangements and layout of the ED. An example of a flow diagram incorporating risk assessment and zoning appears in Figure 2 below. Rapid antigen testing (RAT) may also play a role in the allocation of patients to various zones within the ED.



Figure 2 Example of a flow diagram incorporating risk assessment screening and zoning

In the setting of significant rates of community transmission, we recommend that consideration is given to:

1. Designating the entire ED as a ‘high-risk’ zone. In effect, this would require staff to use PPE for airborne precautions for every patient interaction.  This strategy may decrease the risk that staff inadvertently become ‘close contacts’ (resulting in furlough), and reduce complexity in processes.
2. Implementing rapid testing procedures, such as RAT, as part of a forward triage model. This may assist with the early identification of high-risk patients, especially when history of epidemiological or symptom risk is unavailable or has become less reliable.

Wherever possible, patients with suspected COVID-19 should be separated from those with confirmed infection. This requires a dynamic approach to flow and bed management.

The hierarchy of isolated treatment spaces is summarised in Figure 3 below. While patients with suspected or confirmed COVID-19 should ideally be managed in a negative pressure room, this may not be feasible as patient numbers escalate.

We recommend that, in the setting of a mismatch between the supply and demand for isolated treatment spaces, clinicians:

1. Assess the infection control risks posed by a particular patient on an individual basis (see example below).
2. Prioritise treatment spaces with a higher level of isolation for patients who pose the greatest risk of virus aerosolisation and those who are more vulnerable due to co-existing immunosuppression.

In the event of a mismatch between demands for care and the available resources, it may be necessary to cohort patients with confirmed COVID-19 in an open or shared area of the ED (within the ‘high risk’ zone). Patients with confirmed COVID-19 should be cohorted separately from other patients, including those with suspected COVID-19. Rapid testing with RAT or polymerase chain reaction (PCR) may play a role in identifying this cohort.

In some circumstances, it may also be necessary to cohort patients with suspected COVID-19. This is not a recommended strategy because it increases the risk of nosocomial infection among patients who test negative.

It may also result in these patients being quarantined as a consequence of exposure to a positive case.

If cohorting is required, we recommend that EDs implement the following strategies to optimise patient and staff safety.

1. Ensure the area is clearly demarcated.
2. Decrease passage by minimising entry and exit points and limiting the presence of non-essential personnel.
3. Physically separate patients to the extent that is possible, aiming for a distance of at least 1.5m between individuals.
4. Ensure all patients, where it is clinically safe to do so, are wearing a surgical or N95 mask according to local guidelines
5. Educate staff regarding standards and strategies for optimal PPE and infection prevention and control.
6. Arrange for this area to be cleaned regularly
7. Adjust air-conditioning and ventilation flows to decrease the risk of aerosol transmission.

While the impact of co-infection with influenza on COVID-19 disease severity remains uncertain, efforts should be made minimise nosocomial transmission of influenza wherever possible. This is particularly relevant during ‘influenza season’.

We recommend that:

1. Hospitals use rapid influenza testing to identify patients with influenza and COVID-19 co-infection, and cohort this subgroup separately.
2. Staff working in high-risk zones or with cohorted patients practice robust but rational use of PPE. Although PPE should ideally be exchanged between each patient encounter, this may not be feasible in the context of limited resources and overwhelming demands for care (see specific recommendations in Section 6).

Similar principles apply to respiratory syncytial virus (RSV) and paediatric patients.

It may be necessary to expand the infrastructure capacity of an ED, using other available hospital spaces and/or temporary structures. This is not an ideal solution, but is a safer option than crowding within the ED.  The advantages and disadvantages of various approaches are summarised in Figure 5.

We recommend that, if an expansion of the ED footprint is required, EDs select an area that is in close proximity to the main department and can be rapidly fitted out to meet ED design and ventilation standards (to the extent that is possible). Outpatient clinics and day treatment areas often represent a good option provided appropriate staffing levels are incorporated into these models of care. 

In exceptional circumstances, the use of temporary structures (such as tents and marquees) may be required. These areas should be set up using the same design and infection control principles discussed above.


Figure 5 Advantages and disadvantages of various approaches to increasing ED capacity and optimising ambulance offload arrangements.
Source: Royal College of Emergency Medicine and College of Paramedics, UK

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.