This study identifies and analyzes spatial adaptive measures taken by emergency departments (EDs) during the COVID-19 surge to emphasize the surge capacity in ED design. The design recommendations are also proposed to enhance ED surge capacity for further pandemics.
Background
The COVID-19 pandemic imposed unprecedented demands on EDs worldwide, compelling EDs to adopt spatial adaptive measures to accommodate overflow patients and mitigate the risk of nosocomial infections.
Method
15 EDs in 3A-Grade general hospitals in the central city area of Shanghai are selected as research objects. Data are collected during the peak surge period (December 2022–January 2023) using a web crawling program and field research to extract patient volume statistics, patient spatial distribution, and spatial adaptive measures from the text and image clusters.
Results
During the surge, the EDs had to accommodate patients with peak volume 2 to 3 times higher than normal patient volume, resulting in ED overcrowding and public space occupation including hallways and corridors. Spatial adaptive measures, including existing space requisition, existing patient flow improvement, and the construction of the “Second ED” were adopted to maintain ED's normal operation.
Conclusions
The COVID-19 surge overwhelmed EDs in Shanghai, prompting the implementation of relevant spatial adaptive measures. Design recommendations include establishing integrated related medical spaces with surge capacity planning, incorporating flexible public spaces by predesign, and designing isolated treatment areas for infectious patients.
Abo-HamadW.ArishaA. (2013). Simulation-based framework to improve patient experience in an emergency department. European Journal of Operational Research, 224(1), 154–166. https://doi.org/10.1016/j.ejor.2012.07.028
BaughJ. J.YunB. J.SearleE.ChynA.BernhardtJ. M.LeClairK.Henshaw-ArcherL.L’HeureuxM. M.RajaA. S.LennesI. T.BiddingerP. D. (2020). Creating a COVID-19 surge clinic to offload the emergency department. The American Journal of Emergency Medicine, 38(7), 1535–1537. https://doi.org/10.1016/j.ajem.2020.04.057
BurgdorfJ.MulcahyJ.AmjadH.KasperJ. D.CovinskyK.WolffJ. L. (2019). Family caregiver factors associated with emergency department utilization among community-living older adults with disabilities. Journal of Primary Care & Community Health, 10. https://doi.org/10.1177/2150132719875636
6.
CasagrandaI.GolaM.BelloneA.CoenD.BrambillaA.GuiddoG.PaolilloC.LerzaR.CapolongoS.BoeriS. (2022). Challenges of the next generation hospitals: Rethinking the emergency department. Emergency Care Journal, 18(3). https://doi.org/10.4081/ecj.2022.10840
7.
Cetin-SahinD.DucharmeF.McCuskerJ.VeilletteN.CossetteS.VuT. T. M.VadeboncoeurA.LachanceP.-A.MahR.BerthelotS. (2020). Experiences of an emergency department visit among older adults and their families: Qualitative findings from a mixed-methods study. Journal of Patient Experience, 7(3), 346–356. https://doi.org/10.1177/2374373519837238
8.
ChenZ.DengX.FangL.SunK.WuY.CheT.ZouJ.CaiJ.LiuH.WangY.WangT.TianY.ZhengN.YanX.SunR.XuX.ZhouX.GeS.LiangY., …YuH. (2022). Epidemiological characteristics and transmission dynamics of the outbreak caused by the SARS-CoV-2 Omicron variant in Shanghai, China: A descriptive study. The Lancet Regional Health–Western Pacific, 29, Article 100592. https://doi.org/10.1016/j.lanwpc.2022.100592
9.
ChenT. Y.LaiH. W.HouI. L.LinC. H.ChenM. K.ChouC. C.LinY. R. (2020). Buffer areas in emergency department to handle potential COVID-19 community infection in Taiwan. Travel Medicine and Infectious Disease, 36, Article 101635. https://doi.org/10.1016/j.tmaid.2020.101635
10.
