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TV vs. Reality in the Emergency Room
By D. Kirk Hamilton, FAIA, FAHCA and A. Ray Pentecost III, AIA, ACHA, DrPH

Ask a person on the street to describe a typical emergency room, and he or she might use words like "confusing," "cluttered," or "uncomfortable." These words describe the ER that millions of Americans see each week - on television. But is television reality?

For some hospitals, the stereotypical features, symbols, and icons used for the set of NBC's popular "ER" television show are reality. But, as healthcare architects, we know that there is a growing movement in America to design emergency departments that are more welcoming and patient-friendly.

When we visited the "ER" set, Production Designer Ivo Cristante told us that everything is exaggerated for effect. Dark stains on the ceiling work better for the camera he claims. There's a bunch of graffiti by the pay phone and too many posters on the wall. Confusion and clutter is created by huge stacks of paper and charts on the nurse's station and too many supply carts in the main corridor.

Many hospital administrators today know that these symbols of overcrowding and confusion send out the wrong message, so they are creating places for equipment storage and workstations for nurses that promote order and efficiency.

We found out that the "necessary icons" of a setting are used on most television sets to keep the audience from asking, "what's that?" For example, on the "ER" set, the location of the waiting room with its bleak uncomfortable seats is right across from the nursing station. Patients would never see this relationship in reality, but for the sake of drama, the director wants a single shot to be able to contrast the sad character who has been waiting forever with the constant action and movement in the station.

In real ER settings, the trend is to group waiting family members in smaller areas that don't have the character of a bus station, and are free from the tyranny of the ubiquitous blaring TV set. Attention is also being paid to the visual and auditory environment, as well as to providing amenities to patients and families. The ER-7 at Mt. Sinai in Baltimore, Md., for example, features a Starbucks Coffee cart in the waiting area, as well as a concierge. A wonderful garden and waterfall can be seen from the ER waiting room at St. Vincent's in Portland, Ore.

The "ER" set also has lots of windows and transparency that would not occur in the real world. Viewers may see a scene in which the camera turns from the trauma room action to see across the observation bay, into the nurse's station and beyond, to capture the waiting room in a single shot. Cristante told us, "There has to be a dialogue between the spaces and the characters. The dialogue can be used to emphasize harmony, or the intentional disharmony can be used to create dramatic tension."

While real emergency environments must obviously perform their functional role with clinical efficiency, the transparency of the "ER" set suggests a need to carefully screen the public and waiting patients from the "action." Yet, our hospitals are clearly backdrops for real-life dramas. As such, we should be thinking of ways to eliminate many of the necessary icons and symbols that so instantly signal the presence of a high-tech, stressful, institutional environment.

Kirk Hamilton is a principal with Watkins Hamilton Ross Architects in Houston, Tex, and member of The Center for Health Design's Board of Directors. Ray Pentecost is an independent planning consultant in Norfolk, Va.