At the April 2026 conference of the Emergency Department Benchmarking Alliance (EDBA), an audience poll revealed that more than half of the ED leaders were planning for major renovations or complete replacement of their departments. That is a level of activity that hasn’t been present in about four decades. Hospital leaders and emergency physicians must now participate in a process to design the next generation of departments, based on the change in patient populations and service needs, and an ED staff that is more adept at the use of evolving technologies.

Data that Drives ED Design

The EDBA does an annual survey of its members, and survey results have just become available for 2025 operations. American EDs continue to see an increase in volumes. In 2026, about 160 million patients will be seen in EDs, with the volume of patients increasing approximately two percent per year. The patient mix is older, of higher acuity, and with chief complaints related to illness rather than injury.

Figure 1. EDBA Survey on median length of stay for all patients, by type and volume of ED. (Click to enlarge.)

ED patients arrive across the 24-hour day and have a median length-of-stay between three and four hours. Figure 1 displays the difference in patient processing times by type of ED, and volume of patients seen per year. Smaller-volume EDs (under 20,000 patients per year) and EDs that manage pediatric patients can process more quickly. EDs that see high volumes and adult patients have much longer processing times and therefore need more square footage and patient care spaces to provide safe care and reduce patient walkaway rates.

Figure 2. Average number of visits per ED patient care space, by type and volume of ED.

The ED cohorts average 925 to 1,200 visits per patient care space, as displayed in Figure 2. The generic term “care spaces” is defined as designated spaces for patient care, which may include beds and other vertical treatment areas, such as recliners or chairs that have designation and safety elements for patients and staff. This figure includes the data for freestanding EDs. Emergency departments that have high numbers of visits per bed generally have higher walkaway rates. For full-service EDs that saw more than 1,400 visits per space, the walkaway rate jumps.

The need for ED care spaces is impacted by the patients with the longest lengths-of-stay. Those are typically the patients who are being held for inpatient placement, or for transfer to another hospital. EDs in the EDBA survey had ranges of admission and transfer that tend to be inversely related. Admit rate rises with volume (9 percent in the smallest EDs to approximately 27 percent in the busiest); transfer-out percentages trend the opposite way (6 percent in low volume to 1 percent in high volume EDs). Small EDs stabilize and ship out the patients they cannot admit. Across all EDs, there must be space (and staffing) to safely manage the patients waiting for admission and transfer.

Figure 3. Average percentage of ED visits that result in admission or transfer, by type and volume of ED. (Click to enlarge.)

A data parameter used to guide ED design is the number of visits per square foot. EDs are built (and renovated) into a physical space that contains gross square footage. The visits per square foot are calculated by dividing the annual patient volume by the gross square footage. It is a crude surrogate for how compact an ED’s space really is. Most EDs are sized so they see about 2.5 visits per square foot.

ED leaders and emergency physicians realize that an ED with an unusually small footprint is noisy, cramped, and short on privacy and room for families. It is possible that sophisticated analysis would show that these EDs have higher infection rates, lower rates of staff satisfaction due to cramped workspaces and constant noise, and less need for sophisticated staff communication systems.

EDs that are spacious with a low number of visits per square foot need sophisticated staff communication systems, monitor systems that track patients or families, and methods for staff to traverse open spaces without fatigue.

Next Generation ED Priorities

Emergency department design must accommodate evolving elements of the care system. The digital technologies must facilitate staff work, flow management, and an electronic health record. Video systems are used for recording certain key patient encounters, for passive protection of staff members, and reducing the potential for patient elopement. Protecting ED staff from violence requires a multi-layered approach combining facility visibility, security measures, ongoing staff training, and clear, zero-tolerance reporting policies.¹

Every ED must be prepared for mass casualty and mass violence incidents. This has been outlined as a priority in the RAND Health Quarterly report, “Strategies for Sustaining Emergency Care in the United States,” published in September 2025.

Emergency departments that are designed to have a greeting area outside must have signage, lighting, an intercom system, water, electrical, and computer outlets that will facilitate the expedited greeting process. Victims may arrive with no EMS triage or care initiation. Patients contaminated by biologic, chemical, or radiologic debris or material must have a reception area and a decontamination space that is safe for staff and victims.

All EDs need an effective EMS reception area that has an area designed for decontamination, a resuscitation area, and an area to accommodate family who do not want to be in the patient care space. The design of EDs that see more than 40,000 patients per year must include some specialized areas. These EDs have patient volumes and needs that justify the development of a functional patient greeting area, vertical treatment areas for low-acuity patients, mental health suites for safe patient management, imaging suites, comfortable staff work areas, and clinical-decision units.

Emergency physicians and ED leaders must be able to use and understand the elements of ED design that provide an environment for high-quality and safe emergency care. The design must accommodate higher patient volumes, acuity, and management of patients through the diagnostic and treatment phase of emergency care. Where boarding is necessary for patients being admitted or transferred, there must be sufficient space, staffing, and services for inpatients.

The post-pandemic period provides an environment for every emergency physician and ED leader to redesign the practice environments and systems, recognizing the community’s needs for acute, unscheduled care and standby capacity for community public health emergencies.

Dr. Augustine is the vice president of the Emergency Department Benchmarking Alliance and a clinical professor in the department of emergency medicine at Wright State University in Dayton, Ohio. He serves on the Innovations Advisory Group of the ACEP Emergency Medicine Data Institute. He also serves as medical director for the International Association of Fire Chiefs.

Reference

1. Policy Statement. Protection From Violence in the Emergency Department. Ann Emerg Med. 2016; 68(3): 403-404.