No waiting

As a healthcare provider, how do you get patients in and out quickly? A novel approach in emergency departments around the country puts doctors at the front of the house to evaluate patients for the urgency of their condition when they first arrive. Physician's assistants, nurse practitioners, and physicians examine the more serious cases. Patients waiting for test results or whose care can be delayed are upright, dressed, and reading magazines in a comfortable lounge, rather than prone, gowned, and impatient in a treatment bed.

While attempts at this approach have failed in the past, innovative methodologies such as Physician-Directed Queuing (PDQ); Rapid Medical Evaluation; Physician in Triage; or Rapid Assessment, Triage, and Efficient Disposition are making a difference and being deployed by hospitals to address crowding. The success of this process depends greatly on core process redesign. Process redesign was once an anomaly, but now this operating method for the ED is being adopted more widely and improving with each iteration. To support this new procedure, there are a number of design strategies that should be considered.

Path of minimal exigency

The goal of the triage process has not changed due to the insertion of a physician to the process. However, the addition of a physician to the team allows the process to develop even further.

Although exact methodologies vary at this point, two basic paths have developed. Upon presentation, urgent patients who require all emergency department resources are sent to the core of the emergency department for treatment. Also called “horizontal patients” due to their typical position during treatment, they may be tested and scanned on their way to the treatment room. The treatment of these patients then proceeds much as it has in most emergency departments for the past decade: The patients may be registered at bedside, evaluated, and treated in an exam room while lying on a stretcher, and then discharged or admitted to the hospital.

The new, alternate paths are developing for non-urgent patients. While traditional “fast-track” or “quick-care” areas segregate by acuity, other innovative methodologies are segregating by resource or even completing low-resource evaluations upon arrival. With these “vertical patients,” the objective is to give them access to the resources they need without ever having to enter the core of the emergency department and occupy a bed. In the PDQ methodology, at triage, non-urgent patients are divided into those who need additional diagnostic testing and those who can be dispositioned without additional testing. Those not requiring testing are quickly treated in triage or nearby exam rooms, then registered and discharged. Physical plant design is crucial to the long-term success of these process innovations.

For those patients requiring diagnostic testing, the physician writes the order, tests are administered, and the patient returns to a results lounge. After the results are reviewed, treatment is given and the patient is discharged. Key elements of the process are having the right waiting spaces available, using those spaces to queue for results, and not using the treatment space as a waiting room.

Designing for treatment

The first visible design change should be made in the triage area or arrival zone, which must be spacious enough for a four-person team. The team, at minimum, includes a physician, a triage nurse, a tech, and a representative from registration. The area should allow each individual adequate working space with the physician area close enough to the triage nurse to be able to provide support when necessary. Ideally, in the PDQ model, the physician location should allow both visual and audible observation of the triage process. Preferably, the area also should allow for observation of walk-ins and ambulance arrivals.

Secondly, a series of treatment or evaluation rooms must be close to triage. Here, on the periphery of the ED, the physician will treat the non-urgent, low-resource cases. Two rooms are required at minimum to allow the physician to provide care to a patient in one while registration completes the checkout process in the other. The appropriate number should be determined by reviewing the department's volume.

In order to ensure efficient ebb and flow, each evaluation room should be designed with adequate storage for regularly used supplies. All other supplies should be stored directly outside the room, preferably in color-coded, easily restocked carts.

The location of diagnostic imaging and lab rooms is also critical to the process. Ideally, they will be located, along with their respective waiting areas, within steps of the triage area. Positioning these departments within the ED often will pose a challenge, as they also need to be accessible by trauma and the remainder of the ED staff.

Results lounges at Hershey Medical Center

One potential process change that affects design is the location of waiting spaces. Typically, emergency departments have a waiting space upon arrival. However, during the design of an addition to the emergency department at Hershey Medical Center, the space allocated for the expansion was reduced drastically. At that point, the team had to determine the best way to use the limited space available for expansion.

Led by Dr. Chris DeFlitch, Hershey Medical Center recently completed a departmental simulation that utilized operation data and queuing theory to evaluate the effect of the addition of a physician to the triage process. After developing the PDQ methodology, the initial pilot tested the simulation study assumptions that would eventually become the PDQ process. Patients who left the ED without being seen decreased from 5.6% to 2.7%; door-to-physician time improved by 37%; patient satisfaction scores rose from the 17th percentile to the 75th percentile; and throughput time of all patients improved 23%. All of these outcomes occurred without changing staffing numbers. The results of the pilot program prompted the team to re-evaluate the benefit of public waiting spaces and re-assign that square footage to interior clinical waiting spaces.

These interior waiting spaces are used as results lounges, keeping patients vertical and out of treatment beds, but still close at hand for when test results come back. This is much more pleasant for patients and staff. Results lounges can be used effectively as family waiting spaces to personalize the visit. They also provide an atmosphere where private information can be obtained during registration, or to provide discharge information if the patient does not require the use of a treatment room.

Separate waiting areas are effective for imaging services, patient registration, blood drawing, or other lab sample-gathering procedures. It is also important to have waiting available at triage for multiple patient arrival scenarios.

Another area overlooked in front-end design is the process for acquisition of information from patients. Most institutions choose a single method of information gathering, whether it is the traditional registration desk, private registration rooms, or bedside registration. The current patient-flow environment, however, dictates that all methods of registration have a place in the ED, and that by having the flexibility to use them all, EDs will be able to increase patients' satisfaction and improve flow.

Once the renovation and expansion of the emergency department at Hers
hey Medical Center was completed, and the PDQ methodology was completely implemented, the rate of patients who left the ED without being seen was maintained at 0.4%. In addition, the door-to-physician time was 18 minutes and the total length of emergency department stays improved three-fold from the traditional model of emergency care practice.

The design of emergency departments is evolving as rapidly as medical science. Even simple interior alterations like these discussed can make a huge difference in emergency department effectiveness.

Ted Przybylowski, Jr. and Mary Frazier are healthcare architects with EwingCole in Philadelphia. They worked with Dr. Chris DeFlitch, chief medical information officer and vice-chair, Department of Emergency Medicine, at Penn State Hershey Medical Center. Healthcare Design 2010 November;10(11):32-38