ChenK.LiZ. (2020). The spread rate of SARS-CoV-2 is strongly associated with population density. Journal of Travel Medicine, 27(8). https://doi.org/10.1093/jtm/taaa186
ClaretP.MartinezM.CesareoE.MontassierE.Le ConteP.TreilleJ.CasalinoE.HausfaterP.ChauvinA.LoubetP. (2020). Prise en charge des patients Covid-19, ou suspects, en structures d’urgence. Société française de médecine d’urgence et Société de pathologie infectieuse de langue française.
13.
DerletR. W.RichardsJ. R. (2000). Overcrowding in the nation’s emergency departments: Complex causes and disturbing effects. Annals of Emergency Medicine, 35(1), 63–68. https://doi.org/10.1016/S0196-0644(00)70105-3
14.
DingF.ZhangH.SuoT.CaoL.ZhangY.TongC.YaoC.ZhengJ.HuB.GaoX.SunZ. (2022). Practice and thinking of emergency management in non-designated hospitals during the epidemic. Chinese Health Resourses, 25(05), 547–551 + 559. https://doi.org/10.13688/j.cnki.chr.2022.220692
15.
DouilletD.SalouxT.RavonP.MorinF.MoumnehT.CarneiroB.RoyP. M.SavaryD. (2021). Adaptation of ED design layout during the COVID-19 pandemic: A national cross-sectional survey. Emergency Medicine Journal, 38(10), 789–793. https://doi.org/10.1136/emermed-2020-211012
16.
Facility Guidelines Institute. (2024). Guidelines for design and construction of health care facilities. American Society for Health Care Engineering.
17.
FeldmanJ. A.BurtonJ. H. (2020). When the aberrant becomes the accepted: The rise of hallway care in emergency medicine. Academic Emergency Medicine, 27(3), 256–258. https://doi.org/10.1111/acem.13886
18.
FilipR.Gheorghita PuscaseluR.Anchidin-NorocelL.DimianM.SavageW. K. (2022). Global challenges to public health care systems during the COVID-19 pandemic: A review of pandemic measures and problems. Journal of Personalized Medicine, 12(8), Article 1295. https://doi.org/10.3390/jpm12081295
19.
GamberiniL.ConiglioC.CilloniN.SemeraroF.MoroF.TartaglioneM.ChiariniV.LupiC.BuaV.GordiniG. (2021). Remodelling of a regional emergency hub in response to the COVID-19 outbreak in Emilia-Romagna. Emergency Medicine Journal, 38(4), 308–314. https://doi.org/10.1136/emermed-2020-209671
20.
GharaveisA.HamiltonD.PatiD.ShepleyM.RodiekS.McCallD. (2024). How visibility may reduce security issues in community hospitals’ emergency departments. HERD: Health Environments Research & Design Journal, 17(1), 135–147. https://doi.org/10.1177/19375867231188985
21.
GharaveisA.PatiD.HamiltonD. K.ShepleyM.RodiekS.NajarianM. (2020). The influence of visibility on medical teamwork in emergency departments: A mixed-methods study. HERD: Health Environments Research & Design Journal, 13(2), 218–233. https://doi.org/10.1177/1937586719885376
22.
GolaM.JohnsonA. A.La MiliaD. I.CadedduC.BardiniF.BianconiB.BiscegliaR.PumpoM. D.GenoveseC.GriecoA.PirasG.GuerraR.DamianiG.FavarettiC.MontagnaM. T.CapolongoS.RicciardiW. (2024). Rethinking the healthcare facilities: The role of the buffer space. HERD: Health Environments Research & Design Journal, 17(2), 24–37. https://doi.org/10.1177/19375867231222563
23.
HartnettK. P.Kite-PowellA.DeViesJ.ColettaM. A.BoehmerT. K.AdjemianJ.GundlapalliA. V. (2020). Impact of the COVID-19 pandemic on emergency department visits - United States, January 1, 2019-May 30. MMWR. Morbidity and Mortality Weekly Report, 69(23), 699–704. https://doi.org/10.15585/mmwr.mm6923e1
24.
HassanT. (2003). Clinical decision units in the emergency department: Old concepts, new paradigms, and refined gate keeping. Emergency Medicine Journal, 20(2), 123–125. https://doi.org/10.1136/emj.20.2.123
25.
