In 2002, Mary Washington Hospital in Fredericksburg, Virginia, thought it had solved all of its emergency department (ED) problems by doubling its size to 50 beds and 26,000 state-of-the-art square feet. It had seen 75,000 patients that year, with a 6% walkout rate. A year later, patient volume had climbed to 83,000, but all beds were in constant use and the walkout rate had climbed to 14%, including 3,000 walkouts over a four-month period.
Patients arriving with no more than earaches or sore throats—the primary care cohort that most EDs commonly see these days—were waiting more than 2.5 hours for attention. Three years later, a young ED physician, Jody Crane, despairing he could never be maximally effective in such a setting, began studying for an MBA and a possible career in business. He learned of Toyota Motor Corp.’s Lean manufacturing processes—and the rest is ED history.
By 2009, the walkout rate at Mary Washington had dropped to below 2% despite an increase in volume to 100,000, while length of stay declined from four to fewer than three hours. The ED’s average wait time was 25 minutes.
Crane’s Lean work (more later), which has since included consultations with hospitals throughout the United States and authorship of the book “The Definitive Guide to Emergency Department Operational Improvement,” is only one harbinger of a new era in ED design. With ED volumes increasing steadily by some 2% a year over the past 20 years, and a growing concern that volumes might escalate geometrically with the advent of healthcare reform, along with the reasonable notion that the ED, generating more than 50% of admissions, is in fact the hospital’s “front door,” the ED has become a focus of healthcare design innovation.
Frank Zilm, principal of planning and design firm Frank Zilm & Associates and a leading advocate of ED redesign, says, “The ED is going through some of the most exciting operational transitions in healthcare. We’re eliminating waste, streamlining processes, managing low-acuity patients more efficiently than ever, abandoning triage for team assessment, and, in general, doing a complete rework of the front end of the hospital. The concepts emerging from this will be accepted by most EDs within the next five years.”
The principal goals of sorting patients into appropriate areas of the ED and getting each cohort as close as possible to needed resources are guiding these efforts. For example, the traditional “ballroom” layout so familiar to many, with examination rooms surrounding a common work/observation area, seems to have hit its useful limits with a maximum of 16-18 exam rooms.
Beyond that, the optimum visibility the layout promotes fades, and its basic inflexibility in terms of patient volumes and staff initiative becomes obvious. A more recent alternative has been the “pod” layout, dividing the ED into clinically specialized units but still facing difficulty “flexing” up or down with patient population, and the linear model, with parallel units bordering a central work area; this allows maximum flexibility but requires a commitment to decentralized staff.
More recent variations on these models have emerged, including James Lennon’s “matrix” layout, interspersing exam rooms with work areas for more efficient adjacencies and—as we’ll see in a moment—universally equipped “care zones.”
The Mary Washington Hospital experience, in added detail, helps show how all of this came about and where it is heading. Crane’s redesign team began in 2006 by focusing on the lowest-acuity patients entering the ED—the earaches, the sore throats, and so forth. The team created a “Super Track” with two or three beds and a small dedicated team of nurses and technicians examining and treating patients within an hour. This required relocating equipment storage so that the types and numbers of medical equipment needed for this particular group were readily available only a few steps away. Central storage eventually came to be a thing of the past. From this change alone, the length-of-stay numbers (LOS) and improved patient flow were dramatic.
Crane’s team went on to tackle the challenge of more rapid assessment and assignment of “semi-urgent” patients. It used a pivot nurse to make quick assessments and stream the patients accordingly to Super Track, the main ED, or to an “intake” area geared to handle 12 to 14 patients an hour—again, with point-of-care supplies. A results area was provided for patients waiting for lab and radiology results, clearing them from the flow of ED processes.
The new program was dubbed “RATED ER”—Rapid Assessment, Triage, and Efficient Disposition of Patients in the Emergency Room—a “brand” that grew to achieve national recognition. Along the way, Crane applied such healthcare-exotic concepts as queuing theory and Lean tools, like value stream mapping, inventory management, flow-based planning, and root cause analysis. “We focused on our biggest bottlenecks and decided which Lean concepts to apply,” Crane recalls in a podcast. “It’s important to note that this quantitative approach helped in getting physician buy-in and, eventually, the staff owned it, too.”
