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ED Redesign Takes Study and Imagination

Welch, Shari J. MD

doi: 10.1097/01.EEM.0000326304.06286.5e
Quality Matters

Dr. Welch was the quality improvement director in the emergency department at LDS Hospital in Salt Lake City for 10 years. She is on the faculty at the Institute for Healthcare Improvement in Boston and speaks internationally on emergency department quality improvement. She also has served as a quality consultant for VHA, is a member of ACEP's quality improvement and patient safety section, and is a member of the Emergency Department Benchmarking Alliance. She has been published in numerous journals, and just finished her second book, “Quality Matters: Creative Solutions for the Efficient ED” to be published by Joint Commission Resources Publishing.



With 40 percent of EDs remodeling, designing geographic zones to function as smaller units is an idea whose time has come. Using design to downsize into separate operational systems is a strategy that can help manage the chaos of high-volume EDs.

But a few other design modifications also are necessary for the high-volume ED, including staff corridors (vs. public corridors), different types of work space, intake, diagnostic waiting rooms, discharge spaces, and multifunctional rooms.

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Corridors and Work Spaces

As an ED grows, an increasing number of people will travel its halls. From the patients' point of view, liberal visitation is preferred and will likely become the norm. Complex patients will require an array of diagnostic tests, treatments, and consultations, and this means increased traffic by staff. Among the newer concepts for ED design is having public and staff corridors. This puts the central work zone in a wide staff corridor through which health care workers can traverse and talk freely without worrying about privacy issues. Family members access patient rooms from a different corridor to ensure limited and appropriate access. This may decrease the burdens of HIPAA and privacy to a reasonable level.

The team sport of emergency medicine reaps communication, safety, and efficiency benefits when the staff has access to one another and frequent face-to-face encounters. “Doctor, Mr. Brown is looking a little short of breath again” may turn out to be critical information for the caregivers to exchange. Design which puts them in the same space for these encounters will decrease errors and improve efficiency through improved communication.

That said, there are times when a physician needs uninterrupted time to concentrate on documentation and conversations with consultants. Similarly, for safety reasons, nurses need uninterrupted space to prepare and dispense medications. ED designers should consider creating separate spaces for teamwork and independent uninterrupted work.

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Intake and Waiting Rooms

The need for an abbreviated intake process is practically self-explanatory, but EDs need a greeter and some sort of intake, and these needs increase with volume. According to VHA, the following hours of triage and greeting based on census are needed.

  • ▪ Under 20,000 volume: 0–12 nurse triage hours per day.
  • ▪ 20,000-40,000 volume: 12–24 nurse triage hours a day and 12 greeter hours a day.
  • ▪ 40,000-60,000 volume: 24–36 nurse triage hours a day and 12–24 greeter and technician hours a day.

60,000-80,000 volume: 36–44 nurse triage hours per day, 24–36 greeter hours a day, and 24–36 technician hours per day.

Part 2 in a Two-Part Series

This means a busy ED may need three or four intake spaces, particularly on the evening shift, and this is worth factoring into ED design.

In most facilities, more than 80 percent of patients are discharged, and because 79 percent of EDs report being overcapacity every day, the notion of patients occupying a room for their entire length of stay is outmoded and unsustainable. Instead, patients spend time in a room for diagnostics and treatment, and then go to the diagnostic waiting room while waiting for results. We need to acknowledge that an ED visit involves different cycles, and that these require different types of space. The multiple-zone ED might have waiting areas for the fast track and each zone, a discharge waiting area, and an admission unit.

Because more than 80 percent of patients are discharged, most EDs are not well designed for discharge services. Besides a discharge kiosk for outflow, a discharge lounge, and perhaps even a 24-hour pharmacy adjacent to the discharge area, many units would benefit from discharge services that could deal with insurance questions, transport issues, and the like. This might even be a discharge suite that would look like reverse triage and registration plus a waiting area.

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Multifunctional Rooms

ED rooms should be able to serve any need of any patient. Supplies are brought to the bedside in universal supply carts and subspecialty supply carts. Cabinetry is modular and removable. In this way, room 22 might be a discharge suite today, a social work office tomorrow, and a procedures room in the future.

Our specialty changes rapidly. Doing stress testing from the emergency department and the huge burden placed on the ED with the collapse of the mental health system could not have been foreseen five or 10 years ago. In the late 1980s, having rooms dedicated to particular subsets of patients (the ENT room, the eye room, the GYN room) made sense, but in the current milieu, it is practical and expeditious to have a multifunctional room that can be easily transformed to accommodate changes in workflow.

While on the subject of the mental health burdens on the emergency department, many departments are seeing that they must design for this because there are no other solutions in sight. A mental health suite is a locked unit off the ED with the ability to separate out patients with disruptive behavior. The suite has a security guard available, and is locked to combat flight, something that is difficult to manage in an open ED. There are safe rooms, interview rooms, and an area for low-risk patients to wait for the convoluted and lengthy process most communities have to handle patients needing psychiatric or detoxification admissions.

These are a smattering of new ideas appearing in the ED design world that you should be considering for your new ED plans. Remember, you are designing for census, operations, and workflow you have never seen. This will take study, imagination, and looking to other emergency departments for ideas on managing operations and workflow. Think operations, supplies, people, and space.

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