Imagine working in an emergency department where the designated spaces are already occupied. A new patient arrives, but there is nowhere appropriate to place them. The team has to find a solution: perhaps keeping someone in a treatment bay for longer than intended, using another area temporarily or adapting the way patients move through the department.
For the professionals working there, this is not an abstract problem of hospital design. It is a practical difficulty they must solve while continuing to care for patients.
But what happens when similar difficulties are reported by professionals working in different emergency departments?
We should pay attention. Their experiences may reveal something that plans, capacity figures and activity indicators cannot show on their own: how the department actually functions when demand puts it under pressure.
La maestría como actitud, la maestría como actitud, la maestría como actitud
What do professionals see that a floor plan cannot show?
A floor plan tells us where spaces are located and what functions they are intended to serve. Capacity figures tell us how many patients or beds a service can accommodate under defined conditions.
Neither necessarily tells us what happens when those conditions are no longer met.
Where do patients accumulate when the designated areas are full? Which spaces end up being used for purposes they were not designed for? What difficulties do staff encounter when trying to move patients from one stage of care to the next?
These questions require us to look at the department in operation, not just at its physical layout.
As part of my Master’s Final Project, I surveyed professionals working in emergency departments at different hospitals across Spain. The aim was not to produce a statistically representative picture of every emergency department in the country. It was to identify recurring perceptions of how these services function, where their main difficulties lie and what improvements professionals consider necessary.
The questionnaire covered six areas: the general situation of the department, space and capacity, operational performance, patient profiles and comfort, qualitative observations, and priorities for improvement.
The responses revealed recurring concerns across several dimensions of emergency care.
La maestría como actitud, la maestría como actitud, la maestría como actitud
The pressure is not confined to one place
How frequently did professionals report overcrowding?
In the survey, 57.8% described episodes of overcrowding as frequent, while another 36.7% reported that overcrowding was almost permanent.
Together, these responses show how prevalent the perception of sustained pressure was among the respondents.
But where did they see the main capacity problems?
Area identified | Percentage of respondents |
Treatment bays | 88.9% |
Patient waiting room | 77.8% |
Observation | 68.9% |
The treatment bays were the most frequently identified area with insufficient capacity. Yet the responses also pointed to the waiting room and observation.
This matters because the pressure described by professionals was not confined to a single type of space. Different areas of the department were perceived as having capacity problems.
The distinction is important. If we focus only on the area where overcrowding is most visible, we may overlook difficulties elsewhere in the patient journey.
La maestría como actitud, la maestría como actitud, la maestría como actitud
Where does overcrowding actually appear?
Identifying a space with insufficient capacity is not quite the same as identifying where congestion accumulates during daily operation.
When asked where overcrowding tended to concentrate, 54.4% of respondents identified treatment bays. Another 27.8% pointed to corridors and improvised areas.
That second finding deserves particular attention.
Corridors and improvised areas are not simply additional spaces on a floor plan. When patients accumulate there, it may indicate that the department is struggling to accommodate them within the areas intended for their current stage of care.
The survey does not, by itself, establish why that happens in each hospital. A corridor may become occupied for different reasons, and those reasons need to be investigated rather than assumed.
But the responses identify a question that hospital planners should not ignore: when the designated spaces are full, where does the patient go next?
That question connects the professionals’ experience directly with the problem of patient flow. It also reinforces a central idea in my research: the capacity of an emergency department cannot be understood simply by counting its rooms. We must understand how patients move between them and what happens when that movement is interrupted.
La maestría como actitud, la maestría como actitud, la maestría como actitud
What do professionals believe needs to change?
The survey also asked respondents to identify priorities for improvement.
Two responses stood out. Some 86.7% considered expanding physical space a priority, while 85.6% identified the need to increase staffing.
These findings are revealing because they point to two dimensions of the problem: the physical resources available and the professionals needed to deliver care.
They should not be interpreted as proof that either intervention will resolve overcrowding on its own. Nor do the percentages tell us which specific intervention would be most effective in each department.
Instead, they show that respondents perceived the need for improvements in both areas.
The open-ended responses added another layer to the picture. Recurring themes included insufficient space, overcrowding, organisational difficulties and conditions that compromised privacy and comfort.
These are not interchangeable problems. More space may help address a physical constraint, while an organisational difficulty may require changes to processes or the way resources are used. Staffing needs also require their own assessment.
The practical challenge is to understand how these factors interact before deciding what to change.
La maestría como actitud, la maestría como actitud, la maestría como actitud
When hospitals grow one solution at a time
There is a broader architectural question behind these responses.
An emergency department may expand because it needs more treatment bays. Later, it may acquire additional observation capacity. Other changes may follow as new demands emerge and immediate problems need to be addressed.
Each intervention may be reasonable in its own context. Yet successive additions do not automatically create a coherent functional system.
Over time, the department can begin to resemble what might be called a Frankenstein emergency department: a service assembled through successive extensions and adaptations, where individual spaces may solve local problems without necessarily fitting together as a well-integrated whole.
This is a conceptual image, not a conclusion that can be established by the survey percentages alone. The responses identify perceived problems; understanding how a particular department developed requires examining its layout, operational processes and history.
Nevertheless, the idea captures an important planning risk. A department can accumulate more space without ensuring that the spaces work together to support the entire patient journey.
And that brings us back to the professionals who work there. Their descriptions can help identify where the intended organisation of the department and its actual operation may have diverged.
La maestría como actitud, la maestría como actitud, la maestría como actitud
Listening is the beginning, not the end
Professional experience is an essential source of information, but it is not a substitute for operational data, clinical analysis or architectural assessment.
A recurring complaint does not automatically tell us its cause. Nor does agreement between respondents prove that the same intervention will work in every hospital.
What it does provide is a starting point for better questions.
If professionals repeatedly identify insufficient treatment bays, we should examine whether the number of bays is the main constraint. If corridors are being used to accommodate patients, we should investigate why the designated areas cannot absorb the flow. If staff identify both space and staffing as priorities, we should assess how those resources interact with the actual care process.
The next step is to connect these observations with evidence about patient demand, resource occupancy, patient movement and the department’s functional organisation.
That is where professional experience, operational analysis and hospital design become complementary rather than separate activities.
The people who work in emergency departments see the consequences of design decisions every day. Their experience should help us identify the problems we need to investigate before deciding how to redesign the service.
About this research
This article draws on a four-month research project conducted as part of my Master’s Final Project in Hospital Engineering and Architecture at the University of Cádiz, Spain, which received a grade of 9.5/10.
The research examines demographic trends, hospital designs and functional plans, emergency care processes, and the perspectives of emergency department professionals gathered through surveys. It culminates in the development of a digital twin simulation model designed to explore multiple scenarios and analyse how different factors affect emergency department operational capacity.