Is your hospital planning a new emergency department or expansion? Due to ever-increasing patient volumes, at least once during your career you should expect to be involved in one. Creating a new space involves more than simply adding rooms and square footage – build-outs must be flexible and have longevity. Have you ever wondered what goes into the development of a new emergency department? I did and found Jim Bynum – registered architect at Perkins + Will with twenty years experience in planning and implementation of healthcare architecture – to give me his perspective.
Flexible Use Planning
Bynum’s team came up with an idea to solve the drastic volume shifts that occur in Daytona Beach, Florida. They call them pods: rooms that can see any acuity and are organized to keep rooms nearby and in nurses’ line of sight. Some spaces were oversized, such as designated critical care rooms and trauma bays. Otherwise, any room can be anything.
From blueprints to completion
A single ED project can take three to twelve months to design, and from six to 20 months to build, and is one of the most challenging types of hospital renovation, according to Bynum, “because you have to keep it operational and can’t shut it down.” The more phases you have, the longer the construction and inconvenience to both staff and patients.
****Design within reach: Building a better ED through simple improvements****
Easy access to supplies. Placing a mini-pyxis in each room that has commonly used items,
opened quickly with a wand linked to a patient, eliminates leaving a
room to get items from a central pyxis.
Mini TVs in reach of patients and staff. Flat screen TVs may look cool and save space if high up on a wall, but if they can’t be easily adjusted become a big distraction. “There should never be televisions that can’t be muted or remote controls that can walk off with patients,” says Benator.
Fewer lightboxes. Modern tech has eliminated the need to have these in each room. Having a few near the physician work area is sufficient when the PACS is down or patients bring their own film.
Natural lighting. High “clearstory” windows allow light without views into the room or open ED space.
Bedside Registration. This growing trend to have the nurse or physician be the first contact after walking in the hospital is incorporated into design by eliminating the registration desk.
Wide alcoves and hallways are a simple modification, but help fit patient overflow, and larger mobile equipment that isn’t stored in a particular room.
By using multi-use beds that can be used for pelvic exams, every bed is a potential gyne bed, offering maximum flexibility.
Major considerations in planning
1. Volume: Most expansions are because of increased patient volume and overcrowding of emergency departments, so architects often begin by analyzing present and future traffic with respect to peak times, fluctuations, and cycles for each day, week, and year. These numbers cannot be taken as averages–Bynum designs for the maximum, not the mean, with optimum flexibility for volume shifts. Rooms might be deliberately left empty. “It is cheaper to have an empty room than to have staffing over a period of time that is inefficient.”
2. Longevity: Since most expansions are arduous and expensive, designers anticipate what may be required for the ED over a 40-to-50 year life cycle. During that time, the upfront capital cost (designing and building the structure) represents only eight percent of the total costs. Eighty percent is staffing, and the remaining twelve percent is energy usage. Bynum suggests that despite staffing being the primary cost consideration, hospitals in poor economies often try to save money by lowering the amount spent on construction of the space.
3. Understanding clients’ needs, wants and goals: Every staff member has their own expertise, and MDs tend to focus on the room design–how they are configured, their location, and the ability of staff to meet the needs of the larger overall department space. Nurses tend to concentrate on specific elements in a room, such as layout and line of sight to patients and monitors, and access to medicines. “Other players involved in programming and design are the Ancillary staff,” says Seth Benator, a member or Bynum’s team. “These include staff members like Security, who would be interested in the location of the guard station, camera placement and might provide input in to the design of the psychiatric room. Local EMS can influence the layout of their workroom and possibly the Ambulance bay. If you have X-ray and/or CT in the ED, department directors and technicians from radiology would have a significant say in how their suite is designed.”
Representatives from registration help direct the layout of their link between the waiting room and triage. “They also help plan the interface between staff and patient in the discharge and payment process,” said Benator.
Administration mainly handle the project management and are chiefly concerned with the purse strings and the schedule. “A very important player in ED design and construction is the hospital’s Facility Manager. He or she acts as a link between the design team, hospital staff and hospital administration,” said Benator. “They make sure the project proceeds as smoothly as possible.”
A totally democratic system where every player has an equal say doesn’t work well in ED design, but a totalitarian approach can eliminate critical input from physicians and staff. Communication is oftentimes challenging. The process can vary dramatically at different sites depending on each client’s organizational structure. Sometimes it can be difficult to make sure that everyone gives their opinion without too many voices and personal biases interfering with cohesiveness. And then the difficulty becomes marrying everyone’s interests to space and technology limitations and requirements.
4. Improving workflow and efficiency: The architecture team tries to find better ways to improve patient flow and processing.
