Innovative design solutions: Second floor emergency department?
When the 23-story Ann & Robert H. Lurie Children's Hospital of Chicago opens in June 2012, it will demonstrate a unique approach to hospital high-rise design. The urban site presented a particular challenge for the design team with a fairly small building footprint, leaving a question as to how to best accommodate growing patient volumes in the new hospital's emergency department (ED). Using research, simulation, and meetings with key internal and external stakeholders, the design team developed nontraditional solutions for both the location and patient access to the ED.
Ann & Robert H. Lurie Children's Hospital of Chicago will replace Children's Memorial Hospital, a 270-bed, freestanding children's hospital and academic medical center located in the Lincoln Park neighborhood of Chicago. This state-of-the-art, 1.25-million-square-foot hospital will house 288 inpatient beds (60 PICU, 60 NICU, 144 Acute Medical/Surgical, 12 Psychiatry, six Research, six Epilepsy), multiple pediatric subspecialty outpatient clinics, and a three-floor interventional/procedural platform with 21 operating rooms, five interventional radiology rooms, and the latest diagnostic imaging services. In addition, Lurie Children's will offer a 45-bed emergency department, named The Kenneth and Anne Griffin Emergency Care Center, though this will be located on the hospital's second floor. The decision to locate the emergency care center on the second floor and the considerations for patient access reflect features unique to the chosen site for the new hospital and substantial operations planning.
The decision process to identify the location of the new hospital began in 2005 and over a dozen sites throughout Chicago were considered during the selection process. In the end, it was determined that the future growth of the academic medical center would be best served by relocating the hospital to the downtown “Streeterville” campus of the Northwestern University Feinberg School of Medicine. The decision to move to the Streeterville neighborhood acknowledged a vision to leverage the tremendous opportunities for collaboration within patient care, teaching, and research on the Northwestern medical campus. This location, however, also offered some distinct challenges for our design team. The chosen site, which is adjacent to the recently constructed Prentice Women's Hospital, offered a footprint of only 1.8 acres and would require the construction of a high-rise. Early design planning indicated that the maximum available space on any one floor would be no more than 55,000 square feet.
The ED at Children's Memorial has sustained significant volume growth over the past decade, well in excess of reported ED growth rates nationally. The ED served nearly 40,000 patients in 2000, and this had grown to more than 60,000 visits by 2007. Planning for continued growth at the Lincoln Park site, combined with further growth expected in the new facility, provided conservative estimates in the 68-75,000 annual visit range for the first two years of the new hospital's operation. It was clear that a much larger facility would be needed than the admittedly undersized ED (18 beds in 9,700 square feet with an additional seven urgent care exam rooms in an adjacent 2,300 square feet) in the existing hospital. Space planning and patient throughput exercises, using a 75,000 annual visit model, projected an optimal ED facility with a range of 45 to 55 examination rooms. The question that remained was the following: how big an ED could the new facility house?
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Reflecting traditional thinking, preliminary planning for the emergency care center considered the first floor of the new building. The first floor would need to accommodate some patient arrival and lobby functions, but a more formal and larger lobby would be located on a higher floor. This concept had to be reconsidered when it became evident that the new facility would need to house an internal loading dock function. The size of this loading dock, combined with vehicular drop-off lanes, numerous elevators, and an entry area for ambulances, would leave less than 500 square feet on the first floor for the ED.
Our design team briefly considered the concept of a two-floor ED, with the highest acuity children (e.g., trauma patients) receiving care on the first floor adjacent to the EMS entry point, and with the remaining and larger component of the ED on the second floor. This idea was quickly put aside as it was clear that this would be very challenging to operate and would likely pose a number of patient safety concerns. We searched for working examples of multifloor EDs, and the few examples we found confirmed the concerns we had regarding clinical operations, care quality, and patient safety.
Our design team then considered the second floor as the future location for the emergency care center. This offered more space than the first floor (even if we had access to the space now allocated for the loading dock) and would allow us to resource an emergency service that would better support our anticipated growth. In our present location, the vast majority (85-90%) of the patients we care for arrive via a private vehicle. Most of these patients/families park their car in the garage directly across the street (or on the street) and cross this fairly busy urban street to access the ED. In our future location, our patients/families will also park in a garage located across the street from the new hospital, though this garage will be connected to Lurie Children's via a bridge on the second floor. Therefore, for the vast majority of our patients, the second floor location will make the emergency care center more accessible (and safer!) as this would be the first area these patients/families reach as they enter the new hospital from the parking garage bridge.
The bigger issue, of course, was access for the many patients transported to the hospital via EMS and other ambulance providers. A secondary concern would be those patients who are driven to the hospital by their families, who would be unable or perhaps unwilling to park in the garage. Today, these families can access the hospital's ambulance driveway and drop their children off at the ED's ambulance entrance.
Our planning for these patients again began with a traditional solution, a ramp that would ascend one story up the side of the hospital, allowing vehicles to drop patients off on the second floor.
This access model posed many more problems than it did solutions. First, the characteristics of the site and the structure would limit the width of this ramp, making it difficult-if not dangerous-for more than one vehicle, and particularly larger ambulances, to use the ramp at any one time. Second, these same characteristics would require the ramp to have a 20-degree slope, making the climb up the ramp a significant challenge for inexperienced drivers and larger vehicles, particularly in bad weather. Finally, the ramp plus the parking and turnaround area created on the second floor would come at the expense of space available for the clinical program. This reduced available space translated to an ED with 22-24 beds at most. After struggling for more than a decade with an undersized ED in Lincoln Park, this plan appeared to offer that same immediate outcome in the new hospital.
