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Quality Matters: Data Drove Design of University of Kentucky ED

Welch, Shari J. MD

doi: 10.1097/01.EEM.0000403714.25284.e6
Quality Matters

Shouldn't an emergency department be optimally designed for the patients it sees and for the work being done? Is it possible to find architects who have made a career of designing high-functioning emergency departments and who have a sophisticated understanding of patient flow and workflow, which is evident in their designs? Is there anyone designing and building emergency departments for efficiency, quality, and safety? If you have ever asked these questions, this is a story you need to hear.

The Center for Health Design brought providers interested in research-based health facility designs into the Pebble Project in 2000 with a radical idea: Let data drive design. Goals other than simple aesthetics can and should be built into health facility design. Architects certified in evidence-based design (Evidence-based Design Accreditation and Certification [EDAC]) use research on operations, quality, safety, and efficiency to inform their architectural projects in health care. Leaders like the University of Kentucky's Daniel Miesle, the university's director of facility planning, and Roger Humphries, MD, the chairman of emergency medicine, joined the team. The project partners meld the usual aesthetic requirements with goals to improve ergonomics, patient and staff satisfaction, response time, workflow, process, and return on investment and to reduce length of stay, staff turnover, and workplace injuries.

The University of Kentucky had lofty goals for its new Chandler ED. They wanted a department that was easily accessible to patients so they could easily find their way around, with a convenient entry and a design that made sense. They wanted an efficient department where everything was designed around patient flow and workflow. And they wanted a design that would grow as technology and processes changed. That is a tall order for the design of a new department but an extremely innovative and progressive one that will serve the institution well over time.

The university leadership began planning in 2005, calling on the talents of Jim Lennon, AIA, ACHA, an architect who trained at California Polytechnic Institute and the University of California, Los Angeles, and who has spent his career designing more than $700 million worth of health care facilities. Mr. Lennon has been particularly focused on ED design, and teaches the renowned Harvard ED Design Course. He understood that the design needs of the Chandler ED would depend on the census, acuity, and services provided. He was able to offer the University of Kentucky leadership important design ideas that enhanced work flow. A number of critical design elements were added when the design team married contemporary research to data about the Chandler ED and the services it provides to the community. This allowed for a customization of the ED design based on the type of patients they treat and the work being done. The ED is designed to breathe; pods open and close to accommodate the census changes, and patients are segmented, with pediatrics and lower acuity patients seen in separate zones. Features of the ED include:

* Geographic zones with 12 rooms per pod.

* Attention to noise to make it a low-decibel department.

* Decentralized work areas allowing each zone to function as a separate operational unit.

* A chair-centric fast track to keep patients vertical.

* Work stations designed for the work that takes place in them.

* A large trauma suite that can accommodate six to eight beds.

* Acuity adaptable rooms (a low-acuity room can immediately become a resuscitation suite by raising the headwall).

* Decentralized supply locations to save steps.

* Lighting that the patient and family can control.

* Touchscreen kiosks to help visitors and patients find their way around the facility.

* A swing area that can function as part of the pediatric or adult ED depending on census.

* Lab and radiology straddled by the adult and pediatric EDs. Radiology includes two plain film suites, two CT scanners, an ultrasound suite, and a radiologist's reading room. (EDs often do not allocate enough space for ancillary services.)

* Kiosks for EMS arriving with patients to avoid staff interruptions.

* Power column booms that provide power for all the required technology that might be used now and in the future.

* Psych-safe rooms with ceiling-mounted cameras, a garage-door mechanism to secure monitors and other equipment for safety, shatterproof glass windows, and an adjacent security guard station.

Each pod eoperates as a discrete functional unit, and is supported by a core support area that includes its own medication room, supply area, pneumatic tube, and nourishment center, which minimizes distances staff need to travel for core needs. Infection control was also an important consideration in the Chandler ED design, and considerable time was spent designing infection control into the area, including sinks at the entry of exam rooms and specially designed patient protection and evaluation cabinets outside each pair of exam rooms. The EDAC architects also tried to create a healing environment, placing original art in every exam room. The initiative was part of the new Arts in Healthcare program, and allowed the ED staff to choose the pictures as a team-building activity. All rooms have TVs, pediatric rooms have Xboxes, and the waiting area has an interactive wall.

The attention to communication strategies and noise was fastidious and clever. The emergency department was told there would be no overhead paging system, and they had to craft communication strategies using other modalities. Using a tiered communication system that includes a mixture of face-to-face communication, voice necklace radios, status boards, and dedicated cell phones, the frontline workers developed a carefully crafted communication strategy. After several months, they were allowed to use overhead paging for emergencies, but the new system was well-established and, according to Dr. Humphries, there have been only two overhead pages in the nine months since Chandler opened.

Staff reported that the stress level has decreased with the decibel level, even on busy shifts, providing a calmer environment for patients and families. The Chandler ED is paperless, and that's with 24 residents and at least 50 people on duty at a time. This means access to information is critical, but the ED has an abundance of computers — a whopping 240 in the department! ID badge proximity readers make for easy log-on. An EMS status board also alerts the staff to incoming trauma and transfer patients.

Your CFO is sure to ask about cost. Speaking at the American College of Healthcare Executives Spring Congress in March, Sara Marberry, the executive vice president of the Center for Health Design, and Blair Sadler, the former CEO of Rady Children's Hospital in San Diego, said a typical project incorporating evidence-based design may run 2.5 percent more than traditional construction (based on the first complete hospital design at Fable Hospital). But the return on that slightly increased investment includes things like decreased falls and infections and increased patient and staff satisfaction, which can be more difficult to quantify using typical financial accounting strategies. These costs are recouped in many different measures and market share, they said.

One particularly interesting feature of the Chandler ED design was the morphology of the fast track. At the time of the design, the leadership could not decide whether to build a traditional fast track with beds or a chair-centric area with one examination space and a bank of recliners. Using hypothesis testing, they tested two design models, and found the chair-centric design lowered their left-without-being-seen rate from five percent to one percent. Length of stay in the fast track was reduced by 34 percent, and patient satisfaction scores soared. The final design employed the bank of chairs model, which research has shown to be efficient and well-liked by patients.

By all early reports, the Chandler ED, which opened in July 2010, is a patient and staff satisfier. Planned and designed by a leadership team that was determined to make the space aesthetic while increasing quality, safety, and efficiency, it is a department designed based on evidence and built for the work that takes place in it. Hats off to Dr. Humphries and the entire University of Kentucky team for all they have accomplished!

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