In the emergency department, time counts. “Whether it’s a minor laceration or a massive [heart attack], in the view of the patient and the consumer, it’s an emergency. And they’re looking for rapid treatment,” says Susan S. McGaughan, R.N., central region business mana- ger, emergency departments for Connecticut-based Hartford HealthCare.
EDs once were considered the back door to the hospital, “built without any thought toward patient flow and efficiency,” says C. Michael Remoll, M.D., medical director of the ED at Anne Arundel Medical Center, Annapolis, Md. But increasingly, they’re the primary entry point for hospital patients. “As we become more interested in patient flow and efficiency and patient satisfaction, it becomes more important to determine how you want to function and then to build [the ED] around that,” Remoll says.”
“Nobody wakes up in the morning saying, ‘Hey, I want to go to the emergency room today,’” says Marvina Williams, R.N., of design firm Perkins+Will. “The biggest satisfier for patients is being able to be treated in a timely fashion.”
Efficient ED design is important to both save the lives of seriously ill or injured patients and to make less traumatic cases, like getting stitches, a little less miserable.
◗ Anne Arundel bypasses the waiting room
According to Williams, who is senior medical planner, Lean black belt and senior associate in Perkins+Will’s Atlanta office, reducing waste and providing value to the customer are key to facility design. “Meeting with the users and understanding their current processes and then developing future process maps that improve the patient and staff experience provides a facility that is efficient and functional,” she says.
Efficient triage areas and departmental layouts that separate low-acuity patients from those in need of more acute care can help streamline patient throughput and decrease wait times. At Anne Arundel Medical Center, a rapid clinical evaluation area and several blood draw stations near the front of the ED help to move low-acuity patients through the treatment process efficiently.
Long wait times in many EDs often prompt patients to go home before being seen, but Susan Gray, R.N., Anne Arundel’s ED clinical director, says, on average, only 1.1 percent of people who arrive there leave without meeting with a clinician.
In the ED at Hartford HealthCare’s MidState Medical Center, Meriden, Conn., patients are greeted in the lobby and quickly registered and assessed by a doctor or nurse. There’s no front area called a waiting room, “because our expectation is that people are not waiting on that side of the environment,” McGaughan explains. “They are waiting for their treatment within the clinical space.”
Since the hospital transitioned to its newly designed and expanded ED, the average time it takes for a patient to be assessed by a provider after entering the department has dropped from greater than 30 to 45 minutes to between 12 and 16 minutes, she says. Eighty-five percent of patients are seen by a provider within half an hour, versus less than 50 percent in the old ED.
Newer ED designs include private rooms instead of curtained-off treatment bays. Treatment rooms often are arranged in modular groupings, or pods. The modular layout enables hospitals to staff and operate the ED in accordance with daily or seasonal fluctuations in the patient census.
Special populations, like pediatric and behavioral health patients, are provided dedicated areas where possible so that their needs can be managed more efficiently. Other areas allow patients to await test results in an inviting space and that frees up treatment spaces for use by other patients.
◗ Parkland designs for volume
The ED at Parkland Hospital, Dallas, is designed for 180,000 patient visits annually, a figure Kathy Harper, vice president of clinical coordination for the new Parkland campus, expects the hospital to meet within its first year of operation at the 2.5-million sq. ft., 862-bed facility. “About 80 percent of our inpatient volumes come through our ED,” Harper says. “We had to ask ourselves, ‘What volume can we truly handle on this campus?’”
Maximum inpatient capacity was a significant factor in the design of the ED, which has 154 treatment rooms divided among the department’s standard ED, Level I trauma, women’s health and behavioral health programs.
The treatment rooms are organized into pods of 12 or 14. Windows in the treatment room doorways are made of two panes of glass with alternating stripes of frosted and clear glass, which can be positioned for privacy or visibility. The solid doors have additional leaves so the rooms can be opened wide enough to admit a trauma team.
The majority of the treatment rooms are standardized at 135 sq. ft.; there are also 10 resuscitation rooms that cover almost 700 sq. ft. each. Four trauma rooms are sized and equipped as surgical suites. “If we do not have time to transport the patient directly to the OR [two floors above the ED], which is always our first preference, we can do procedures directly in the trauma rooms,” Harper says.
The ED also has five rooms designed to be used as step-down recovery space.
