Anniversaries invite review of the past and visions for the future. As HEALTHCARE DESIGN celebrates 10 years, it is interesting to look back—from a former emergency department nurse’s perspective—at how emergency departments have evolved and—now, from a healthcare advisor’s perspective—how lessons of the past and new research are optimizing staff performance and the patient experience.
Emergency medicine has made great strides as a specialty practice since the first residency programs began in the 1970s. The role emergency departments play in the healthcare delivery system has become pivotal in the day-to-day delivery of care. Its importance is demonstrated by the overwhelming number of articles, research studies, focus groups, national reports, webinars, and blogs on the subject. It is amazing to examine the progression.
ER to ED evolution
Back in the 1970s and 1980s, the “emergency room” (ER) had more open bay beds than private rooms, less medical equipment, fewer staff on duty, and there was no need for large waiting areas. Board-certified emergency physicians were not the norm, nor were nurses specially certified to handle the vast range of patient ages and clinical cases. Finding specialists for referrals was easy compared to today.
Fears of bioterrorism were uncommon, though mass casualty drills were routinely conducted. Patients’ throughput was tracked by “where” the chart was placed. High-tech equipment included cardiac monitors, and glucose monitors and dip sticks were the point-of-care testing. As demand increased, dedicated X-ray technicians were appointed, but ERs still depended upon remote printouts or phone calls for diagnostic test results.
Yesterday’s ERs typically had easy lines of sight and earshot from the nurses’ station, at the expense of patient privacy. Nurses manually managed supplies, routinely mixed medications, obtained long histories at triage, and had time to hold patients’ hands. Nurses spent considerable time walking—looking behind curtains for physicians or care team partners, or back and forth to the supply cart, telephone, or unit secretary desk. There were few delays in getting patients to an inpatient bed, and mental health patients were easily transferred to community resources.
The 1986 Emergency Medical Treatment and Labor Act, the unfunded act granting rights to emergency care for everyone, was a key trigger to ER volume growth. As hospitals adapted to keep up with escalating volumes, the importance of emergency services received greater recognition with the development of trauma systems to expedite response times and heightened awareness of the role the ER plays in meeting business and community commitments. The ER’s new demands necessitated specialized care providers to expand its capabilities.
New “product lines,” such as observation beds, chest pain centers, and fast tracks, were developed to improve patient throughput. The ER became a recognized hospital “front door,” and thereby its impact on user satisfaction and hospital reputation gained more attention. With this transformation, the ER matured into the “emergency department,” (ED) signifying its broader impact on healthcare business.
Since the 1990s, we have seen continued growth in the volume of people seeking emergency care, while the number of hospital EDs has decreased and access to inpatient beds has lagged. In 2006, the Institute of Medicine proclaimed that our EDs were in crisis. AHA Trendwatch reported growth in ED utilization rates increased from 351 visits per 1,000 in 1991 to 415 visits per 1,000 by 2009. During the same period, the number of hospital EDs decreased 10% and the number of hospital beds shrank by 198,000.
Currently, the majority of teaching and urban hospitals report their EDs are at or over capacity. Level I trauma centers and hospitals with more than 300 beds are even more stressed. On top of ever-escalating volumes, EDs are experiencing significant physician and nurse shortages. Though the pressures on EDs are daunting, operational experts, researchers, planners, and designers are helping providers overcome their challenges in a variety of intelligent ways.
Shaping the ED of the future
Institutions are taking advantage of opportunities to improve old, inefficient layouts and install advanced IT and point-of-care technologies, and implement new workflow processes to improve throughput, communications, and diagnostics. Merging the insight of clinical and design experts has proven most effective in creating the optimum emergency care environment focused on the experience while maximizing efficiency. The ED of the future will build upon findings from the newest generation of design. Key aspects of best performance EDs include:
Lean principles and EBD. As planners and designers, we have learned a great deal from Lean and Six Sigma processes. Better outcomes and achievements result from standardized spaces and designs that support proven practices and improved workflow. Efficient layouts and tracking systems reduce time spent traveling for supplies or searching for care team members, and increase nurses’ presence at the bedside. Time and motion studies, mock-ups, and simulation models are used to test new models of care and add the rigorous assessment required to justify the costs of improvements and identify benefits of reduction in risks.
Pressure will increase for hospitals to be goal-oriented and provide measured post-occupancy performance. Routinely reviewing new research nets crucial knowledge for the continual enhancement of the environment of care. Today there is easy access to vast volumes of information that critique and validate leading practices as well as quality improvement initiative groups, where data, protocols, and operational tools are shared for collaborative performance improvement.
New care delivery models. Operational models are driving departmental layouts that better support team delivery of care. Essential to safety, efficiency, and improved outcomes is the creation of spaces to improve collaboration and communication for the medical team. Incorporation of advanced communication technologies, information management, and decision support is crucial to maximizing physicians’ time. Future adaptability—thoughtfully considering adjacency relationships and future capacities and uses, column grids, floor-to-ceiling heights, weight-bearing and removable exterior wall sections—is key to accommodate growth.
Technologies. Though technologies themselves amplify throughput and quality of care, the location and application of the latest advancements—sophisticated diagnostic imaging, point-of-care testing, physiologic monitoring capabilities for every room, wireless access to electronic records and decision support systems, tracking systems for people and equipment, and pharmacists workstations—dictates their effectiveness. The ED’s adjacency to other high-tech, functionally important departments, such as radiology, surgery, critical care, acute care, and the helipad is a key consideration. And, as more EDs adopt electronic medical records, there will be increased opportunities for researchers to mine the data and contribute to improving care and delivery models.
Disaster preparedness. Today’s EDs reflect the threats of our time. New antimicrobial products are installed to reduce the risk of infections and cross-contamination, while air handling systems are highly technical and can meet a changing desire to isolate “neighborhoods” of the department if needed for bioterrorism or to meet a surge capacity of a pandemic outbreak. An Institute of Medicine report suggests that to strengthen disaster response, it is imperative to have an effective emergency system that is functional on a daily basis.
Trends. Eighty-nine percent of ED physicians (as reported by the American College of Emergency Physicians) believe visit volumes will continue to increase. The vast majority of patients seeking emergency care do indeed require attention, as less than 8% have non-urgent medical conditions (as reported by the Centers for Disease Control and Prevention). As volumes escalate, stronger networks between EDs and primary care, and other community providers such as medical homes and community health centers, are becoming crucial again for follow-up care and ongoing health maintenance. EDs are continuing to develop and refine creative delivery models to better serve varying levels of acuity, such as fast-track areas for less serious cases. Freestanding emergency departments are also successfully helping to ease hospital ED traffic.
With increased scrutiny regarding “appropriateness of admissions,” observation beds or other extended treatment spaces provide an alternative pathway to care for patients needing focused treatment and extended assessments while supporting desired ED throughput. There will be a need for expanded access to after-hours clinics and same-day appointments at the primary care site. More people are expected to access medical advice lines as healthcare reform is implemented. All these trends will help mitigate ED use.
The road ahead
The ED has gone through tremendous change over the past 10-15 years—amplifying the quality of care, expanding access, and improving privacy and safety while being confronted with unprecedented volumes. The next 10 years will also see radical change as the healthcare system faces the challenges within the economics of care delivery and struggles to find the best balance to provide the most appropriate level of care, by the right providers at the right time. One thing does remain constant—the dedication of hospitals, physicians, and nurses to provide the highest level of patient and family-focused care. HCD
Beverly A. Dorney is a Senior Vice President at FKP Advisors. She can be reached at 214.750.9900 or bdorney@fkp.com. For more information on FKP Advisors, visit www.fkp.com.