-By Ray Pradinuk, MAIBC, LEED AP

Imagine being presented with the challenge of creating an emergency department where staff would want to come on their days off. This was the gauntlet thrown down to a design team for a new emergency department in Nanaimo, B.C. A key route to achieving that objective for Nanaimo and a host of other healthcare facilities is daylighting and, equally as important, opening up views to nature.

After decades of relegating staff and patients to the glare of artificial light, many hospitals now are aggressively pursuing daylighting strategies that have long been the accepted as the norm in Europe. A series of research studies over the past decade have underscored the link between daylight and increased productivity, reduced stress, and healthier environments. One study, for example, followed recovering patients with a view of a brick wall versus patients with a view to nature. Those with the natural views were discharged sooner and used less pain medication. Another study found that errors by medical staff also decreased under daylighting conditions.

Now daylight is being shed on one of healthcare’s most challenging areas—emergency departments. Emergency departments (EDs) are typically located on a grade accessible floor within the diagnostic and treatment block (D&T) of the hospital. The ambulance garage, the ED’s requirement for adjacency with diagnostic imaging, and the size of these two departments combine to deprive the ED of perimeter wall for daylighting. Even when treatment pods do have a perimeter wall, the headwall of the treatment bays effectively allows only clerestory or narrow view windows typically into ambulance drive aisles or patient/physician parking lots. Result: the intense use, high-stress ED is among the most daylight deprived care areas of the hospital.

After decades of criticism of the deep plan D&T, North American architects are starting to increase D&T daylighting, typically by introducing plan-enclosed courtyards along global circulation corridors and at the boundaries between departments. More skylighting is in evidence, as well, but few care areas within D&Ts have daylight and nature views from the caregiver’s primary workspace.

Daylighting an ED’s Carespace
At Nanaimo Regional General Hospital (NRGH) in British Columbia a bold daylighting plan was inspired by the users’ desire for a place they would "want to come to on their days off." The 43,000-sq.-ft. expansion and renovation of the Emergency Department and Psychiatric Emergency Services is designed to provide daylighting and views of nature to virtually all patient care and staff work areas.

The design solution is anchored in a series of five small but highly visible, nature-filled courtyards embedded within each of four patient care zones—urgent-emergent, ambulatory, psychiatric evaluation, and psychiatric intensive care. A larger courtyard between the new ED and the existing building contains the storm water detention pond for roof water and is reserved for staff.

In the urgent-emergent medical unit, each of two 15-bay treatment pods is organized around a 20-ft. by 24-ft. landscaped courtyard. Care stations at either end of each courtyard allow caregivers clear visual and auditory access around and across the pod. The full-height glass walls around the courtyards are protected from the direct sun by automatic exterior blinds to ensure optimum daylight and views without glare or excessive heat gain. The necessary supply, soiled linen, and other utility rooms displaced by the courtyards are located between the two pods, a strategy that had almost no effect on travel distances for caregivers.

Aesthetics Soothe the Senses
The courtyards at the Nanaimo ED are filled with nature, and each one is unique. The12-ft.-high exposed wood and steel roof structure around each courtyard increases daylight penetration, improves the operation of the displacement ventilation system, and, of course, increases the nature quotient for both staff and patients.

A similar wood and steel structure is introduced in the main waiting area. A walk-under garden is suspended from the roof structure so that this often anxious space gets some greenery as well.

Cost Benefit Analysis Supports Design Guidance
One of the biggest challenges to increasing daylighting in healthcare facilities is the perception that it is more expensive. In the case of Nanaimo, a comprehensive cost/benefit analysis was conducted wherein the costs of building and maintaining the courtyards was balanced against data provided by hospital administrators on the costs of absenteeism, staff retention and recruitment, and medical error, as well as energy expenditures. The study showed that even applying a very conservative potential benefit of a 3 percent improvement in staff-related costs, the courtyards would pay for themselves in three to nine years, while providing the hospital an operational benefit for the life of the building.

And a reduction in energy costs can be reasonably anticipated. A recent Stantec study of acute care hospitals in two California climates found that increased daylighting with daylight controls reduced overall energy use by approximately 10 percent, with hybrid natural ventilation contributing another 10 percent. Although for many the primary motivation to increase daylighting is to achieve benefits for patients and staff—especially that of connection to the world via operable windows—energy and resiliency benefits should not be discounted.

Daylight Modeling
To balance energy costs, careful use of daylight modeling must be a component of any design where extensive daylighting is used. These models help designers determine window placement, size and orientation, shading options, and how each variation will impact energy use at different times of the day and year based on a micro-climate analysis. With this data, window type, treatment, and controls can be introduced to provide the best comfort and energy outcomes.

Optimizing the Daylit Plan
Once the emergency department has been reconfigured to provide a great deal more daylight to both caregivers and patients, further strategies to explore include:
• Using opening windows to provide a more immediate connection to the outdoors
• Using automatic and intelligent operators on the windows to control air flow and exclude outdoor noise and poor quality air
• Using a hybrid natural/displacement ventilation system combined with radiant heating and cooling to reduce HVAC system energy
• Using daylight responsive lighting layouts and controls to reduce lighting energy

The small gardened courtyards at Nanaimo’s new ED will infuse the care areas around them with daylight and nature. Caregivers and patients will sense the first light of each new day and catch the glistening drops off leaves after a rainfall and the sparkle of snow on a winter branch. Many windows will open to the quiet swirl of sounds around the hospital, connecting staff and patients to nature and to their community. The Nanaimo ED project suggests that the humanizing effects of daylight and nature views can and should be brought all the way in to very core of care areas throughout the hospital.

Ray Pradinuk, MAIBC, LEED AP, is the leader for healthcare research and innovation at Stantec Architecture and a member of the Green Guide for Healthcare Steering Committee.