ED located next to ICU to bolster patient safety

Staff from both departments can lend a hand

How far is your ED from the intensive care unit (ICU)? How far is it from radiology? What about surgery? At the new St. Joseph's Hospital in West Bend, WI, they are all a few steps away, and this was literally by design.

In the wake of the Institute of Medicine's landmark 1999 patient safety report, To Err is Human, the hospital's leaders — who were considering a replacement facility — began to question whether there were things about a building itself that sets people up to make errors. "We had a few preliminary discussions and then a learning lab, which included people from the Joint Commission on Accreditation of Healthcare Organizations, the aviation and automotive industries, and the National Patient Safety Council," recalls Sue McCullough, RN, director of critical care services at St. Joseph's.

Guiding principles for design

The safety experts told them that design definitely could have an impact on patient safety, and they recommended they come up with guiding principles for the design process. (See the box.) "We decided that all of these elements play a role in errors," says McCullough, explaining the selection process.

Following this process, every department manager in the hospital was given a blank board with squares for each department location, and each was asked to submit his or her department's own design. "Of course, every department thought they belonged on the first floor," says McCullough. The hospital has four floors.

To resolve the conflicts, the staff followed the guiding principles for design and conducted a failure modes and effects analysis (FMEA). FMEA is a methodology for analyzing potential reliability problems early in the development cycle, when it is easier to take actions to overcome such issues. "The ICU was originally on the second floor, but when we looked at the most vulnerable patients and the distances they had to travel, we decided the ICU had to be next to the ED," says McCullough. "The FMEA took out the emotion and put in the facts: We have a tube system, so we did not need the lab near us, and we have Pyxis [medication management system], so we did not need the pharmacy near us."

The 'safest' design

In the final design, the ED is adjacent to many critical departments. On the west side is the ICU, and to the north is computed tomography (CT); thus, it is just out the doors for both departments. On the east side is the mental health unit, and on the northeast side is the outpatient pre-admission area. Also to the north of the ED is the surgery department. (See the floor plan.)

The adjacency of the ED and the ICU is "really key for a small facility," says Mike Murphy, RN, vice president of patient care services. "Our core staffing in either department is not equipped to handle the potentially large patient flows we see from time to time," he explains. "I am a former critical care nurse and managed an ED in a former life, and it would have been great back then to have an ICU right next door."

ICU nurses do not want to leave their unit, but if they just have to walk through a set of doors, they can be back at their bedsides in less than a minute, he says.

There is a similar skill sets in the two departments, so the managers realized they could help each other if they were not so far apart, McCullough says. They have a capacity for 14 beds, and during the day they may have only two nurses, which is not sufficient, she says. "So the ICU can come over and take a cardiac patient, or if there is a full house in the ICU and a patient needs to go to CT, they call the ED and we monitor the patient in that department for them," she says.

No fumbling for a syringe

This change has been made easier by another one of the guiding principles: standardization. All of the monitors are exactly the same in all the departments, so there is familiarity, says McCullough. "Every one of the patients' rooms has 'nurse servers' with seven drawers, and they all have the same stuff in every drawer," she says. "It's not like you have to be fumbling around for a syringe."

Murphy says designing the facility this way did not require any additional funds. Traditional design methods have lot of "mirror" designs, with common headwalls between departments, he says. "What we felt — and our builder agreed with us — was that while we would lose the economy of having common headwalls, we would pick up savings because everything was standardized and could be prefabricated off-site," he says. "Our general feeling was that it was no more expensive than a fairly traditional construction technology."


For more information on safety-related ED design, contact:

  • Sue McCullough, RN, Director, Critical Care Services; and Mike Murphy, RN, Vice President, Patient Care Services, St. Joseph's Hospital, West Bend, WI. Phone: (262) 836-8426.