Emergency Response: Answering Patient Needs With A Standalone ED
In a 2013 market review, New Hanover Regional Medical Center (NHRMC) of North Carolina identified the need for a new 29,000-square-foot, 10-examination room emergency facility in northern New Hanover County, N.C. The region is undergoing rapid growth and is popular among young families and seniors. Moreover, the market fluxes dramatically thanks to a thriving tourist industry, especially in the summer months.
In addition to the population and demographic trends captured, customer feedback identified the need for a convenient and accessible location for emergency care in the area. Providing this option stood to increase patient satisfaction and help alleviate high patient volumes in NHRMC’s other two emergency departments (EDs).
With these factors in mind, NHRMC proceeded with a $15.1 million capital investment to create a standalone emergency department (SAED) to meet the current needs of the region as well as anticipated future growth.
Like retail clinics and virtual care centers, SAEDs are among innovative healthcare design typologies aimed at improving the quality, affordability, and accessibility of care. These facilities provide 24/7 emergency services in a dedicated space apart from, but often affiliated with, a hospital. A notable difference between traditional EDs and SAEDs is that SAEDs typically have fewer hospital admissions and shorter wait times.
The design of the NHRMC Emergency Department North (ED North) aimed to be functional and comfortable for patients, visitors, and caregivers. At the beginning of the project, a workshop was held to define how processes could be redesigned to achieve optimal patient- and family-centered care.
A Lean 3P (production, preparation, and process) approach was used to facilitate the rapid creation and evaluation of ideas, with the goal to design a space that supports patient flow and efficient care delivery while also reducing waste. To meet this goal, a multidisciplinary team model of emergency, laboratory, pharmacy, transport, and radiology personnel was formed.
Time to wait
A challenge many emergency departments face is having available exam rooms to treat all patients during peak hours. The team decided that to prevent unnecessary wait times, a patient entering the front door of ED North would be greeted by a triage nurse who could rapidly assess the acuity level of the patient. By increasing the amount of triage bays and providing patient registration at the bedside, the number of patients in the waiting room was expected to be drastically reduced.
Under the proposed model, ambulatory patients would be guided to triage for registration and, from there, head to a “results pending” area to wait for lab results in a quiet space away from other ED operations. This area would accommodate patients who don’t require a bed to lie down, with the overall design allowing for the sicker or “horizontal” patients to be the priority for treatment rooms in the main area of the ED. Moreover, by separating low-acuity from high-acuity patients, exam room bottlenecks could be avoided.
To ensure that the model would lead to a reduction in wait time as anticipated, a simulation trial was undertaken at the NHRMC Orthopedic Hospital emergency department. The patient treatment flow in the ED was adjusted to replicate the system proposed. Time motion studies and patient interviews were conducted throughout the trial to determine if wait times and patient satisfaction were impacted.
The results revealed improved patient satisfaction and faster door-to-door times, with the average time spent within the department reduced by 49 percent. Based on these results, the final design of ED North includes four triage bays and a 400-square-foot results pending area with seating capacity for 10 patients.
Examining the exam room
A structured mock-up experiment was also used to test various exam room configurations and patient flow models. Built within a large storage room at NHRMC’s main hospital, the exam room was made of typical stud construction walls, foam cutouts as cabinetry, spare fixtures, and medical equipment to simulate the proposed designs. Several sessions were held with existing ED caregivers, and in between walk-through sessions, the mock-up room was reconfigured to test a variety of layout options. For example, family zone seating and sink location were switched from one end of the room to the other. Once the participants toured the room, they were given a questionnaire asking about the performance of the room’s design.
To prevent biased responses, staffers were asked not to speak with one another while viewing the mock-up or responding to the questionnaire. None of the participants knew that the mock-up room’s configuration was altered between sessions.
The experiment revealed several statistically significant impacts of the design on the participants’ responses. For example, participants did not approve of the sink on the headwall because it was an obstacle to family-centered care; a sink at the footwall was preferred because handwashing could take place before and separate from entering the sterile care zone around the patient bed.
Family seating at the footwall was seen by many as an obstacle for portable equipment such as X-ray machines. Moreover, family seating at the footwall was also found to affect family-centered care, with 26 percent of participants saying they were less likely to face and communicate easily with patients and their visitors in that configuration. Additional analysis of the participants’ open-ended responses demonstrated that placement of family seating at the headwall would allow the visitor to advocate for the patient during emergencies and while a caregiver was at the bedside.
Based on this process, the sink was placed at the footwall and the family bench at the headwall. The outcome reduced the square footage and the amount of cabinetry required in each exam room.
Research informs design
The Patient Protection and Affordable Care Act redefines the landscape of healthcare delivery with a greater focus on improving the quality, affordability, and accessibility of care within a variety of healthcare environments, with new innovations being identified, such as SAEDs. Design research methods—Lean events, simulation trials, and mock-up experiments—are becoming necessary design delivery tools that demonstrate the value of a potential design to meet and even exceed the aims of the reform, with the ED North research process serving as just one example of this. It validated and advanced design for a new care model that stands to provide long-term value from operational efficiencies and an improved patient experience.
Hilke Schoonvliet, EDAC, LEED Green Associate, is a healthcare planner at BBH Design (Raleigh) and can be reached at firstname.lastname@example.org. Nicholas Watkins, PhD, is director of research at BBH Design (Raleigh) and can be reached at email@example.com. Christy Spivey, RN, BSN, MBA, CEN, NE-BC, is an administrator for emergency department and trauma services at New Hanover Regional Medical Center and can be reached at firstname.lastname@example.org. Chelsea Greemore, AIA, LEED AP BD+C, is an architect and associate at BBH Design (Raleigh) and can be reached at email@example.com.
The authors would like to thank Jack Barto, president and CEO of New Hanover Regional Medical Center; Mary Ellen Bonczek, NHRMC’s chief nurse executive; Donna Bost, NHRMC vice president; t
he leadership team of the NHRMC emergency departments; NHRMC construction and planning services; NHRMC Lean department; the multidisciplinary Lean 3P team; Healthcare Performance Partners; Tim Spence, principal and healthcare market lead of BBH Design; Steven Triggiano, project manager for BBH Design; Nathan Zeidler, project architect for BBH Design; Esperanza Harper, medical planner and research associate for BBH Design; and Julie Zook, research associate for BBH Design.