There are two trauma elevators. The largest, specially designed to hold an entire trauma team and equipment, is known at the hospital as the “megavator.” It can transport patients from a rooftop helipad to the trauma department in about 30 seconds, a trip measured in minutes at the existing Parkland Memorial Hospital. “Seconds count when you have a trauma,” says Harper.
Dan Thomas, senior medical planner and director of health care planning in the Dallas office of design firm HDR, says evidence-based design informed much of the project, such as the inclusion of natural light in all waiting areas. Harper says the design is intended to help people who are experiencing a health emergency feel comfortable and give them privacy and family space, so “they can just be who and what they need to be at that particular time.”
◗ Florida Hospital picks up the pace
Streamlining patient flow was one of the primary concerns in the expansion of the ED at Florida Hospital Kissimmee, says Robert Geissler, director of nursing, emergency services and observational medicine. “There are a lot of correlational studies that say the sooner [patients] can see a doctor, the better outcomes they have.”
The expanded ED has separate entrances for walk-in patients and those who arrive by ambulance, and a separate pediatric waiting room. There are two triage rooms, one for rapid assessment and one in which caregivers can begin treatment protocols. Two eight-bed, fast-track treatment areas for low-acuity patients are located on one side of the ED; on the other side, there are 18 critical care beds — including two trauma bays, one for adults and one for pediatric patients, and two rooms for behavioral health patients.
In a separate area are four treatment rooms designed specifically for pediatrics; each has an underwater theme and lighting that can be changed to match a child’s favorite color. The ED also has a test results waiting area furnished with 12 recliners and a big-screen TV.
Geissler reports that since completing the ED project last October and subsequently building a three-story bed tower at the facility, admissions at Florida Hospital Kissimmee are up 20 percent. “They used their ED as kind of the seed for that market,” says Todd Robinson, AIA, EDAC, principal, Earl Swensson Associates Inc., Nashville, Tenn. Despite the higher volume, the ED’s door-to-provider time and the time it takes to transfer an ED patient to an inpatient bed both have gone down by about 30 minutes, and patient satisfaction scores, as measured by Press Ganey Associates Inc., South Bend, Ind., have risen to near the 50th percentile nationally, from below the 25th percentile, Geissler says.
◗ At PPMC, a pavilion for advanced care
The Pavilion for Advanced Care is a six-story expansion to Penn Presbyterian Medical Center, Philadelphia, which is part of the University of Pennsylvania Health System. In addition to increasing PPMC’s ED capacity by 16 beds — plus a five-bay rapid assessment treatment area and space to wait for test results — the project added a Level I trauma center to the facility.
“While it originates in the ED, [trauma] touches every department,” says Alyson Cole, assistant executive director for professional services at PPMC. “It requires some special thought in the design of the building.” The new tower is topped by a helipad large enough to accommodate a Black Hawk helicopter. Two of the new pavilion’s floors are dedicated to intensive care. The radiology and surgery departments are positioned to allow easy access from the trauma center and ED; one operating suite is designated for trauma cases. To help the medical center manage an influx of higher-acuity patients, the project team developed a compounding pharmacy for the facility and ensured that the blood bank had the capacity to support a Level I trauma program, says Mary Frazier, principal of Philadelphia-based design firm EwingCole.
The trauma center and ED include several features designed to make them more comfortable and efficient for patients and staff. Clerestory windows bring natural light into as much of the space as possible, Frazier says. This includes the five-bay trauma resuscitation area. Treatment room and trauma bay numbers are indicated by bold, bright floor graphics. The emergency medical services’ Star of Life insignia is incorporated into the flooring at each trauma bay to identify where EMS providers should stand as part of a care team. The 29 ED treatment rooms include coat hooks and outlets for charging handheld electronics for family members’ convenience.
One treatment room, designed for bariatric patients, is outfitted with an overhead patient lift. Garage-type doors can be rolled down to conceal carts and casework in one treatment room, so it can be converted easily to ensure the safe care of behavioral health patients. Two rooms in the department are designed for bereavement or consultations.
Cole says the impact of the project is difficult to measure just yet, because ED renovation is ongoing and scheduled for completion at the end of this year and the trauma center has been open only a matter of months. However, she notes that ED and hospital admissions are up and referrals continue to be strong. In the community, “there’s a perception that we have a new capacity for care,” she says.— Amy Eagle is a freelance writer in Homewood, Ill. •