Many healthcare organizations are in the position of upgrading, expanding, or replacing their emergency departments. There are several trends in ED design (such as segregating lower-acuity-level patients into fast track areas), but few have been quantified. With the University of Kentucky (UK) HealthCare’s emergency department open for just over a year, the team is embarking on a research project to document the results of the design of the chair-centric component of the department’s Express Care operational model, as well as to share some of the lessons learned about the design of both operations and the space.

Responding to increased demand, UK HealthCare’s master plan calls for a phased replacement of the original Chandler Hospital building and expansion of current medical center services. When fully fit-out, the 1.2-million-square-foot facility is projected to cost almost $850 million and will include: a trauma center/emergency department; an eight-story, 512-bed patient care tower; 27 advanced operating rooms; a diagnostic and interventional center; public spaces for patients, families, and staff; a health education center; advanced technologies serving clinical, information, and communication needs; and support spaces.

Pavilion A represents the first phase of the master plan. The initial step of the project was completed at 5 a.m. on July 14, 2010, when the first patient came through the doors of the new emergency department at the University of Kentucky Chandler Hospital—Central and Eastern Kentucky’s only Level 1 trauma center. This step culminated thousands of hours of planning by staff, architects, and facilities experts that doubled the size of the previously existing ED to 39,000 square feet.

Featuring carefully planned spaces that enable staff to treat and discharge patients quickly or admit the patient promptly for inpatient services, the ED is designed to provide services for 75,000 annual visits. Simulations were used to determine the overall sizing, but also were used as a mechanism to develop operational throughput processes.

Planning for the new ED was based on UK HealthCare’s guiding principles that shaped the facility and were used by the team to define and develop specific spaces that will better serve the needs of its users by: 

• Providing a comforting and welcoming environment that is easy to navigate;
• Incorporating amenities for patients and their families;
• Supporting an integrated care delivery system;
• Increasing quality and safety for patients and staff;
• Responding to future technology with a flexible design;
• Supporting the academic mission; and
• Establishing a new image for the healthcare enterprise. 

Careful attention to every detail, from the color palette and artwork to lighting was considered to create a comfortable and soothing environment. Additionally, specific focus was placed on how to best reduce stress for patients and staff. The ED features three separate self-sufficient centers, with dedicated team work areas and services so care is timely and efficient.

The latest technological advances have been incorporated into the new ED, including electronic documentation of high-risk cases, computerized order entry, Wi-Fi coverage in waiting areas, and wireless and mobile X-ray and endoscopy carts to speed delivery of care to patients. In addition, the department incorporates the “quiet ED” concept that reduces overhead announcements by using specialized communication devices.

The Makenna David Pediatric Emergency Center

Adjacent to the Adult Emergency Center, the Makenna David Pediatric Emergency Center has a separate entrance and waiting area that is child-friendly in color scheme and furnishings, and includes a play table, interactive wall, and computer play station area. Additional features of the pediatric services area include: 

• Ten standard exam rooms, two high-acuity “crisis” rooms, and two triage rooms;
• Distinct patient, staff, and family areas in each room;
• Televisions for patient education and entertainment;
• Direct access to adjacent radiology and inpatient services; and
• Private consultation rooms for families with special circumstances.

Adult Emergency Center

The adult acute services area is located in the center of the ED and includes 32 exam rooms organized in pods that operate as independent treatment zones. As in the pediatric center, each zone is self-sufficient, with dedicated supplies and services so care is timely and efficient. Additional features of the Adult Emergency Center include: 

Twenty standard exam rooms, four high-acuity “crisis rooms,” and four secure rooms to serve the special needs of behavioral care and security-restricted patients;

• Multiple negative pressure rooms for at-risk patients;
• Distinct patient, staff, and family areas in each room;
• Televisions for patient education and entertainment;
• Access via the waiting area or ambulance entry;
• Direct access to trauma and express care areas; and
• Private consultation rooms.

UK Level I Trauma Center

The UK Level I Trauma Center is located just beyond the Adult Emergency Center, in the core of the department. It includes three major trauma rooms capable of caring for up to eight patients based on the complexity of their treatment needs. Equipped with state-of-the-art monitoring and life support systems, the trauma rooms can handle any life-saving procedure. The center is immediately adjacent to dedicated CT technology and general radiology rooms for efficient diagnostic evaluation. The UK Level I Trauma Center also includes:

• Immediate access via specific large trauma elevators directly from the roof helipad or through the ambulance entry; and
• Dedicated work areas for trauma physicians, nurses, paramedics, and other support staff.

