Design choices can increase ED’s efficiency

Changes improve patient flow, streamline operations

In an effort to increase efficiency and handle increasing patient volume, many EDs are designing new facilities from scratch or remodeling existing facilities. "There is a major contribution that design can make to improve efficiency of operations," says John Currie, senior vice president of Cannon, an architectural, engineering, and planning firm that specializes in health care.

Many EDs are challenged to improve efficiency while facing staff cutbacks. "We need a more effective use of space and equipment with fewer people," says Merlin Lickhalter, a Cannon architect.

It’s important to do firsthand research — What works for one ED may or may not work for another. "When redesigning, you really should be familiar with different EDs in your area," says Peter Moyer, MD, director of the ED at Boston Medical Center, which was redesigned in 1994. "In Boston it’s not so hard — Within five miles you can look at 10 EDs, but in Iowa you’d have to travel to do that."

Accessibility is chief concern

Like many EDs, design problems at Boston Medical Center were extensive. "The ED was not well laid out, with a long way from the ambulance to resuscitation room, room for only two ambulances, a woefully inadequate acute side, and no central clerical stations," Moyer recalls. "Also, X-ray was three floors away and CAT scan was four floors away."

The renovation added six ambulance bays, enlarged the acute side of the ED, created a centralized station, and positioned X-ray and CAT scan facilities next to the ED. "Design has made a major difference in terms of staff morale, patient throughput times, the care we deliver, and literally in terms of saving lives," says Moyer.

Here are some operational and physical issues to consider when designing an ED:

• Keep pediatric and adult patients separate if possible. Depending on the volume of pediatric patients, this may mean specifically designed pediatric treatment rooms or an entire separate ED. Loma Linda (CA) University Medical Center’s new ED will have a single building that will house separate EDs for pediatric and adult patients, with a single entrance and single triage site, a combined fast track, and a separate waiting room for pediatric patients.

Administrators initially planned on having separate entrances for adults and children. "Eventually, they realized the gross inefficiency of having the two separate entrances and acknowledged the validity of a single triage area to serve both adults and pediatric patients," says Lickhalter. A semisecluded circulation path was designed for walk-in pediatric patients who didn’t belong in the trauma area so they could go directly to the treatment areas they’d be seen in.

When designing a pediatric waiting room, it’s important to plan enough space for parents and siblings. "You need a bigger room which can handle additional people without inconvenience," says Currie.

• Make access to key areas a priority. "In the ED itself, you need immediate access to major resuscitation areas. Ours is 20 feet down the hallway from the ambulance entrance," says Moyer. "From there, you need immediate access to radiology, so we have CAT scan right around the corner."

For efficient delivery of lab specimens, consider a pneumatic chute system, which makes the proximity of the lab a moot issue. "Regardless of where the lab is located, you need a system where you can get samples in a hurry," says Moyer.

• Consider benefits of closed vs. open architecture. At Boston Medical Center’s ED, the area housing acute patients has open architecture with no separate rooms. "You’re gaining visual access to the patient at the expense of privacy, but if somebody is seizing or in the middle of a heart attack, you want to see them and not isolate them off in a room," says Moyer.

Patients in the ED’s orthopedic suite also need to be kept within sight. "We often use anesthetic agents in there, and if you don’t monitor patients, you can get into trouble," notes Moyer.

Enclosed rooms with doors or curtains are used for patients with specific privacy needs. "We do procedures such as pelvics on the non-acute side, so privacy becomes paramount and closed architecture is essential," says Moyer. Closed architecture also is used to prevent disturbances from inebriated patients. Psychiatric patients are located adjacent to the ED but far enough away so they won’t create a disturbance. "They often have other problems such as substance abuse, and it’s important to have medical personnel around them," he adds.

There are tradeoffs to openness. Open architecture provides health care workers with auditory and visual access to patients, but also affords ED staff less privacy, with patients privy to conversations that could be misinterpreted. Also, open areas invite exposure to the general public. "On occasion, family members taking the wrong elevators can wind up in the trauma areas, and unwanted traffic becomes a problem," says Luis Alvernaz, an administrator at Boston Medical Center.

