Eleven pitfalls to avoid when redesigning the ED
Redesigning an ED is a major project with many potential pitfalls. In this issue of ED Management experts give advice on how everything from staff input to shifts in the health system can influence construction needs in the emergency department. The following are some common mistakes ED managers can make when beginning an ED redesign.
1. Getting little or no input from ED personnel. Make sure that architects get plenty of ongoing input from caregivers. "The architects need to actually be out there with the staff," says Joanne Ingalls McKay, RN, MSN, CEN, the ED operations analyst for Freeman White Architects in Charlotte, NC. "They should start by observing them and documenting work flow, as opposed to just talking with administrative people. Staff love having the opportunity to contribute right from the start. It shouldn’t just be the administrative people making decisions for the clinical people."
Managers should encourage their staff to design their ideal ED, says McKay. "They need to think of themselves as the process owners. We ask people, if it was their millions going into operating this department, would they spend their money doing things as they are today? One hundred percent of people say, Heck no.’"
Rebuilding the ED involves more than just structural changes. The staff should also consider a multitude of new technologies and possibilities which they may not have been aware of. "We ask them, What if you didn’t have a paper chart and had a bedside computer system with access to anything at your fingertips? What if the registration process was different than the one you’ve been using for the past 25 years? What if physicians didn’t have to use a dictating system and everything was on-line on the computer so you didn’t have to wait two hours to get the report, or [what] if you had a pneumatic tube system?" says McKay.
It’s important to make staff view the redesign as a golden opportunity to make widespread changes. "After we open their minds to the possibilities, it’s usually a very exciting process for staff," says McKay. "Oftentimes, in the beginning, it’s met with a lot of sarcasm. They don’t think it’s possible because they’ve been burned on numerous occasions with a lot of promises, and at the last minute the money gets cut."
2. No study of work flow. Staffing issues can make or break a redesign. After getting staff input about work flow, the architects should visit the site during peak times. "We need to validate that what they said matches what we see," says McKay. Work-flow diagrams are created based on this and posted on a wall board so staff can make comments."
Work flow should be fully understood before proceeding with the design. "You have to know and understand what you currently have before you can talk about what you’d like to have," says McKay. "You can then seek to correct operational bottlenecks."
To eliminate bottlenecks, it’s necessary to carefully consider the current state of operations. "If we take a process like triage and registration, it’s necessary to consider all aspects of that process," says McKay. That may include cross-training of staff, new technology, and operational changes. "The process won’t be better if you move it into a pretty new department without changing it. It’s like taking old wine and putting it into a new bottleit doesn’t mean the wine will be better. Take the time to decide how you wish to operate within that new department."
3. Absence of planning for managed care. In the next few years, most EDs will be going in one of two directions: either downsizing or offering a more comprehensive model of care. How a new ED should be designed depends largely on which road your ED will take.
Even if managed care hasn’t penetrated your region yet, it pays to look ahead a few years. "Managed care keeps coming into play, but ED visits keep going up," says John Huddy, director of Freeman White’s ED design team. "When managed care first hits an area, ED visits take a dip but then suddenly skyrocket. It may take two or three generations of managed care for things to even out."
In the meantime, flexibility is key. "Managed care may cause some EDs to streamline their space and others to expand their services," says Huddy. It’s a good idea to have flexible groups of rooms that could someday be converted to an ambulatory clinic, fast track, or primary care space.
Design modular components into the ED that can later be subdivided without decreasing the efficiency of the other areas. "If annual visits decrease because of managed care, it allows a section of the department to be broken off to be used as a clinic space or separate function without disrupting the overall operation of the ED," says Huddy.
Other EDs may want to expand their services into areas such as occupational health. "If you’re going to add additional space in your department in the future, you have to ensure the payback is going to be there for reimbursable care," says Huddy.
For care to be reimbursed in the future, those clinic areas may have to be completely separate from the ED. "We’ve had to literally design in extra support and storage spaces for those areas, because they need to keep all their materials and utensils separate so they can bill separately from the ED," says Huddy.
Patient access to these areas needs to be considered. "You need to decide if the area will be accessed from the exterior or other departments within the interior," says Huddy. "If you have an occupational and employee health area in the future, you may not want those populations servicing out of the same area as the ED."
4. No space for future technology. When designing a new ED, think ahead a few years. "You have to consider where the future of emergency care is going," says McKay. Trends such as the movement away from a paper-based charting system to computerized information systems need to be addressed.
In addition to the physical space needed for future equipment, support systems also have to be considered. "There are communications closets now as big as exam rooms for telemedicine items or certain computer systems," says Huddy. "You also have to realize how future technology will streamline and change the way you deliver care. For example, in some discharge areas, people may be able to watch a video-on-demand about wound care. That’s going to free up exam rooms more quickly than before and allow for a higher turnover of patients."
