When terrorists flew the planes into the World Trade Center towers three years ago, the nation watched as medical personnel gathered at New York City’s emergency rooms waiting for casualties to stream in. Unfortunately, the catastrophic nature of the attack left little for the doctors, nurses and paramedics to do. But, even before the Sept. 11, 2001, attacks, a nationwide initiative called Project ER One brought together 200 experts to make recommendations on how to make emergency rooms (ERs) better able to prepare for large-scale disasters, such as terrorists attacks.

The federally funded project started in November 2000 and involved MedStar Emergency, Washington D.C., in collaboration with other medical centers, universities, non-governmental organizations and federal agencies. The first of two phases "was to compile design features and specifications that hospitals could use as solutions to ER limitations," says Dr. Michael Pietrzak, director of Project ER One at Washington Hospital Center. The group came up with over 700 suggestions. The individual hospitals did a vulnerability and hazard assessment to choose those features specific to their site and mission, Pietrzak says.

The second phase involves taking all of the specifications and building a prototype at the Washington Hospital Center. "It’s important to have a place where people can see in a hands-on way how these ideas can work," says Mark Smith, chairman of emergency medicine at the hospital. Smith, Pietrzak and colleague Craig Feied are the three key ER One project principals. Pickard Chilton, New Haven, Conn., is the lead design architect and HKS Architects, Dallas, is the lead planning architect.

The prototype has to address many of the possible threats, such as biological, explosives, chemical releases, dirty bombs with radiation and even a nuclear detonation. "But, the facility still has to look and feel like a healing environment, not a fortress," says Pietzrak.

In practical terms, this means a hospital needs surge capacity to handle 20 patients at a time, or 20,000. It also needs a robust decontamination facility and a communication system that will work under any circumstances. Click here to view chart

While the prototype waits for funding, the ER One recommendations can have immediate impli-cations for hospital design, renovation and operations. They not only can improve the readiness of hospitals for large-scale disasters, but also can increase hospital efficiency and safety.

"What we have here is a paradigm breakthrough," says Smith. "What is important is to be better prepared to handle daily operations with common illnesses like multi-drug resistant tuberculosis." Smith notes that half of the people who contracted the SARS virus in Toronto were health-care workers.

A number of ER One ideas may help prevent such outbreaks in the future. "In the immune room concept, everything is portable," says David Vincent, senior vice president at HKS Architects. An exam treatment room in an emergency department would have life-support medical gasses, lights and power all attached to a gurney rather than built into the structure. This would allow hospital staff to move a contagious patient with all equipment and not worry about decontaminating the equipment after the patient left. This idea already is being used in the U.S. military.

Under the concept, the immune room itself should have a seamless environment, with smooth surfaces, covered corners and blister covers on the light switches. And the surfaces should be self-decontaminating with an ionic-silver impregnation. Bacteria-harboring sink drains would be neutralized by high-velocity water spouts.

The Centers for Disease Control estimates that 90,000 patients develop hospital-induced infections each year. The immune-room concept would reduce that number and be cost-effective even without a terrorist attack or natural disaster, according to the team.

Special immune-room ventilation procedures also would protect hospital employees and patients from exposure to airborne diseases such as tuberculosis, measles and Legionnaires’ disease. The ideal room should have a negative-pressure air-handling system so that air in the room is removed through a dedicated exhaust system and is not recirculated through the general hospital system, according to the concept. This also is evident in new ventilation standards established by CDC that require isolation and decontamination rooms to use negative air pressure systems that change the room air twelve times per hour.

Air coming into the hospital also must be protected and cleaned. Vincent says most buildings have air intakes that are unprotected. "So, if you want to spread...