Fast-track treatment in the emergency room
We've all heard stories from friends and family members who rushed to an emergency department with a swollen ankle, for instance, only to wait hours in a waiting room before seeing a doctor. This occurs because hospital emergency departments triage all incoming patients and treat the most serious cases first and as the highest priority. If you are having a heart attack, you'll be seen immediately, but patients with less severe complaints must wait until a bed and a caregiver are available.
Hospitals are increasingly challenged to reduce these inherent waits and delays in moving patients into and out of inpatient beds. Establishing a “fast-track” process for patients with urgent conditions that can be treated quickly can reduce extensive waits and improve the overall flow of patients through the emergency department. A physician often can multitask by treating a fast-track patient while waiting for results for a more seriously ill or injured patient. A separate process can also be established for patients who require additional observation, such as patients with chest pain or asthma. Implementing a fast-track process can reduce the overall length of a patient's stay in the emergency department and increase both patient and staff satisfaction.
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Wellstar Paulding Hospital in Dallas, Georgia, has retroactively embraced the concept of a fast-track emergency department in its current facility, and administrators are currently planning to build a fast-track area into the new emergency department of a replacement facility that will open in April 2014. The new 208,000-square-foot Wellstar Paulding Hospital will replace the current 69,679-square-foot facility located roughly five miles away.
The current 55-year-old facility houses 34 inpatient beds, 15 ER beds with five fast-track spaces, two ORs, one GI procedure room, and various ancillary spaces for other services. The new Wellstar Paulding Hospital will open with 56 inpatient beds (shelled for 112 beds), six ORs, 40 ER beds (including 10 pediatric ER spaces), and extensive imaging and ancillary capacities, at a total cost of $135 million. The current emergency department volume of 36,755 patients is projected to grow to 47,655 upon opening in 2014. Because of this expected exponential growth, Wellstar Paulding Hospital has focused its efforts on improving overall ED customer satisfaction and successfully serving a growing portion of the population.
In May 2009, Wellstar Paulding Hospital decided to bring a multidisciplinary team together to evaluate the emergency department and the possibility of dedicating a separate section of the current footprint to efficiently treat minor emergencies. The hospital recognized that the emergency department was its front door to the community, and patient perceptions of Wellstar Paulding were often based on hearsay or patients' own personal experiences in the ED. Long waits not only gave a bad impression, but they were uncomfortable for patients who came into an ED with an injury or feeling sick.
Another contributing factor to a long ED wait time at Wellstar Paulding was the fact that Monday through Friday, the ER shares six of its 15 beds with the surgery area from 6 a.m. to 3 p.m. Although not desirable for either department, this was necessary due to space constraints and pre/post-operative needs for patients. The ED medical director recognized the need to have a fast-track process and brought together hospital administration, the ED director, nurses, techs, architects, engineering, and finance to brainstorm ideas for creating an efficient and effective treatment plan. The team quickly came up with four characteristics for the new fast-track strategy. They are:
Create a separate area with separate staff. This would effectively segregate fast-track patients from the main ED and prevent unnecessary admissions. The staffing mix was determined to be one RN, one tech, and one midlevel provider.
Define criteria to identify appropriate patients. A key factor for the success of this new area was the appropriate triage of patients in the waiting area.
Commit to consistent hours and staff. To eliminate confusion and streamline patient flow on an ongoing basis, the “fast-track” hours were agreed upon to be 11 a.m. to 11 p.m. This was measurably seen as the heaviest patient volume period.
Encourage patients to stay vertical. By outfitting the area with chairs instead of beds, patients remained upright, and caregivers were able to encourage movement and expedited care in the space.
The team identified a small space located directly across the hall from the existing emergency department that contained the surgical pre-op testing department and the ED director's office. CDH Partners was contracted to help both renovate and redesign the space at an architectural fee of $4,675 and a renovation cost of $35,000. The square footage allowed for four patient recliners with hanging curtains for privacy and a fifth private room for sensitive cases and procedures. A private waiting area was also created for the fast-track patients. Because the tile on the floor was green, the ED staff felt it appropriate that their new fast-track area be called the “Green Zone.” The space opened in June 2009, and ED customer service scores increased 5% immediately, while overall emergency department door-to-door times decreased for the hospital.
While the initial implementation was a success, according to customer service scores, turnaround statistics, and staff responses, there were multiple post-occupancy concerns about the layout and accommodations from family members, patients, and staff. Due to the curtain separators between the treatment chairs, patients had minimal privacy and were privy to conversations in other areas. There was limited accommodation for family members in the treatment area, and many family members were forced to remain outside in the waiting room while treatment was in progress. Also, because the nurse supply cart was unattended in the middle of the space, there were instances of stolen or depleted supplies.
There were also flow and efficiency downfalls of the first phase set-up of the Green Zone. The methodology of having a quick turnaround time for these patients worked to decrease the door-to-door metric, but it also discouraged caregivers from taking the time to sit with the patients and have eye-to-eye connections. Without this connection, it was difficult to build trust and fully understand what was ailing the patient. Finally, extended periods of waiting for test results sometimes bottlenecked each treatment space and prevented a quick turnaround time.
With the methodology of the Green Zone in place, the visioning team began brainstorming again to improve the appearance and utilization of the space. The primary goals for the renovation were increased privacy, increased accommodations for family members and staff, and the creation of a sub-waiting area to divert patients who were awaiting tests or results. The team drew out multiple designs that would accomplish the goals, and these drawings were presented to the medical director along with many emergency department staff members for opinions and final decisions. The overall consensus was to change the space from curtains to a cubicle-type layout with accommodations in
each treatment area for supplies, visitors, and staff. Wellstar Paulding Hospital partnered with Nurture by Steelcase to design the space, and the result was again retrofitted into the existing space.
The cost of the Nurture consult and installation totaled $25,710 and included many new features for aesthetics and functionality. There are now four cubicle-type patient treatment spaces, each outfitted with an oversized, comfortable patient chair; a family bench; a caregiver stool; and a supply station. The walls of each space were high enough to afford seated privacy and visibility from the nearby nurses' station. A nearby family consult room was also converted into a sub-waiting area using chairs from the previous Green Zone space, and it was finished to be spacious enough for three waiting patients. The installation was completed in less than a day, and the space was open for patient treatment in July 2010. After three months of seeing patients in the new space, customer service scores were maintained, while privacy and accommodations were both improved.
Immediately upon opening the space, behavior patterns with patients and staff suggested that the walls were too low to afford complete privacy for patients. Although visibility from the nurses' station was ideal, the ability to speak with patients without being seen from other cubicles was the more desired design feature. Nurture was again contacted, and, in August, 2010, 20-inch clouded glass stackers were installed on top of the existing walls to give standing privacy to each cubicle at a cost of $5,810.
After the three iterations of the Green Zone at Wellstar Paulding Hospital, the visioning team and all emergency department staff are pleased with both the appearance and effectiveness of the space. Low-acuity patients are no longer forced to wait behind true emergency cases, and the goal is a 90-minute patient turnaround time. With the design and construction of the Wellstar Paulding replacement hospital in the near future, the multidisciplinary design and subsequent lessons learned from the Green Zone project will facilitate the successful proactive design of a fast-track space for the growing volume of future Dallas patients. HCD
Whitney Haller, BSIE, MSHS, is an industrial engineer and project coordinator at Wellstar Paulding Hospital and can be reached at firstname.lastname@example.org.
Vicky Hogue, RN, MSN, CCRN, is the assistant vice president and chief nursing officer for Wellstar Paulding Hospital and can be reached at email@example.com. Healthcare Design 2011 January;11(1):22-24