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Quality Matters: The Emergency Department, By Design

Welch, Shari J. MD

doi: 10.1097/01.EEM.0000410110.93592.27
Quality Matters
Physicians are situated in a bullpen with laminated glass on three sides to-discourage interruptions and protect physician workflow.

Physicians are situated in a bullpen with laminated glass on three sides to-discourage interruptions and protect physician workflow.

It was set to open this past summer: A 50-room emergency department replacing two smaller community EDs that were expected to see approximately 70,000 visits a year. The finishes were beautiful: cherry and granite. The esthetics were appropriate for a five-star hotel. But the processes, operations, and patient flow would be a nightmare.

The 50 rooms were laid out around an area the size of a football field. It was impossible to see into the acute care rooms from the main work areas, and there were not enough work stations for the staff members who needed them. The design team had no idea what the work of the ED was about, and the physicians, staff, and patients will pay for these lapses for decades to come.

Even in 2011, emergency departments are still being designed in ways that disregard what we know about efficient ED operations. The design itself places obstacles to communication and smooth patient flow. But it doesn't have to be that way. An ED can be designed to mitigate the most common and pressing problems we face in emergency medicine. The CoxHealth emergency department in Springfield, MO, is a perfect example of how good design can be married to good processes, and the result is smooth and efficient patient flow and safe patient care.

CoxHealth is a community hospital seeking Level I trauma designation. The emergency department sees 68,000 visits a year, boasts an astonishing 31 percent admission rate, and uses design features to optimize patient flow. The department opened in September 2010, and was heavily influenced by its two medical directors, Cathy Homeyer, MD, and John Archer, MD, and the health care design team at Beck Architecture.

Emergency departments face big challenges in the delivery of patient care, but design can help the ED staff to meet those tests:

Communication: No randomized controlled study has identified the optimum number of patient care rooms that should be managed from a central hub. But unpublished data from the Emergency Department Benchmarking Alliance's annual member surveys show that smaller departments are operationally more efficient. An article by Frank Zilm in Health Facilities Management similarly suggests that smaller working units with high visibility improves workflow. (2003;6: 43.) The CoxHealth ED has what they call racetracks. The 62-bed department is designed with 10-15 beds around a central work area with great visibility of patient rooms. Communication is efficient because the staff work in close proximity at all times, and have constant contact. Most communication is face-to-face and frequent because the design promotes that. The staff members work in teams in geographic zones formed by the racetracks.

Variation in Census and Arrivals: Most departments experience 300-400 percent variations in census and arrivals in a typical 24-hour ED cycle. (Jt Comm J Qual Patient Saf 2007;33[5]:247; J Ambul Care Manage 2004;27[3]:215.) The best new departments are designed to breathe, opening and closing sections of the department in response to arrivals and census. The CoxHealth department has five racetracks as well as a 26-bed clinical decision unit. Racetracks open and close during the day in response to patient arrivals and surges.

Patients who no longer need a bed are placed in subwaiting areas where they can pass the time watching television or reading while test results are pending.

Patients who no longer need a bed are placed in subwaiting areas where they can pass the time watching television or reading while test results are pending.

Some nonacute patients are managed in recliners.

Some nonacute patients are managed in recliners.

Service Quality: One of the biggest correlates with satisfaction in the ED is acceptable wait times. (2008 Emergency Department Pulse Report, Patient Perspectives on American Healthcare, Press Ganey Associates; Ann Emerg Med 1993;22[3]:586.) Allowing patients to be vertical and entertain themselves during an ED visit makes the wait seem shorter and improves satisfaction. (“The Psychology of Waiting Lines” [see FastLinks]; Acad Emerg Med 2005;12[2]:119.) Because 87 percent of patients nationwide are discharged, there is a movement to keep patients vertical and only to put them in a bed when they need diagnostics or treatments that require it. In the Beck-designed ED, some nonacute patients are managed in recliners, and patients who no longer need a bed are placed in attractive subwaiting areas where they can pass the time watching television or reading while test results are pending. These spaces are attractive, akin to hotel lobbies.

Interruptions: Emergency physicians are interrupted an astonishing 10 times an hour, and half the time they do not complete the task that was interrupted. (Acad Emerg Med 2000;7[11]:1239; Ann Emerg Med 2011;58[2]:117.) These interruptions are a patient safety issue. The CoxHealth department situates the physicians in a bullpen with laminated glass on three sides to discourage interruptions and protect physician workflow.

Imaging Services Capacity: Though the average ED census has doubled in the past 20 years, most emergency departments have not doubled imaging capacity. (J Emerg Nurs 2010;36[4]:303.) The Beck architects dedicated three plain film, two CT, and two MRI suites to the emergency department, and placed them strategically. They also embedded the radiologist's offices in the department to facilitate communication and expedite reads.

Privacy: Hamstrung by the enforcement of HIPAA (often misapplied), emergency departments are limiting the display and communication of vital patient information to keep it from the public. (Welch SJ. “Hang onto that Whiteboard,”EMN 2010;32[12]:22.) A creative new design feature in the CoxHealth ED involves a public hallway and an integrated hallway to be traveled only by ED personnel. This allows strategic patient information to be posted on whiteboards and computer screens all over the work area to improve patient safety and efficiency.

The Mental Health Burden: The volume of patients presenting to the ED with psychosocial chief complaints continues to grow. (Acad Emerg Med 2009;16[11]:1110.) Patients who are psychotic or under the influence of drugs are often loud and disruptive, and may become violent. The Beck design offers two features in response to these needs: a highly visible security station at the entrance to the ED and a psychiatric holding area with an observation suite.

Prolonged workups: The aging of the population, the complexity of their health care needs, and pressures not to admit contribute to longer ED stays. This problem will grow in the health reform model that penalizes readmissions, which means that time and resources will be required to ensure that it is safe to send patients home. These patients will likely populate a clinical decision unit, and CoxHealth has wisely anticipated this and included a 26-bed CDU.

The take-home message is this: The space in which we work can be designed in clever ways that understand and facilitate the work that we do. Imagine how good work flow can be married to good design. If there is a new build, remodel, or redesign on the horizon for you, you should demand that it incorporate what we know about smooth operations in the ED and that it support the work that you do. There are architects who-understand the work of the ED. Sean Wilson, the director of health care design at Beck Architecture, noted, “In order to design a successful emergency department, you must define your operational goals and determine the processes necessary to achieve them. Once those are in place, it's about working with capable team members [who] can help you realize your vision.”

Dr. Welch

Dr. Welch

© 2011 Lippincott Williams & Wilkins, Inc.