Bolstering ER security through environmental design

May 22, 2013
Experts discuss security considerations for building, renovating hospital emergency departments

One of the biggest headaches for any security manager in the healthcare environment is dealing with risks associated with their emergency departments. Sitting in a hospital emergency room is an inherently stressful situation for most patients and their families. In fact, long wait times in emergency rooms was listed as one of the primary factors contributing to rising crime rates at healthcare facilities across the nation in a study underwritten by the International Association for Healthcare Security & Safety (IAHSS) released earlier this year. The answer to mitigating the risks found in the ER, according to experts, lies in how the facility is designed and constructed.

According to Randy Atlas, Ph.D., AIA, CPP, president of Fort Lauderdale-based Atlas Safety and Security Design, Inc., emergency departments by definition are “high risk, high threat, high asset” areas where a “high level of vigilance” needs to be maintained.

Atlas, who has an entire chapter of his upcoming book, “21st Century Security and CPTED,” devoted to hospital security, says the first step any healthcare facility needs to take when they’re either building a new emergency department or renovating one is to conduct a thorough risk assessment/CPTED (crime prevention through environmental design) survey, which will help them determine what risks and threats need to be mitigated against, as well as assets that need to be protected and  vulnerabilities that should be addressed.  “Once that is refined for the emergency room or emergency department, then it is going to be much clearer and more apparent what particular mitigation steps are needed to protect it from a critical incident,” says Atlas.

Tony York, chief operating officer of Colorado-based hospital security provider HSS Inc., and author of "Hospital and Healthcare Security, 5th edition," believes that security managers need to have a seat at the table early on with the building owners and architects of any new healthcare facility. “The principles of CPTED, which is really what we are all trying to follow, is the concept of layers of protection. We’re looking at lighting and landscaping to make it a warm, inviting and safe environment. But once inside the emergency department, it is imperative to think about the high emotional state that most people arrive in.  So the first impression is important once they arrive.  Making a decision on whether the initial greeting by a security officer or by a triage nurse or receptionist,” York says.

York, who chairs the IAHSS Council on Guidelines participated closely with the group that developed the IAHSS’ Design and Renovation Guidelines, believes that these guidelines will be a “game changer” for the healthcare industry, as many had not even considered some of these best practices in the past. “I was just talking to an architect not too terribly long ago and he said, ‘wow, I never really stopped long enough to think about designing security to this extent.’ They (architects) think about locks and hardware, but they don’t really think about how you design it from the outside thinking of a patients’ perspective on security – from being in the waiting area to the patient care room,” says York.          

Being that many people drive themselves to the hospital when they’re extremely ill or wounded, York says that you want to position emergency entrances at an angle so that a person can’t intentionally or unintentionally plow their vehicle into the facility. York also recommends using some type of barrier at the entrance of the ER, such as curbs, bollards or some other type of physical deterrent.

 It’s also vital, according to York, that workers inside the emergency department have a good line of sight to both people entering the facility and sitting in the waiting room. “What we find is that if someone is agitated, they’re usually going to start showing signs of that inside the waiting area and we want someone to be able see it,” he explained.

In addition, York recommends that hospitals create separation within the waiting area itself to avoid potential conflicts between, for example, families or rival gang members whose relatives or friends have been brought to the facility for treatment. “When we can, we want to be able to make certain we have that ability to have some separation of the waiting area itself, especially if we have someone who is acting out,” says York  

Atlas says that hospitals should use both human and camera surveillance in their emergency departments. “All of those CPTED principles (access control, surveillance and territoriality) apply to an ER/ED by having good natural surveillance by staff of public areas and having good mechanical surveillance with cameras watching the hallways and the entry points to have the ability of playing it back later if someone steals something, someone gets hurt or a patient walks off and all of those kinds of things,” says Atlas. “You also have what I call organizational surveillance meaning you have either the receptionist or the triage nurse that interviews people as they come in and tells them how long it’s going to be and manages the flow of people.”

York says it is also a great psychological deterrent to position a camera and corresponding video monitor either inside the waiting area or in the entrance vestibule where people can see that their actions are being recorded. “It is much more effective than signs and it really helps us understand what is going on. Patients and visitors entering the facility are able to see themselves on the monitor and realize the security is taken with importance here,” he added.