HeL.ZhangY.ChenY.ChengY.YangX.MaJ.WangC.HuJ.ZhangX.ZhaiX.LiuG.LuG. (2022). Experience on prevention and control management of the pediatric emergency department during the pandemic of Omicron variant of novel coronavirus in Shanghai in 2022. Chinese Pediatric Emergency Medicine, 29(10), 773–778. https://doi.org/10.3760/cma.j.issn.1673-4912.2022.10.004
26.
Hernandez-MejiaG.ScheithauerS.BlaschkeS.KucheryavaN.SchwarzK.MoellmannJ.TomoriD. V.BartzA.JaegerV. K.LangeB.KuhlmannA.HolzhausenJ.KarchA. (2024). Architectural interventions to mitigate the spread of SARS-CoV-2 in emergency departments. Journal of Hospital Infection, 151, 1–10. https://doi.org/10.1016/j.jhin.2024.05.019
HickJ. L.BarberaJ. A.KelenG. D. (2009). Refining surge capacity: Conventional, contingency, and crisis capacity. Disaster Medicine and Public Health Preparedness, 3(S1), S59–S67. https://doi.org/10.1097/DMP.0b013e31819f1ae2
29.
HickJ. L.HanflingD.BursteinJ. L.DeAtleyC.BarbischD.BogdanG. M.CantrillS. (2004). Health care facility and community strategies for patient care surge capacity. Annals of Emergency Medicine, 44(3), 253–261. https://doi.org/10.1016/j.annemergmed.2004.04.011
30.
IlardiA.ChieffiS.IavaroneA.IlardiC. R. (2020). SARS-CoV-2 in Italy: Population density correlates with morbidity and mortality. Japanese Journal of Infectious Diseases, 74(1), 61–64. https://doi.org/10.7883/yoken.JJID.2020.200
31.
IşıkG. Ç.ÇevikY. (2021). Impact of COVID-19 pandemic on visits of an urban emergency department. The American Journal of Emergency Medicine, 42, 78–82. https://doi.org/10.1016/j.ajem.2021.01.011
KirbyJ. J.BrimM.MorenoA.PhillipsD.PowersA.d’EtienneJ. P.IlomaC.KhongA.MageeM.JrAlanisN. (2020). ACEP COVID-19 field guide. Updated.
35.
LuG.ZhangY.ZhangH.AiJ.HeL.YuanX.BaoS.ChenX.WangH.CaiJ.WangS.ZhangW.XuJ. (2022). Geriatric risk and protective factors for serious COVID-19 outcomes among older adults in Shanghai Omicron wave. Emerging Microbes & Infections, 11(1), 2045–2054. https://doi.org/10.1080/22221751.2022.2109517
36.
LvC.GanY.FengJ.YanS.HeH.HanX. (2023). Occupational stress of physicians and nurses in emergency departments after contracting COVID-19 and its influencing factors: A cross-sectional study. Frontiers in public health, 11, 1169764. https://doi.org/10.3389/fpubh.2023.1169764
37.
MarinelliM. (2020). Emergency healthcare facilities: Managing design in a post COVID-19 world. IEEE Engineering Management Review, 48(4), 65–71. https://doi.org/10.1109/EMR.2020.3029850
38.
MeghanM.ElizabethP. (2025). Emergency department crowding: An examination of older adults and vulnerability. Nursing Ethics, 32(1), 99–110. https://doi.org/10.1177/09697330241238333
39.
MengY.WangX.DongP.YangY.WangK.YanX.HuG.MaoA.QiuW. (2023). Comparative analysis of prevention and control measures toward COVID-19 epidemic between Shanghai and Beijing. Frontiers in Public Health, 11, Article 1121846. https://doi.org/10.3389/fpubh.2023.1121846
40.
MillerN. M.JonesI.RussS.SlovisC.YeatmanJ.ClarkG.JeffreyA.BarrettT. W. (2020). A model for rapid emergency department expansion for the COVID-19 pandemic. The American Journal of Emergency Medicine, 38(10), 2065–2069. https://doi.org/10.1016/j.ajem.2020.06.026
41.