Healthcare design firm HDR Architecture took things a step further as part of its ongoing Parkland Memorial Hospital (Dallas, Texas) project by creating an ED of nine linear pods, or care zones, incorporating 12 universal examination rooms into each pod. “Each room is universally equipped to handle all kinds of emergencies, as well as triage, registration, and discharge,” explains Associate Vice President Dan Thomas, AIA, EDAC, senior designer on the project. “Each pod has a support area within 30 to 50 feet of the exam rooms for staff efficiency, and the zones can flex from one to the next as census increases.” Each zone has five physicians and a dedicated nursing staff, as well as a SWAT (strategic workup and testing) capability for lower-acuity patients and a radiology component.
With this design, Parkland’s ED went from a 10-hour LOS and 20% walkout rate to a 365-minute turnaround door-to-door and a 7% walkout rate, even though it quadrupled in size from 26,000 to more than 100,000 square feet. Also important to Thomas was provision for onstage/offstage corridors to separate the public from the medical staff, an especially sensitive consideration in an emergency setting.
Other important developments have occurred in ED design, especially post-9/11, with new provisions to quickly convert spaces to drastically expand capacity when needed and measures to disaster-proof the facility as much as possible. The “ER One” study sponsored by the Office of Homeland Security generated many new ideas along these lines, including rapid conversion of waiting areas and parking facilities to treatment spaces, and sealing off key areas against invasion by infective organisms, fire, or weaponry.
Dedicated HVAC systems are designed to achieve proper air balance to ensure isolation and provide HEPA-level filtration. Other design changes being used include use of infection-resistant materials and finishes, and construction techniques that seal off wall, floor, and ceiling interfaces, electrical conduits and wiring, and lighting fixtures.
Tampa General Hospital’s ED, designed by Gresham, Smith and Partners has become a disaster-resistant prototype, with special locked cabinets for oxygen, medical air, suction, and electrical supplies; headwall capacity for two patients in each examination room; and dual se
rvice ceiling booms in each room to accommodate a surge event. The prototype complex at Washington Hospital Center in Washington, DC, has been designed to respond to a four-fold surge in volume, high-risk infectious pandemics, and a direct attack with bombs and bullets.
A kinder, gentler ED modification of late includes features intended to accommodate the nation’s growing senior population with comfort and dignity. Their target population is not the frail elderly who commonly are housed in nursing homes, but rather relatively independent elderly who are nevertheless experiencing slowing reflexes and fading senses. The flagship facility for this is St. Joseph Ann Arbor Hospital in Ann Arbor, Michigan, where lighting is more natural and subdued, signage is large-print, floors are nonskid, corridors are lined with handrails, and beds have special support surfaces to improve comfort and protect against pressure ulcers.
The St. Joseph ED manages up to 60 patients a day over an 18-hour day. St. Joseph’s parent company, Trinity Health System, plans to open 19 more geriatric EDs by 2013. Others, in what is sure to become a significant trend, have opened in Texas, New Jersey, Missouri, and Kansas.
Future developments in the ED are likely to continue the move toward fast-as-possible sorting and management of individual patients and adjustments to handle any influx generated by healthcare reform legislation (should it survive politically). “With healthcare reform, I see a growing need for observation rooms in EDs,” Zilm says, “particularly as pressures grow to deny costly hospitalization and sicker patients arrive at the ED as a result. It’s only a theory of mine, but this wouldn’t surprise me to see this as a major development in five years or so.”
HDR’s Thomas wonders if the ongoing trend toward designing more spacious EDs won’t be brought up short by increasing healthcare budgetary constraints. “Technology has made process quicker and easier, but the infrastructure required to support that technology has grown tremendously, requiring bigger closets and more overhead space. Reconciling the trends of spacious EDs, healthcare budgetary constraints, and required technology infrastructure is a dilemma we’ll all be facing in future healthcare design,” he says. HCD