Anticipating the future
Adaptability is the new mantra in ED design. While having individualized rooms for a variety of specialties seems like a nice idea – having all the tools you need integrated into the room – it only works well when those rooms are full with no one else waiting in the queue. For instance, having a gyne area unconsciously reinforces the idea that suspected gyne-table requiring patients must be placed there and nowhere else. Sometimes gyne patients wait until a new gyne bed is available even though other rooms might be free to use. Psych rooms can be a challenge, too, as empty rooms are wasted and due to their deliberately bare design, if filled with non-psychiatric patients are not as useful.
In a push for an optimally productive ED, many are designing standardized rooms and opting to shuttle in the necessary mobile specialty equipment. Steve Strata and Debbie Jacobs, authors of “Making Room: Optimizing ED space to increase patient capacity” (Health Facilities Management Magazine, 2010) call it “flexible use planning.” They write that this type of design improves the efficiency of care delivery, and in turn significantly increases capacity. This kind of system increases the longevity of a facility since as needs change, rooms are not locked into a specific conformation.
Bynum’s team independently came up with a similar idea in order to solve the drastic volume shifts that occur in Daytona Beach, Florida. They call them pods: rooms that can see any acuity and are organized to keep rooms nearby and in nurses’ line of sight. Some spaces were oversized, such as designated critical care rooms and trauma bays. Otherwise, any room can be anything. There would not be fast track, ENT, opthamology, ortho, psychiatric or gyne subspecializations. Instead of having, for example, a large thirty-six room ED with a single nurses station, and straggler rooms that aren’t visible to the central area, the space could be subdivided into three or four manageable pods. Each one would have dedicated nurses, techs and doctors situated in an island surrounded by the treatment rooms. (see diagram on page 16)
In a common scenario where departments have fast tracks running 12 noon to 12 midnight, rather than have an area dedicated to that specific function, a fleet of pods could be opened up during the hours that the express care would be given. Then shut down, or turned into ordinary rooms when it closed at midnight.
Designing for a Growing Community
As a general rule, says Bynum, it is optimal to limit an ED to less than 100,000 visits per year, due to “the loss of efficiency, the physical size of the department and the bottleneck of bringing that many patients to a single point of access.” There needs to be a plan to address an increase in volume once the new ED is built as hospitals can be a victim of their own success. If you build it, they will come.
Once local population patterns start to exceed this threshold, an ED expansion alone might not be sufficient to address volume issues – a community-wide assessment must be made. At this point a multi-phased plan may be required that diverts traffic to other specialized areas such as a separate venue for pediatric emergency care, urgent care centers, and tertiary clinics.
Bynum gives an example of this phenomenon from a project he worked on that had a large indigent population overwhelming the hospital primary care clinic. The solution stemmed the volume to the main campus by creating hospital-branded satellite clinics and urgent care centers off campus throughout the community concurrent with the planned ED expansion. The onsite primary care clinic was then downsized and reintegrated into the hospital.
Every community has special population needs, and the architect’s job is to combine volume information with historical data about acuity, pediatric and geriatric populations. If a large pediatric influx, special kids areas, including waiting rooms, are often designated. If in a known retirement community, there might be a hospital branded Geriatric hospital built nearby to handle their unique needs to prevent overwhelming the ED with complicated patients who require extensive testing and hospital resources.
To solve the problem of having inactive patients tying up rooms needlessly, Bynum created a discharge lounge (above) that has recliners in view of the nurses station, freeing up treatment areas for new patients.
Strategies for getting design right the first time
1. Shadowing: Architects can walk through current spaces in real time to get a feel for the flow, identify inefficiencies, and incorporate solutions through new design.
2. Medical personnel participation: The more specialty knowledge the better, and most information comes from the on-site players. However, many architecture firms have medical personnel on-staff to give key insights that might be missed otherwise.
3. Get patient input when possible: According to Bynum, in most situations, the onus is on physicians to act as patient advocates during the design process. However, Kaiser has spent billions of dollars building new clinic facilities, and to ensure an optimum design for their needs they created mock-up “movie sets” in a massive warehouse space that had physicians, nurses and actor-patients interacting in the proposed space. This yielded real-time criticisms that were invaluable in modifying and optimizing the health care centers. This might not be as useful for a single hospital building, however, the Mayo Clinic is investigating the possibility of doing something similar.
4. Setting priorities. Conflicts occur – aesthetics are not always functional and budgets might not allow for desired appearance and technology. Setting clear goals in order of necessity ensures that the most important elements get incorporated into the final design.
The right ED design can allow the same number of people to be more productive in an even larger space. It is not always possible to accommodate everybody’s wants and needs within the budget provided, but with clear priorities, and good communication amongst all the players a new space can be built that improves efficiency, increases patient satisfaction, and whose design is still functional decades into the future.