Express Care

Express Care is a relatively new approach to handling emergency patients who are not critically ill or injured. Patients with less serious needs for evaluation and treatment will access this area directly from the adult waiting area, accelerating care for this type of patient and making the best use of staff and treatment resources. Express Care also includes: 

• Five exam rooms plus a “chair-centric” room with six comfortable lounge chairs;
• Flexible levels of care and the ability to handle overflow capacity needs; and
• A convenient exit path away from more seriously ill patients.

A literature review on the operational aspects of fast track areas was conducted, but the evaluation of several papers revealed little mention of the physical settings in which the care is delivered. In light of this, the physical design of Express Care at UK HealthCare was developed to test two types of settings. The first, four single-patient exam rooms with beds, has two points of entry—one for patients and one for staff—in order to provide more efficient flow and minimize traffic in the core of the ED.

The second, a chair-centric design, is comprised of a single large room with seating for six patients and a private exam room directly adjacent to this area. The chair-centric model provides an alternative interim space for patients waiting to see a clinician or to receive test results, so they avoid returning to the waiting room, but do not occupy a bed needed for another patient and may potentially report less pain associated with higher levels of comfort in a recliner.

UK HealthCare is currently collaborating with partners AECOM Ellerbe Becket and Nurture by Steelcase on a research project to quantify the benefits of a chair-cen
tric design as part of the ED Express Care. Specifically, the study will look at: 

• To what extent, if any, is patient and family satisfaction affected by the chair-centric model?
• To what extent, if any, is staff satisfaction and efficiency affected by the chair-centric model?
• To what extent, if any, is patient throughput affected by the chair-centric model?
• To what extent, if any, is there a difference in self-reported pain level between patients seen in different room layouts? 

This study enacts an innovative ED concept of care for lower-acuity patients with significant process changes supported by a novel ED design. Focus groups, in addition to patient, family, and staff satisfaction surveys, will be used to assess the first two components related to user satisfaction. Throughput will be evaluated using the available ED technology that “time stamps” so many activities in the patient cycle. Behavioral observations and pain management reports will be used to gauge perceived pain. The structure for the research project was recently approved by the institutional review board and data collection will begin in the fall.

The ED volume has seen an increase of 25% since moving into the new space. Although design can help drive operational change, staff involvement and commitment at the onset are crucial to the overall success. Cultural change takes time and must be recognized as an ongoing opportunity. Perceivably the biggest change may be the physical space, but it is imperative that all associated operational systems be included in planning, design, and transitioning. In this case, the many hours of discussions, site visits, mock-ups, and simulations resulted in a very successful facility. Staff and patients alike rate their satisfaction levels quite a bit higher than in the past. For the staff, the central core areas as well as the “quietness” of the space, even during busy times, are high satisfiers.

Staff and families of pediatric patients truly appreciate the separation and pediatric focus of the McKenna David Pediatric Center and an overall measure of satisfaction (left without being seen) has seen a significant improvement across all areas of the emergency department. The ED was the first phase of this project to open, with the inpatient tower opening in May 2011. It was anticipated that several operational issues would prevail during this interim period. Now that the ED is no longer operating in the new space alone, the team will be able to better evaluate any operational issues that are truly affected by the design rather than the phasing associated with the build out.

As host of the Fall Pebble Project Colloquium, UK HealthCare featured the ED as part of a facility tour for both Pebble Partners and additional attendees of a Research in Practice Workshop. In conjunction with MedStar Health’s Institute for Innovation and its Pebble Project, ER One, the workshop was an opportunity to discuss the latest design research, applications, tools, and processes for designing an effective, efficient, and safe new emergency department. Many of the stakeholders (both designers and end-users) were active participants in sharing their lessons learned. “There is not a more sophisticated facility in the world than our new emergency department at UK,” says Dr. Michael Karpf, UK’s executive vice president for health affairs. “In the event of a large-scale emergency, the UK Chandler Emergency Department and its highly trained professionals will prove invaluable for our entire community and this region.” HCD

Jennifer A. Christmann, FACHE, is the Assistant Director of Facilities Planning & Development for UK HealthCare. She can be reached at jennifer.christmann@uky.edu.