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Redesign helps EDs improve patient flow
The ED managers and administrators at Cuyahoga Falls (OH) General Hospital and the Greater Baltimore Medical Center agree that careful attention to design considerations in their new departments significantly improved patient flow and communications among staff members.
"We measured operational and patient satisfaction outcomes, and you could easily say embedding radiology [in the ED] helped take us from an average time of 60 minutes to 20 for X-rays," reports John Wogan, MD, chief of the ED at Greater Baltimore.
In addition, the department had been going on diversion about 200-300 hours a month, and that number is down to 15-25 hours a month, he says. "Diversions had been a real problem, and that's a metric that works for us," he says of the reduced times. In addition, he notes, door-to-doc times in the department (when all operations were housed in a single unit) were 60-70 minutes prior to the redesign. Now, they are at 50 minutes in the urgent care portion of the department, and 20-30 minutes in the pediatric section.
The "circumscribed" footprint of the new ED, as Wogan describes it, was designed to accommodate a change in flow. "We wanted to trifurcate the ED into three areas [the main adult ED, the urgent care center, and pediatric ED], and create a different operational model in the triage process," Wogan explains. The reception area was designed to help move registration from the waiting room to the bedside. They set up a triage reception area where the receptionist cohabitates with the triage reception nurse, he says. It's "where they do a 'quick look' — name, date, chief complaint — and if there is a room available in the back, they can get there quickly," says Wogan.
There are effectively three nursing pods that are on the interior of the department and patient rooms circling around on one continuous track, he explains. This setup provides for maximum flexibility, Wogan says. "Even though urgent care has a designated eight rooms, if there is overflow from the main ED, we can use that space," he says. "We can easily co-opt three rooms for either of the two other units."
Kathy Rice, president and CEO at Cuyahoga Falls, where the new ED also has a circular design, says, "The redesign has not only made us more efficient, but the staff can work more effectively in teams, and it provides a more closed setting for patients. The great advantage is having staff and physicians in one [central] block of space so they can communicate verbally easy and take visual cues from the computer tracking system, so everybody has the same information at the same time."
What's more, the department was created by remodeling an existing clinic, which was much less costly than it would have been to build an entirely new ED, says Frank Zilm, DArch, FAIA, president of Frank Zilm & Associates, Kansas City, MO, and the architect for both facilities. "We did it all for under $2 million, and it probably would have cost about $5 million to build a new department," he says. "It shows you can work within existing walls to create operational improvements. It would have been a very difficult site to expand on."
It's hard to link design to dollars
While ED managers are convinced that careful attention to design results in a more efficiently run department, they concede it's difficult to draw a direct link between design elements and cost savings. That's because there usually are other process changes going on simultaneously.
For example, at Greater Baltimore Medical Center, the ED moved to a different information system at the same time its new facility was being created. So in turn, the design allowed for the creation of five areas where staff could access computers. "We also placed large tracker boards strategically in the ED, which immediately gave useful cues on the status of work-ups, how many people were in the waiting room, and so forth, so all the staff could 'own' the flow process," explains John Wogan, MD, chief of the ED. "Our previous ED was radically decentralized, and it was difficult for people to know what was going on."
So, in addition to having computers in each patient room, there are computer substations at the nurses' station to increase access, and a computer station in the hallways between every two rooms. "You can't ever get enough computer resources, but the bedside ones are remarkably effective," Wogan says. "We have them on mobile arms and can do registration right there."
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