This article was originally published on Feb. 12, 2014, and is among Healthcare Design's Top 10 most-read articles of 2014. To see a full list, click here.

Emergency departments across the nation are constantly faced with increasing and unpredictable patient volumes. At the same time, there’s the constant need to improve quality and efficiency while enhancing the value of medical care provided to emergency patients. Lehigh Valley Hospital–Muhlenberg (LVH-M), a community hospital in Bethlehem, Pa., was in this very predicament, challenged by a growing patient volume that exceeded its ED capacity.

The 23-bed department, which included a four-bed fast track, was completed in 1994, built to accommodate 30,000 patient visits a year (the annual census at the time was 25,000). Between 2004 and 2009, LVH-M experienced rapid growth overall at an average rate of 8 percent, followed by a 4 percent growth between 2009 and 2010. Patient visits surpassed 52,000 annually, a volume that exceeded the hospital’s 2,000 patients/bed threshold and pressed the need to increase capacity.

The ED renovation
Goals for a new space were to not only manage patient volumes, but to do so with a team that sought a transformation of both space and operations. ED leaders, providers, nurses, and ancillary staff worked collaboratively with consultants including Todd Warden, MD, of Emergenuity (Woodbury, N.J.), in-house project managers, and architects including NBBJ (Seattle) to develop an innovative design solution, adopting a model designed for the rapid assessment and evaluation of emergency patients: a rapid assessment unit (RAU).

Using this model, developed by Emergenuity’s Warden, a patient would arrive at the ED and be seen in the RAU by an intake team composed of a nurse, registrar, and provider who would quickly evaluate the patient and provide immediate treatment.

The renovation of the department provided the opportunity to develop a dedicated space to support the logistics of the RAU function. This new unit and method allows the ED team to improve throughput metrics, safety, and quality of care. For example, by minimizing the waiting room experience, a more immediate connection between providers and patients creates a new level of patient satisfaction and value.

Patients rarely wait to be seen, and, in fact, the RAU was constructed in the footprint of the ED’s existing waiting room space with a smaller waiting room designed for the RAU model to accommodate visitors. On average, patients wait 20 minutes. After the rapid assessment is complete, the patient is moved to another section of the ED for further care, creating a constant stream of patient flow that keeps the RAU beds available to incoming patients.

Another important aspect of the ED renovation was the differentiation between “vertical patient flow” and “horizontal patient flow.” The RAU team decides whether a patient would be better served by remaining seated (vertical) or by taking a recumbent position (horizontal), as opposed to placing all patients on a stretcher regardless of need. Vertical patients remain seated in a chair or recliner while they receive minor treatment and/or wait for test results prior to discharge. This occurs in a space designated “internal disposition area” (IDA).

By eliminating the need for stretchers, the IDA can accommodate a greater number of patients per square foot than the traditional emergency design. Furthermore, these patients can flow through the system more expeditiously. Sicker patients, who require a more intense or thorough workup, are placed on a traditional stretcher and moved to the main emergency room for more in-depth testing and treatment.

Keys to success
The sum of these changes at LVH-M has led to a net increase in capacity through the efficient use of space while at the same time significantly improving ED metrics, quality of care, and patient satisfaction. The arrival-to-physician time decreased from an average of 60 minutes to 20 minutes. Volume increased by 5 percent, while the number of patients leaving without being seen decreased from 2.4 percent to 0.2 percent. Overall length of stay also decreased. Patient satisfaction scores have also seen a dramatic increase, moving from the 40th percentile to the 90th percentile, while hours of ambulance diversion decreased from approximately 700 hours per year to 0 hours over the past 11 months.

The LVH-M project illustrates that by creating smaller, more efficient units within the ED, operations were improved, as process linearity was eliminated and replaced with the more efficient parallel method of the RAU. Its success was achieved through the collaboration of design professionals, architects, consultants, department/hospital leadership, along with the engagement of frontline staff and an open dialogue between all. Simply expanding the size of an inefficient and outdated ED may have only lead to greater inefficiency.

As we approach the challenges and uncertainty of healthcare in the 21st century, it’s clear that improving patient care will be driven by innovative thinking and redesign. Ultimately, we can achieve better outcomes in patient care through this type of approach. This is one example of how thoughtful spatial redesign can lead to operational excellence.


John F. Wheary, DO, MBA, FACEP, is the site director for the department of emergency medicine at Lehigh Valley Hospital-Muhlenberg. He can be reached at