The Mini-Hospital: Rethinking the Emergency Department
The National Center for Health Statistics (NCHS) recently reported a 14% increase in U.S. emergency room cases between 1997 and 2000. NCHS attributed part of the jump to the growing number of people with the highest rate of emergency room and inpatient hospital use nationwide: those aged 75 or older. Moreover, an increasing number of automobile crashes has been reported as contributing to the spike in emergency department visits during the past two years. However, the largest volume of emergency patients involves neither the elderly presenting with cardiac problems nor even ambulance-delivered emergency patients. They are the walk-in patients who go to the emergency department because they know it is open around the clock. They know they will be treated before they leave—and, in the case of patients who do not have healthcare insurance, the law requires that they be seen regardless of their ability to pay
Most emergency departments were not built to be either critical care centers or walk-in clinics. But they have, in fact, become Mini-Hospitals that must treat many older, more critical patients and many relatively healthier walk-in, “light care” patients simultaneously. So, do we just build bigger emergency departments that are modeled on the traditional ED, or do we take into consideration the types and increased volume of patients, their severity of illness beyond the immediate emergent requirements, and the intensity of service required during the more critical patient's extended stay?
The Mini-Hospital design solution is an emergency department that has been designed to stand alone as a full-service outpatient and inpatient hospital within a larger medical center. The Mini-Hospital combines incoming patient triage, clinic exam, emergency treatment, intensive care, cardiac care, critical observation, and patient stabilization services into one clinically effective, operationally-efficient unit for delivering seamless patient care.
On one hand, the Mini-Hospital is larger than an emergency department, but on the other hand, the gross square footprint of the medical center should remain much the same, since the additional services within the Mini-Hospital are those same services that had been previously departmentalized outside the ED walls.
As a hospital corpsman in the United States Coast Guard in the early 1970s, the author found the idea of the Mini-Hospital beginning to take shape as he learned more about military field hospitals. Under the MASH tent roof, the same medical staff take care of their patients from the beginning to the end of the “care cycle”. They meet the ambulances and helicopters at the tarmac, triage the incoming wounded, provide lifesaving services, and then take care of the soldiers for as long as necessary until they are ready to be discharged. The “hospital” for more long-term, critical patients is usually a long helicopter flight away from the MASH unit.
To date, the Mini-Hospital concept has been implemented in a few rural community hospitals that must maximize their clinical nursing staff during days and weeks when there are low patient volumes. With a Mini-Hospital, these small to medium-sized facilities can virtually turn off the lights in the inpatient units until increased inpatient volumes warrant their opening. Once such units are opened, the facility's ability to queue patients is greatly enhanced by having a versatile Mini-Hospital stage the block-by-block opening of the needed patient care units.
Facility planners designing larger medical centers are now beginning to look at a much larger Mini-Hospital as a means to deal with today's higher-volume and more critical incoming emergency department patients. The basic layout of the Mini-Hospital follows logical categories of patient need: trauma and critically ill patients are clustered near the ambulance entrance, with “flex” medical and surgical patient rooms on an outside wall per regulations. Between the flex rooms is a cluster of intensive care rooms, with a central core of observation and holding rooms. Physicians’ office-type exam rooms are at one end of the Mini-Hospital perimeter, and the medical/surgical “stabilization unit” is located as closely as feasible at the other. If designed to be contiguous with the Mini-Hospital, the stabilization unit doesn’t have to be “opened” when there is an influx of patients.
Historically, one of the first Mini-Hospital design models was developed in 1997 for Wahiawa Community Hospital, Oahu, Hawaii, in its exploratory analysis of a replacement hospital. The plan was subsequently used as a template for the design of a hospital expansion project for Tri-Lakes Hospital, Batesville, Mississippi, which opened its doors in 2000.
The next iteration of the Mini-Hospital model was picked up by SunLink Healthcare, Atlanta, Georgia, for its 50-bed replacement hospital in Ellijay, Georgia, slated for opening in late 2008 (figure). Along with the usual emergency department services, there will be six intensive care beds and four med/surg beds within the Ellijay Mini-Hospital, so that during very low patient volumes, the Mini-Hospital will be the only hospital functioning.