MoseleyM. G. (2013). Effects of expanding an ED clinical decision unit. Physician Executive, 39(1), 50–55.
42.
National Health Commission of the People's Republic of China. (2020). 关于印发综合医院“平疫结合”可转换病区建筑技术导则（试行）的通知 [Notice on issuance the architectural technical guidelines for convertible wards in general hospitals for both normal and epidemic situations (trial)]. https://www.gov.cn/zhengce/zhengceku/2020-08/18/content_5535492.htm
National Health Commission of the People's Republic of China. (2022b). 进一步优化就医流程做好当前医疗服务工作的通知 [Notice on further optimizing medical treatment processes and enhancing current medical services]. https://www.gov.cn/fuwu/2022-12/08/content_5730650.htm
NikkiL.LepistS.PaavilainenE. (2012). Experiences of family members of elderly patients in the emergency department: A qualitative study. International Emergency Nursing, 20(4), 193–200. https://doi.org/10.1016/j.ienj.2012.08.003
48.
ObeidatB.AlrebeiO. F.AbdallahI. A.DarwishE. F.AmhamedA. (2021). CFD analyses: The effect of pressure suction and airflow velocity on coronavirus dispersal. Applied Sciences, 11(16), Article 7450. https://doi.org/10.3390/app11167450
49.
PaganiniM.ContiA.WeinsteinE.Della CorteF.RagazzoniL. (2020). Translating COVID-19 pandemic surge theory to practice in the emergency department: How to expand structure. Disaster Medicine and Public Health Preparedness, 14(4), 541–550. https://doi.org/10.1017/dmp.2020.57
50.
ParkJ.-H.LeeS.-G.AhnS.KimJ. Y.SongJ.MoonS.ChoH. (2021). Strategies to prevent COVID-19 transmission in the emergency department of a regional base hospital in Korea: From index patient until pandemic declaration. The American Journal of Emergency Medicine, 46, 247–253. https://doi.org/10.1016/j.ajem.2020.07.056
51.
PratiwiI. N.NihayatiH. E.SantusR.RamooV.NursalamN. (2023). Psychological impacts of the COVID-19 pandemic on nurses and coping strategies: A systematic review. Journal of Public Health and Emergency, 7, 19–19. https://doi.org/10.21037/jphe-22-57
52.
QuanX.GentgesJ. A.KoenigsknechtB. J.SchaeferS. M.BurnsB. D.MallaS. V.DuncanT. R. (2024). Emergency department environmental responses to COVID-19 pandemic: A qualitative study. HERD: Health Environments Research & Design Journal, 17(4), 23–44. https://doi.org/10.1177/19375867241271436
53.
Royal College of Emergency Medicine. (2020). RCEM position statement. COVID-19: Resetting emergency department care.
54.
SayahA.Lai-BeckerM.Kingsley-RockerL.Scott-LongT.O'ConnorK.LobonL. F. (2016). Emergency department expansion versus patient flow improvement: Impact on patient experience of care. The Journal of Emergency Medicine, 50(2), 339–348. https://doi.org/10.1016/j.jemermed.2015.06.068
55.
ScanlonM.TaylorE.WaltzK. (2023). Evaluating efficacy of a COVID-19 alternative care site preparedness assessment tool for catastrophic healthcare surge capacity during pandemic response. Healthcare.
56.
SetolaN.NaldiE.ArnetoliM. V.MarziL.BolognaR. (2022). Hospital responses to COVID-19: Evidence from case studies to support future healthcare design research. Facilities, 40(1/2), 131–145. https://doi.org/10.1108/F-03-2021-0023
57.
Shanghai Municipal Health Commission. (2022). 对急诊、发热门诊、透析室、手术室、重症监护室、孕妇分娩室等，做到“非必要不封控” [For emergency rooms, fever clinics, dialysis rooms, operating rooms, intensive care units, and delivery rooms, the principle of ‘no lockdown unless necessary’ shall be implemented]. https://wsjkw.sh.gov.cn/xwfb/20220326/10c7658959744ca4ad0569d71e719902.html
SmolovaM.SmolovaD. (2021). Emergency architecture. Modular construction of healthcare facilities as a response to pandemic outbreak. E3S Web of Conferences.
