Treat[ED]: Shifting the Emergency Department Paradigm

I’ve designed quite a few Emergency Departments, from large to small and concepts from zoning, to universal rooms to interior nurse cores and observation units. I have even participated on a team developing standards for one of the nation’s most prominent health systems. While all of these efforts focused on the patient experience and the standard of care, what we have really been doing is rearranging deck chairs on the Titanic that is the ED. ED volumes keep increasing at a pace that no expansion strategy could ever really address. Patients are not getting better access to care, in spite of our efforts. I guess that’s what happens when you treat the symptoms instead of the problem.

I have had some recent exciting conversations with Dr. Todd Warden whose work on implementing aggressive processes to improve ED throughput is a game-changer.  An article detailing his work

explains how we have traditionally been using not only the wrong metrics to project volumes during programming, but also the wrong paradigm for processing patients. As architects, we love a good form follows function argument and Dr. Wardens’ insights into ED function create some very interesting implications for design that I share with you here:

The ED is not a hopeless case

“I think the ROI benefits of strong new ED processes tightly integrated with complentary design bodes well for future of ED. I am working with a revenue cycle company Besler, who is interested in the impact of ED improvements on increased revenue and decreased cost of operations.” To help us better understand how this works, Dr. Warden focuses on some specific patient statistics. “The moving parts are Left Without Being Treated (LWOTs), elimination of Diversions, and over time increased volume due to improved patient satisfaction.” These variables can be significant when you consider the following example for a typical ED that sees 50,000 patients per year. “LWOT’s, if at 5% for a 50K volume ED is $400-500 for every patient that walks out and about 10% of those patients would be admitted, representing a loss of anywhere from $1 to 1.5M.” There is also a tendency to over-focus on the external causes of ED overcrowding, including efficient interface with other departments and the ability to get patients who will be admitted out of the ED. Dr. Warden’s concept for managing ED throughput challenges traditional process in order to deliver a more efficient outcome from within the department. This might seem like a management or operational exercise, but it is actually supported by the built environment:
1. The patient shouldn’t own the bed
Dr. Warden’s approach begins with a challenge to the way we program space. His study of departments has indicated that the way we typically calculate a peak ED volume actually does not account for the amount of fluctuation between the highest and lowest daily volumes and therefore provides an underestimation of the number of patient spaces needed. Further, we typically understand one patient space to mean one patient bay or exam room. In fact, many patients who come to the ED do not require a stretcher or a private room or bay at all. Even those who do may not need to be in such a space for the entire length of their stay. “By adhering to the idea that the patient owns the bed, we create a lot of needless crowding and bottlenecks”, says Dr. Warden.
2. Integrating process with Design
Two areas that Dr. Warden focuses on are capturing the true measure of volume and efficiently moving that volume of patients through the department. Interestingly, building more rooms is usually not the answer he recommends. “I really see three levels of intervention. The first is completely process-driven. By getting the ED staff to work more efficiently, they can get patients in and out of the department quicker. The second level involves renovation to create a better space for handling patients who are not ready for discharge but do not require a bed. Sometimes, giving up a few ED rooms or a section of waiting are can create this space and allow more patients to be treated. The final intervention occurs at facilities that must add additional space in order to manage their volumes. In these cases, I actually recommend that they build a space called a Rapid Evaluation Unit or REU. More importantly the additional volume created with a high-performance method such as the REU allows the additional volume to be absorbed usually without needing additional staff so most falls to the bottom line. By applying these principles to design, the ED unit is about a third of the construction cost of a typical unit but provides double the annual capacity of the same number of traditional ED beds.”

Read more similar content in an article by Dr. Frank Zilm, FAIA and FACHA on New Directions for the ED