• Plan the layout for ideal patient flow. Effective layout of the ED can enable patients to get care without having to go through other areas of the ED. "The goal is to get people from a triaging point near the entrance of the facility, directly to places where care is offered," says Lickhalter.

• Improve your waiting rooms. There are two schools of thought on waiting rooms. Some experts insist that a spacious waiting room is an essential component of a modern ED. Since waiting is the number one complaint of patients in satisfaction surveys, efforts should be taken to make the environment as comfortable as possible.

Seating ideally should include both individual clusters and grouped areas. "That way, we’re not just jam-packing everybody in the same place," notes Currie. "Families may want to be alone at first and then decide they don’t want to be, and you have families with kids and without. You need a variety of choices, while still being under the administrative control of ED."

However, some ED experts say if you’re operationally efficient, you shouldn’t need a big waiting room. "Try to get people out of the waiting room and into an exam room," says Currie. "There’s nothing more disheartening than sitting there with a bunch of sick people and worrying about your kids catching something."

• Establish a private room for family members. "Every ED needs a room where family members of a seriously sick patient wait, or can be told that a relative has just died," says Moyer. "Ours is immediately adjacent to the ED, but you don’t have to go through the ED to get to it."

Depending on an ED’s patient volume, two private rooms may be helpful. Boston Medical Center’s ED has two 12 x 12 rooms with two couches and additional seating. "We’re fairly busy and might have two families who need access to a private area," says Moyer. When a room is in use, a portable phone is hooked up to a jack in the wall. "It’s absolutely key to have a phone so family members can be notified, and a portable phone is ideal so people don’t get in the habit of using the phone in the rooms," says Moyer.

• Consider expanded use of observation units. Many EDs now have observation units, where patients can be held for up to 23 hours without being admitted. In addition to observation, the patient’s initial treatment is often started. "That’s changing the way inpatient medicine is being practiced," says Currie. "Providers are being encouraged to think about shorter stays, and they’ll do everything to keep the patient out of the hospital."

Observation areas should have adequate room for family members. "There should also be space for sophisticated interventional devices, since many observation units are becoming like a hospital within a hospital, where intensive care activity takes place," says Currie.

At Daniel Freeman Memorial Hospital in Englewood, Calif., a planned four-bed observation area is eagerly awaited. "Managed care plans increasingly want us to hold patients in the ED before admitting them, and we want to accommodate them," says Kim Colonnelli, nurse manager for emergency services. "Right now we’re not really set up for that, so those patients are tying up an acute bed, which has a three-inch thick mattress that isn’t too comfortable."

• Create larger treatment rooms. Today’s treatment rooms require extra space. "We’re seeing more being demanded of the exam and treatment spaces," says Currie. "The old 100-square-foot exam room in the ED just isn’t adequate for a whole host of reasons. It’s not just a surrogate doctor’s office anymore."

The population in those rooms is increasing, and the rooms must accommodate extended families, teaching demonstrations, and more extensive procedures. "With a bigger room, it’s easier to get a stretcher in and out; it’s easier to examine the patient, have a visitor sit in with the patient, and do procedures," says Currie. "If something goes wrong, it’s nice to be able to get resuscitation equipment in easily."

• Consider the impact of technology. During the process of construction, plan for future innovations in technology. "It won’t be long until we see virtual or electronic medical records being available to clinicians immediately, so they can see lab results or MRI-acquired images right now on the screen and make notes and change things all within the computer in a paperless environment," says Currie. "We have to be smarter about making the ED a very highly automated environment with fast access to data." Experts agree that significantly increased counter space is important as computer workstations explode in number.

• Move diagnostic testing to the ED. There is a trend toward having radiology equipment in the ED itself. "Our recent experience has been that the the folks in emergency would like more of this equipment in the ED, while the traditional imaging department leadership seems to want to keep it out of the department," says Lickhalter.

In general, it’s better to move patients as little as possible, so it’s important to try to accomplish as much as possible within the ED. "Making the ED a self-contained diagnostic and treatment department is really important," says Currie.