60.
StellaF.AlexopoulosC.ScquizzatoT.ZorziA. (2020). Impact of the COVID-19 outbreak on emergency medical system missions and emergency department visits in the Venice area. European Journal of Emergency Medicine, 27(4), 298–300. https://doi.org/10.1097/MEJ.0000000000000724
61.
StichlerJ. F. (2022). How the coronavirus pandemic has changed healthcare design. HERD: Health Environments Research & Design Journal, 15(1), 12–21. https://doi.org/10.1177/19375867211060822
62.
SunB. C.HsiaR. Y.WeissR. E.ZingmondD.LiangL. J.HanW.MccreathH.AschS. M. (2013). Effect of emergency department crowding on outcomes of admitted patients. Annals of Emergency Medicine, 61(6), 605–611.e6. https://doi.org/10.1016/j.annemergmed.2012.10.026
63.
TekwaniK. L.KeremY.MistryC. D.SaygerB. M.KulstadE. B. (2013). Emergency department crowding is associated with reduced satisfaction scores in patients discharged from the emergency department. The western journal of emergency medicine, 14(1), 11–15. https://doi.org/10.5811/westjem.2011.11.11456
64.
TuffuorK.SuH.MengL.PinkerE.TarabarA.Van TonderR.ChmuraC.ParwaniV.VenkateshA. K.SangalR. B. (2023). Inequities among patient placement in emergency department hallway treatment spaces. The American Journal of Emergency Medicine, 76, 70–74. https://doi.org/10.1016/j.ajem.2023.11.013
65.
Van HeelL.PreteltM.HerweijerM.Van OelC. (2024). Perspectives on assessing the flexibility of hospitals for crisis mode operations: Lessons from the COVID-19 pandemic in the Netherlands. HERD, 17(1), 34–48. https://doi.org/10.1177/19375867231201633
WuZ.McGooganJ. M. (2020). Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA, 323(13), 1239–1242. https://doi.org/10.1001/jama.2020.2648
68.
XueY.YanhongZ.YeC.YangC.LimingH. E.WenchaoW.GuopingL. U.JianM. A. (2022). The practice and effect of bubble management in the emergency department of Children's Hospital of Fudan University during the pandemic of Omicron variant of COVID 19 in Shanghai from March to May 2022. Chinese Journal of Evidence-Based Pediatrics, 17(3), 175–178.
69.
YinH.SunT.YaoL.JiaoY.MaL.LinL.GraffJ. C.AleyaL.PostlethwaiteA.GuW.ChenH. (2021). Association between population density and infection rate suggests the importance of social distancing and travel restriction in reducing the COVID-19 pandemic. Environmental Science And Pollution Research, 28(30), 40424–40430. https://doi.org/10.1007/s11356-021-12364-4
70.
YuC.LeiQ.LiW.WangX.LiW.LiuW. (2020). Epidemiological and clinical characteristics of 1663 hospitalized patients infected with COVID-19 in Wuhan, China: A single-center experience. Journal of Infection and Public Health, 13(9), 1202–1209. https://doi.org/10.1016/j.jiph.2020.07.002
71.
ZamaniZ. (2019). Effects of emergency department physical design elements on security, wayfinding, visibility, privacy, and efficiency and its implications on staff satisfaction and performance. HERD: Health Environments Research & Design Journal, 12(3), 72–88. https://doi.org/10.1177/1937586718800482
72.
ZhangX.ZhangW.ChenS. (2022). Shanghai's life-saving efforts against the current omicron wave of the COVID-19 pandemic. The Lancet, 399(10340), 2011–2012. https://doi.org/10.1016/S0140-6736(22)00838-8
73.
ZilmF.BerryR.PietrzakM. P.ParatoreA. (2008). Integrating disaster preparedness and surge capacity in emergency facility planning. Journal of Ambulatory Care Management, 31(4), 377–385. https://doi.org/10.1097/01.JAC.0000336556.54460.25
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