Our design team went back to work, developing solutions that would maintain a sufficient clinical program footprint to support our anticipated volumes and growth, while affording timely access for patients arriving by ambulance and for those who might need to be dropped off by their families. Added to this, our team also considered emergency care center access for patients arriving via the helipad, which would be located on the roof of the new hospital.
In our list of desired attributes for the new hospital, ED clinical leadership had expressed a preference for a climate-controlled facility for arriving ambulance patients, and likewise, an area for patient decontamination. The weather extremes in Chicago, particularly mid-winter, can be challenging for acutely ill or injured children. Due to their unique anatomic and physiologic characteristics, children are especially prone to the deleterious effects of hypothermia. Currently, our hospital's ambulance entrance is covered, but otherwise not protected from the elements. Our present decontamination facility is a tent, which is set up in an area near the ED entrance. While the tent is heated and we endeavor to use heated water, once decontamination is complete, treated children must then traverse the external environment to access the hospital.
By moving the emergency care center to the second floor, we now had space available for an ambulance bay. This ambulance-only entry on the Chicago Avenue side of the building would offer a secure entrance and climate-controlled garage for these arriving patients. Built into this ambulance bay would also be our climate-controlled decontamination facility. Likewise, an area for families seeking emergency care who need to drop their children off would be established at the entrance of the new hospital, off the proposed driveway. This emergency care center arrival location would be distinct from the area used by patients and families arriving and/or departing the hospital for all other purposes.
But how would ambulance patients and paramedics then access the emergency care center? The solution would be found with a series of dedicated elevators. To assure continuity of operations, the ambulance bay will offer a primary elevator option and several back-ups. There will be two elevators dedicated solely for the ambulance bay and emergency care center, these will serve as the primary access route for ambulance patients. These elevators will be sufficiently large to accommodate a patient stretcher and several care providers. On the second floor, these elevators will offer immediate access to the critical care core of the emergency care center, just steps away from the trauma/resuscitation rooms. In addition to the two dedicated ambulance bay elevators, two trauma/critical patient transport elevators, which link the helipad to the rest of the hospital, will serve as a back-up for emergency care center access, as well as direct access to other hospital units (e.g. the ICU) and floors. The trauma elevators also offer immediate access to the critical care core of the emergency care center. In addition to the ambulance bay and trauma/critical patient transport elevators, there are two elevators adjacent to the ambulance bay designated for the transport of noncritical patients. These elevators will serve floors 1 to 23.
At the hospital's main entry on the first floor, families seeking access to the emergency care center will be directed to a special entrance and drop-off area separate from the main entry. This entrance will be staffed so that families requiring urgent assistance will receive the support they need. An emergency valet service will be available for car drop-off, thus allowing parents to remain with their children. This entrance will offer timely access to the emergency care center via two dedicated and strategically positioned elevators. Families arriving to the second floor through these elevators will find that they are literally steps away from the patient check-in desk and triage rooms. Disaster and emergency power plans will assure that the dedicated emergency care center elevators, as well as trauma and patient transport elevators, will be prioritized to operate during such events.
This design plan appeared to afford an opportunity to maximize the available clinical space on a single floor for a high-volume and high-acuity urban children's hospital ED and trauma center, and efficient access for patients arriving by ambulance, car, and helicopter. It also offered an opportunity for a secure climate-controlled ambulance bay and decontamination facility. The proposed system of elevators appeared to be safer and perhaps quicker than the alternative solution employing a steep ramp. The second floor location also offered optimal access for the vast majority of our arriving patients via the bridge from the parking garage. Our design team believed this to be the best of all available solutions. This belief also needed to be evident to key stakeholders: our local EMS agency, the Chicago Fire Department, the trauma system, and the medical and administrative leadership for the Chicago and Illinois Health Departments.
A series of meetings with these key stakeholders was necessary before we could proceed further. We were able to demonstrate, through the use of simulation, that the actual transit times to our resuscitation/trauma rooms for critical patients arriving via ambulance through the proposed first floor ambulance bay and emergency care center elevators was quicker (55 seconds) than the time it would take for that same patient inside an ambulance climbing the proposed ramp, backing into a parking area, and entering on the second floor (75 seconds). The potential hazards of patient transit in the elevators were effectively contrasted to the risks of the narrow and steep ramp. Finally, the implications of an undersized ED and the shared interest of hospital leadership, our planning team and our community partners in our ability to meet the needs of growing patient volumes was also discussed. In the end, we were successful in stating our case and our design for The Kenneth and Anne Griffin Emergency Care Center was approved.
We now have the opportunity to study the implications of some of the innovative features unique to this vertically organized hospital. Among these include the efficiency and safety of high-acuity patient transports, including those external to the hospital (e.g., critical patients arriving by EMS and/or helicopter to the elevator-dependant emergency care center,) as well as intra-hospital patient transport (e.g., trauma patient transit from the second floor to the ICU or OR). A second floor ED may ultimately prove to be a desirable and effective option to a traditionally located first floor ED, particularly for hospitals constructed on urban sites, or those in flood-prone areas. Our participation in the Pebble Project will provide a valuable opportunity to conduct research in our new facility and we aspire to add to the body of evidence on the relationship between healthcare design and care quality and patient safety. HD
Steven Krug, MD, is Professor of Pediatrics at Northwestern University Feinberg School of Medicine and Head of Division of Emergency Medicine at Children's Memorial Hospital.
Katharine Bertani is Manager of New Hospital Transition and Occupancy Planning at Children's Memorial Hospital.
Sue Ann Barton, AIA, LEED AP, EDAC, is Principal at ZGF Architects LLP. Healthcare Design 2010 August;10(8):14-21