Both York and Atlas believe that access control is paramount when it comes to protecting any healthcare facility.

In the emergency room itself, York says that security personnel need to have the ability to restrict access to the facility with the push of a button. “How is the flow of traffic coming in and out of the emergency treatment area? We want to have one major point of control,” York explained.

According to Atlas, there should be separate ingress and egress points for patients/visitors, as well as clear, separation of the access paths for the public and for staff members. Healthcare facilities could also consider having a third entrance just for nurses and doctors. “There also should be mechanical access, either biometric, card access or some kind of electronic access device, preferably hands-free to restrict access to private areas,” Atlas explained.

Atlas added that the third CPTED principle, territoriality, is also important from a psychological perspective to help set the “ground rules” for behavior once people arrive at the facility. This can be accomplished through good signage. “Where do you want people to go? What do you want them to do? And where should they go or not go?” says Atlas.

There are also many subtle ways that hospitals can reduce tension among patients and visitors to the emergency department.  For example, York said hospitals need to have basic necessities in place, such as restrooms, vending machines, telephones, and televisions. York says hospitals that do have televisions need to make sure that they are tuned to programming that is not going to potentially fan the flames of angst.

“Be smart with your visitor comforts. I encourage most of the clients I work with to closely manage who has control of the television,” says York. “Jerry Springer or other emotionally inciting programs are not recommended. The hospital should control the programming.”

According to Atlas, one of “prime directives” in designing an emergency room or emergency department is stress reduction.  “You want to have good acoustics so it is not loud and noisy. You want to have the ability of communicating clearly and not having to shout with the triage nurse or vice versa, especially in an ER,” says Atlas. “You want to have a clock in the waiting area , so people can watch and see how long they’ve been there and giving them information about when you are going to see them and what you’re going to do for them. Another important design directive is lighting and having lighting that is good quality but not obtrusive with glare. Color is a very important issue in ERs in that you want to use color schemes that are calming and soothing. There actually needs to be a discussion about the mood that you’re trying to present in the ER.” 

York says that chairs should be fastened together or to the floor to ensure that they cannot be thrown or used as weapon. That also applies to planters, fire extinguishers and other hard objects. Inside the patient care rooms, York says that architects also need to consider the height of things such as paintings and coat hangers, which could become hazardous in the event of an attack of a patient against a nurse or other staff member. “I think most architects are not giving consideration to what the heights of those items are. So, if you’re an average man of average height and you get thrown up against a wall because you have some majorly aggressive patient, what ends up happening? You find yourself having that thing go up against the back of your neck in a place where it could really hurt you,” says York.

York also believes that if security is present, then the security workstation should be visible by both visitors and staff members; ideally in the waiting area itself. York said he challenges leaders working in the healthcare environment that believes security isn’t important to go to their emergency room on a Friday or Saturday night and witness first-hand the issues staff in that environment are dealing with on a regular basis. “I think they’ll quickly realize that they’re not doing enough to keep their employees and patients safe,” says York.      

York and Atlas emphasized, however, that no matter what measures are in place or how much thought has been put into security design, it will mean little if it is not accompanied by thorough training of staff members.

“I think that there is a direct correlation between good design of security in these emergency departments and good training efforts that are making a difference,” explained York. “But, unfortunately, we’re talking about an industry that is just fraught with a culture of tolerance.  There are some (healthcare) organizations that are having thousands of (security) events in the course of a given year. You won’t find any healthcare security practitioner not witnessing an increase in their patient-generated violence episodes.”

Atlas says that while many older hospitals didn’t understand the importance of incorporating security into the design of their emergency departments, most modern ones are aware of how they can mitigate threats by implementing these aforementioned recommendations. “It’s getting a lot better, I think,” he says. 

About the Author

Joel Griffin | Editor-in-Chief,

Joel Griffin is the Editor-in-Chief of, a business-to-business news website published by Endeavor Business Media that covers all aspects of the physical security industry. Joel has covered the security industry since May 2008 when he first joined the site as assistant editor. Prior to SecurityInfoWatch, Joel worked as a staff reporter for two years at the Newton Citizen, a daily newspaper located in the suburban Atlanta city of Covington, Ga.