Editor’s Note: This post is adapted from a white paper co-authored by Bryan Langlands and Durell Coleman, Founder/CEO of DC Design, and originally published by the Facility Guidelines Institute (FGI). The white paper is based on the “Reimaging the ED” workshop sponsored by FGI and the American College of Emergency Physicians (ACEP) and held at the 2017 Healthcare Facilities Symposium & Expo in Austin, TX, where more than 100 ED clinicians, design professionals and students gathered.
Today in the United States, nearly 50 percent of all hospital care begins in the emergency department (ED) and, over the last 20 years, ED patient volume has increased by 23 percent as many Americans use the ED to access primary care services. Many factors have contributed to these trends, including:
- The aging of the baby boomer generation
- Increased longevity of people with chronic diseases
- Gaps in provision of care for behavioral health patients
- Limited operating hours of primary care providers
- Lack of affordable insurance and other issues affecting individual access to medical care
- Requirement of the Emergency Medical Treatment and Labor Act (EMTALA) for EDs to treat everyone, whether they have insurance or not
While the U.S. health care system struggles to determine how to address these difficult and complex issues, there are changes that can be implemented now to improve the function and flow of emergency department services and facilitate quality patient care: by (1) improving arrival and front-end operations, (2) reducing patient length of stay, and (3) improving the experience of behavioral health patients.
(1) Improve arrival and front-end operations with technology.
Technology could be deployed to make patient arrival, sorting, and waiting processes more efficient. One idea: providing a registration kiosk for low-acuity patients. Another idea is a vitals-monitoring bracelet that could be used to assess and monitor patients in the waiting area. Such approaches could result in reduced stress and better flow for triage and front-end operations.
(2) Reduce low-acuity patients’ length of stay.
A significant problem is the treatment of low-acuity, non-emergency patients in spaces designed for patients who require a bed. Some solutions: smaller treatment spaces for these “vertical” patients, or treatment rooms that could easily and quickly be converted to hold multiple low-acuity patients during peak hours. Such spaces would speed up delivery of care for low-acuity patients and reduce the amount of time they — and consequently all patients — spend in the ED.
As one way to identify these low-acuity patients, the ED could be zoned by Emergency Severity Index (ESI) level. Creating ESI zones would support more flexible and efficient use of space and could decrease patient waiting times. Each area in the ED would be designed with patient care stations sized appropriately for the type of patient seen there.
(3) Create spaces for behavioral health patients.
There are many concerns surrounding behavioral health services provided in the ED setting, including the tendency to hold these patients in the ED for two to three days before placement in an inpatient unit or transfer to a psychiatric hospital. Spaces are needed that better suit this patient population. Because the ED is not specifically designed to provide care for the behavioral health population and the typical patient stays longer and requires different attention than typical ED patients, the flow and throughput of the entire emergency department is negatively affected when suitable behavioral health facilities are not provided.
It is important to remember the ED is not a “place” but a “process,” a point that underscores that many problems seen in EDs are the result of operational processes rather than design issues. Further, the primary factors of many problems are neither design nor operational, but issues that result from demographic changes, behavioral health and insurance deficiencies, and EMTALA requirements. For this reason, quite a few problems might not require specialty operational or design solutions if the overall health care system were doing a better job of addressing the larger issues that bring many patients to the ED.
Nonetheless, it is an important first step when health care organizations and designers work together to address operational and design problems through careful project planning.
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