As noted earlier, the Mini-Hospital is currently being explored for larger medical centers as a way to ensure maximum flexibility during peak volumes of critical patient admissions that would customarily force the hospital into ambulance diversion status. In Marin County, California, where the author lives, the overcrowding of patients at one hospital reportedly caused an ambulance diversion to another hospital so much farther away that an accident victim died before reaching her destination. The patient logjam in the first hospital had occurred ostensibly because the emergency department had reached critical capacity to serve the patients already being seen, and there were many more patients waiting on emergency department gurneys in hallways for beds elsewhere in the hospital. The existing hospital emergency department had been designed only for rapid throughput of patients. Had there been a space designed for longer patient stays, it is surmised that most of the ambulance diversions could have been avoided.
What are the conditions and anticipated demographics that would warrant planners of new facilities to consider planning all or part of a Mini-Hospital? Many emergency departments already have internal radiography, nuclear medicine, and other diagnostic services, as well as fast-track, urgent care, and cardiac observation units. Does this mean that these multiservice emergency departments could already be designated as Mini-Hospitals? Not necessarily.
In the author's opinion, a Mini-Hospital exists when:
There are intensive care and critical care inpatient rooms within the emergency department under the care of qualified emergency department staff;
There are medical and/or surgical inpatient rooms either within or proximal to the Mini-Hospital, such that qualified staff can be cross-utilized between the two; and
The emergency physician provides hospitalist services to all inpatients and outpatients within the Mini-Hospital.
Key indicators for integrating a Mini-Hospital into a new medical center design are in one or more of the following circumstances:
In a new demographic, where the patient volumes are currently too low to ensure bottom-line performance the day the doors open but are projected to grow exponentially over a 5- to 10-year period;
In a demographic where there are extreme seasonal fluctuations that are difficult to manage at either end of the high and low inpatient-volume spectrum;
In a demographic that is either in a very competitive market or in a location that lacks the glamour to draw clinical nursing staff, such that the clinical nursing staff need to be cross-utilized and potentially be paid more to stay on the job; and
4. In a demographic that must have the fewest core staff possible working during the low-volume periods or just to break even.
Key indicators for converting an existing emergency department into a Mini-Hospital include one or more of the following circumstances:
In a medical center that constantly experiences facility-wide logjams of patients waiting to move from one unit to another;
Where the emergency department is often full of patients waiting for a bed on inpatient units;
In an emergency department that goes on diversion because patients within the department are awaiting internal or external transfer;
In an emergency department where the percentage of elderly patients presenting with cardiac problems increases to the point that they are the majority of patients waiting for an intensive care unit or critical care unit bed.
There may be other circumstances, but this list is enough to convey the message.
Where the “No Hidden Patient” design for a patient care center (see the July 2006 issue of HEALTHCARE DESIGN, p. 58) raises the patient-safety bar for patient-focused care, nursing accessibility, and a nurse-friendly environment, the Mini-Hospital raises the patient-processing bar for expeditious clinical service and internal continuity of care. To elaborate: Internal continuity of care is all about the combined importance of enhancing a patient's comfort and safety by avoiding transport from one department to another, making one department fully responsible for a patient's care, and offering staff satisfaction in their being able to take care of their patients from entry to discharge. Ultimately, “one-stop caring” becomes the priceless reason to consider a Mini-Hospital for any medical center destined to be built, replaced, or remodeled.
Anna Mullins, RN, DNSC, project director of the California Nurses Foundation, sums it up nicely. She says, “With a Mini-Hospital, the quality of care will improve in terms of the potential for fewer errors and complications due to patients’ receiving the appropriate level of care with skilled clinicians in a more expeditious manner. This can lead to dollar savings to the hospital, better patient care outcomes, better patient satisfaction and, therefore, potentially greater market share for the hospital over time”. HD