Proximity of ancillary tests can impact heavily on patient care. "When we had CAT scan four floors away, you had to go through a lot of logistic decisions about those four floors, such as is the patient too sick to go up to CAT scan?" says Moyer. "Now with the CAT scan right next door, we can take unstable patients there with a nurse, and you can get the CAT scan in 10 minutes."

• Make the ED as calming as possible. Anxiety builds up quickly in the ED, and design choices can impact heavily on that stress factor. "Coming to the ED is an anxiety-producing affair even with a relatively minor complaint," says Currie. "You’re already in a position where you’ve give up some control over your life. I think it’s almost arrogant of architects and planners to ignore that in their design response."

Design choices such as soothing colors, natural light, and clearly marked signs can go a long way toward alleviating stress. "You also want to give the people who will use the building different kinds of spaces to be in," says Currie. "That way, they can go somewhere else and still be in the confines of the ED, instead of being in one big room like a train station." That may mean a soundproof room off the waiting room for children to play, an outdoor smoking kiosk, or a small library.

ED designers have to rise to the challenge of making buildings people-friendly. "We have to go beyond just keeping water out of the building and making sure it stands up properly," says Currie. "You really have to go to that extra level of thinking about these people as individuals or families just like you and I, except they’re sick."

• Build flexibility into the ED. Although every ED has certain architectural limitations, there are ways to make subsequent changes easier. "Facilities have to be flexible, because things change. Volume may go up, or the community the ED serves may change," says Currie. "You’ve got to remember when designing a building that it’s going to be there for a while, so you need flexible design solutions."

It’s important to think ahead. "Try to forecast at the time of planning which areas might experience future growth over the next few years," says Lickhalter. "For example, we wouldn’t put in a big electrical panel in a wall that may come down in three years, or put in a heating or cooling system which was stretched to the limit, so you couldn’t add a couple thousand feet to it five years down the road."

• Get input from all users of the ED. Patient satisfaction surveys and focus groups will be used during the design phase at Daniel Freeman. "We’ll also get input from our other clients, like EMS, police and fire departments, and the medical staff," says Colonnelli. "We’ll ask them what they need when they bring a patient into the ED in the middle of the night."

• Make plans for operating during the renovation. If the ED isn’t being entirely rebuilt in a new facility, it may be necessary to work in an ED undergoing construction. "We’re looking at pushing out into the admitting department, which is adjacent to the ED, and moving admitting elsewhere while we renovate," says Colonnelli. "We’re hoping we won’t have to renovate our existing space and work in it at the same time."

Some EDs that are expanding simply operate in the new area while the old area is being worked on. Others aren’t so lucky and have to renovate in phases while working in the facility. "It then becomes a checkerboard kind of act," says Lickhalter. "The architect has an obligation to demonstrate what the ED’s environment will be like at certain milestones, with interim snapshots to show you each stage until the project’s completion."

• Make the ED appealing to a broad range of patients. Experts agree the ED needs a new image if it hopes to attract a broader patient population. "In most people’s minds, an involuntary chill goes down the spine when they hear "emergency department," with visions of gunshot wounds and sirens," says Bayliss Yarnell, MD, FACEP, director of Daniel Freeman’s ED. "Clearly, that element is there, but we want an ED which is much more accessible and open, and not intimidating."

A major goal of many EDs is to be able to handle increased outpatient services as the number of admitted patients is decreasing. "We’re looking to expand our ambulatory and urgent care, and that expanded role calls for more space in the ED than in the past," says Yarnell. "As hospitals evolve away from inpatient towards outpatient services, the ED can be a key factor in that transition."

First impressions when walking in the front door of the ED can impact heavily on attracting patients. "Many EDs have cold, grim lobbies with a couple of clerks, and sometimes the windows are bulletproof," says Yarnell. "We serve an inner-city population near South Central L.A., so obviously we need to be concerned with security, but every effort will be made to make this as open and friendly an environment as possible."

• Design for staff efficiency. A major design goal of many EDs is to increase efficiency of existing staff. "Currently we waste a great deal of effort with many unnecessary steps made every day, and the redesign will change that," says Yarnell.