LAST YEAR, more than 113 million people were treated in hospital-based emergency facilities, 1 visit for every 3 people in the country (Center for Disease Control and Prevention [CDC], 2006). Statistically, you, or a family member, will pay a visit to an emergency facility at least once every 3 years. For some, it will be for life-saving intervention, for others treatment of less severe injuries, and for many diagnosis and care for minor illnesses. How we as design facilities can play a significant role in the success of the patient experience.
What are the major issues that we should be addressing?
OVERCROWDING
Since the mid-1980s, visits to emergency facilities have increased at an annual growth rate of 2% nationally. Combining this with the closure of hospitals and trauma services, many emergency departments (EDs) are experiencing a 5% net annual growth. As a result of this growth, the inability to admit patients, the addition of new services, and obsolete operating systems, there is frequently insufficient space to allow quick access during peak times of day. Be prepared to wait (Fig 1).
Two major components contributing to this expansion are the basic growth in population and changing utilization rates. Data reported by the CDC show a 26% increase in the visits from the population aged 65 and older over the past 10 years. Other age groups have shown similar but less dramatic increases in use rates. Race can also contribute to increases in hospital visits. Use rates by black or African American are more than double the rate of Asian populations, with white and Hispanic populations falling between these two groups (CDC, 2006).
Closure of trauma and emergency services, combined with the lag in construction, has created severe overcrowding in many facilities. Also contributing to the overcrowding of emergency facilities are constraints in the ability to admit patients resulting from limited critical care and other beds. One recent study estimated that new intensive care unit capacity reduced the emergency service average length of stay for critical care admission by 25 minutes, as well as significantly reduced ambulance diversions (McConnell et al., 2007).
The resulting increase in length of stays within emergency facilities has limited the functional capacity of treatment spaces. The estimated visits per treatment bed have dropped over the past 20 years, with current ratios typically in the range from 1400 to 1500 visits per bed annually (Zilm, 2004).
Hospitals are scrambling to figure out how to respond to these pressures. Freestanding EDs, located miles from the main hospital, providing a full scope of emergency services, are operational in Virginia, North Carolina, Seattle, Houston, and other locations. Other community hospitals are exploring this concept as a way to alleviate capacity constraints at their main campus and as a way to stake out new geographic markets.
Other strategies include establishment of urgent care clinics, streamlining the triage function during peak periods with "rapid assessment" units, and creation of observation/ clinical decision unit to manage longer stay patients.
ONE LEVEL OF CARE
Perhaps, no other component of our healthcare system demonstrates what emergency services achieve daily-one class of care. All patients are seen and true emergency care is provided equitably on the basis of medical needs by highly dedicated, frequently overworked, staff. And patients leave the ED with something unfortunately too unique in outpatient care-an immediate diagnosis.
Management of low-acuity patients is currently one of the hotly debated issues within the American Society of Emergency Physicians. The CDC data cited in several studies point to a high percentage of low-acuity patients seen in EDs, with "safety-net" institutions seeing a 25% high level. The costs of providing care within the emergency service shows little sensitivity to overall volumes, inferring that the marginal costs of providing care remains high (Jan, 2007). An equally significant issue is the effectiveness of emergency care in the management of chronic conditions when compared with outpatient setting that can provide consistent monitoring and consultation. Some institutions, such as Aurora Sinai Medical Center in Milwaukee, have achieved significant reductions in ED visits by establishing a network of urgent care center and careful counseling of selected, primarily chronic diagnosis, patients and scheduling of those patients into hospital-supported clinics.
The entry of low-cost alternative services, such as Minute Clinics, currently has minimal overlap with emergency service populations, but could evolve into a viable alternative for selected low-acuity ED visits.
ADMISSION PORTAL
For most community hospitals, the emergency service will account for more than 50% of admissions, replacing the main lobby as the front door to the institution. Unfortunately, this basic fact is frequently not recognized in the image and location of emergency services. Many hospitals continue to locate EDs in the "rear" of the hospital complex, remote from the main lobby and public circulation.
Emergency physicians look in dismay at apparent marketing inconsistencies where millions will be invested in birthing centers to appeal to a fraction of the volume of women that will be treated in substandard emergency service facilities.
The role of the emergency service related to observation and admission patients has also become more complex. Changes in physician reimbursement, pressures related to insufficient bed capacity, and the desire to confirm the appropriateness of discharge from the ED for selected patients has stimulated renewed interest in clinical decision units/observation units within, or adjacent, to emergency services.
ANTIQUATED FACILITIES
Patient-Focused Care is a vision that recognizes the importance of treating patients, as well as their family members, with dignity and support beyond the direct medical needs. As this concept migrates from inpatient care to the ambulatory care setting, the patient, as well as family, experience during care will become a major policy agenda. "One-stop shopping," for example, with direct access to an individual treatment room is becoming the standard, reducing the number of stops from arrival to actual treatment. This approach emphasizes treatment room triage and registrations rather than separating these functions at the public entry to the service.
New facilities are moving away from open treatment bays to individual rooms, providing acoustical and isolation capabilities and adequate space for families. A current minimum guideline for these rooms is 120 net square feet (Facilities Guideline Institute, 2006).
EDs are designed using concepts developed decades ago for a much lower volume of patients, such as the "ballroom" organizational concept illustrated in Fig 2. One of the original goals of this model was to allow visualization of patients from a central work area.
This functionally limited the ballrooms design to 16 to 18 examination rooms around a single "core" of charting and support functions. A major challenge with this concept is how to design to larger volumes and how to incrementally modify the design as demands change. A typical response is to develop multiple "pods," replicating the basic organizational concept. The management of "staffing up and down" throughout the day to respond to patient arrival patterns may render this organizational model inefficient, with lags in opening a pod until efficient staffing ratios can be achieved.
Alternative organizational models are emerging to respond to these, as well as other issues. One model is a "matrix" layout, incorporating multiple entry portals into the emergency (Zilm & Lennon, 2003). Examination and support spaces can be clustered to focus on a specific type of care (eg, pediatrics, fast track, observational care) while maintaining shared support and the ability to overlap, or swing, treatment spaces. This concept abandons the goal of visualizing every patient from one location, but does allow observation of major patient corridors. Lateral expansion of this organization concept provides a strategy for incremental growth as needed and for the potential of sharing staff and support to respond to patient arrival patterns (Fig 3).
Hospitals are designing new ED with perimeter corridors to allow family direct access to the patient room without passing by other patients and staff work areas. This provides easy access to the patient by family and protects staff from unnecessary cross-traffic with public. Staff has clear visualization of the teamwork areas, and the decentralized concept places the staff in proximity to patient rooms and accommodates adjustments in staffing more effectively than the previous two models. A third advantage of this concept is the ability to expand the design, site permitting, without changing the basic organizational concept. The efficiency of this design concept (measured as by the gross area per bed and the ratio of net to gross square feet) hinges on the ability of the design team to utilizing the "core" work area for a variety of support functions (Fig 4).
"ALL-RISKS-READY" EDs
Over the past 10 years, lessons learned from natural and man-made disasters point to the need for emergency facilities to be designed to absorb a 4-fold surge in volume if a significant event strikes a community. Few can do this. As we look to the future, new services and designs are being developed to respond to these issues and anticipated needs.
We now know that emergency facilities will be a major component of the response to natural disasters, pandemic epidemics such as SARS, mass casualty events, and potentially direct terrorist attacks. New concepts for designing emergency facilities are being developed through research and demonstration projects at the national level. Unfortunately now, the funding to implement these concepts at key facilities throughout the country is nonexistent.
The federally funded ER One project at Washington Hospital Center provides insight into what should be considered regarding the design of emergency facilities to respond to "surge" and high-risk events (ER One, n.d.). The prototype complex is design to respond to a 4-fold surge in volume, respond to high-risk infectious pandemics, and survive a direct attack (ER One, n.d.; York Central Hospital, 2003). The scale of this prototype is beyond the resources of many institutions. There are components that should be considered in the planning of new facilities:
* A second public entry portal for use in high-volume surge events and to potentially triage contaminated patients outside of the emergency services.
* Increased size of examination rooms to accommodate double occupancy.
* Patient toilets between every 2 examination rooms to minimize exposure of patients and staff to special risk patients.
* Increasing the number of air-isolation rooms from 1 to 6.
* Modifying the mechanical system to allow for cohort quarantine groups of epidemic patients.
* Increased corridor width to allow the response to a surge through use of corridor space.
* Increased waiting room area for potential conversion to patient care areas.
* Large storage for disaster planning to house required gurney, disposable protective equipment, and other critical items.
The future of emergency services should be viewed within the larger picture of our national policies for healthcare. How we deal with indigent care, how we find nursing and physician manpower, and how we integrate innovation into diagnosis and treatment will shape the specific facility plan. The one certainty is that the emergency service will form a critical element in our healthcare network.
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