Flexible areas to use for these purposes need to be identified. "You need to realize that in the future, an area may switch over to a new function. Equipment alcoves can be walled in and turned into computer rooms," says Huddy.
5. No dedicated space for paramedics and police. Prehospital personnel need adequate space to complete reports and make telephone calls. "A lot of EDs don’t have that space, and nurses often don’t like sharing their space," says McKay. "With their own separate space, paramedics tend to hang out less and take care of business. The staff need to keep on working, and it’s hard when people are trying to engage you in social conversation."
6. Confusing entrances. Separate entrances for urgent care facilities, fast tracks, and emergency care can be confusing. It’s best to have a single walk-in entrance so the patient doesn’t have to decide. "You can do separate physical entrances, but they need to come in at the same point," says Huddy. "You want the health care professional triaging the patient and avoid having the patient treat themselves. Otherwise, someone may have congestive heart problems and decide to go in the urgent care entrance."
A separate ambulance entrance is necessary, however. "Otherwise, there is the danger of ambulance traffic backing in and out," says Huddy. Also, it doesn’t lend a feeling of comfort when you’re trying to walk into the ED and ambulance patients are rushing in past you."
Ambulance entries should be weather-covered, even if local codes don’t require it. "At least where the door is, you have to make sure ambulances don’t have to dock in a place where there is no cover if weather is bad," says Huddy.
7. Lack of space for the nurses’ station. The nurses’ station should be a centrally located hub with adequate room to allow it to function optimally. There needs to be a clear line of vision to treatment spaces, and ample storage space. "You need a space for consulting physicians, space for physicians to dictate, and space for residents or attendings," says McKay.
In the future, the nurses’ station may double as a communications center. Computer terminals in the ED may eliminate the need for clerks to remain stationed at a central location. "Anyone can access information from wherever a computer is, so remaining at the nurses’ station becomes less imperative," says McKay. There will always need to be a centralized communications center to field phone calls. "But as things become computerized, the role of the clerk in the ED will probably change predominantly to communications, because doctors and nurses will be entering their own orders at the bedside."
8. Focusing only on short-term needs. For a redesign to be most effective, long-term issues must be included, adding product lines such as chest pain centers or observation units, for example. "The traditional approach to architecture is, how many more rooms do you want? Think about where you want to be in five years, in terms of the level of care delivery. What is the facility’s goal and long-range plan?" says Huddy.
9. Overspecializing treatment areas. It’s important for areas to be as flexible as possible. "We try to create work spaces that can be used for different purposes," says McKay. "You may choose to use a grouping of rooms for a fast track, but if, in the future, it becomes less of a demand with managed care, those rooms could be used as main treatment rooms for emergency patients."
Flexible areas can also be used as "swing space." "At different times of the day, you may need to use them as fast-track rooms, but when the fast track is closed, you can see regular emergency patients," says McKay. "If you have a chest pain center, you shouldn’t say that these four rooms are strictly for chest pain, because you may need to use them on any given day for other types of patients."
Rooms should never be sitting empty with patients waiting for appropriate rooms. "You have to look closely at the patient types you serve or project to serve and build flexibility, so rooms won’t sit there empty," says McKay. "You need enough rooms with negative air pressure for patients with TB or coughs, so staff or other patients aren’t endangered."
10. Not experimenting with room mock-ups before the design takes place. Create a 3-D environment to construct the future design in an open area such as a storage room or basement. "Ask your facility people or in-house construction to throw up some fake walls with 2 x 4s and paper," says Huddy. "Staple the paper to the frames, and make sure the walls are movable propped-up walls."
Allow staff to come in and get a feeling for the space. "We’ve never done it without making design changes," says Huddy. It’s a lot easier to move paper walls back a foot than real ones.
"It’s very difficult to look at a piece of paper and try to picture it in a 3-D setting," says McKay. "Trying to imagine it in real-life size is difficult for clinical people. The nurses’ station may look really large on paper, but you can’t conceptualize how it’s going to feel in real life."
Creating a mock-up allows staff to "test the waters" before the design becomes a reality. "They can feel how much space would be available with a stretcher, and can actually try moving it in and out," says McKay. "They can figure out how it would feel to run a code in a room this size, with five people around a stretcher, or determine whether there’s enough space for doctors, nurses, and clerks to conduct business at the patient’s bedside with a computer terminal."
The process can allow staff to make design decisions based on actual experience. "You can decide how high the countertops need to be, and do you want the computer at the head of bed, or off a wall in the back?" says McKay. "Or, where do the sinks fit best in this room? You can try different scenariosif the sink was over here, I’d do a procedure with patients and then wash my hands, or should it be at the head of the bed?"
11. Failing to consider legal requirements early in the process. Fire codes, building codes, Centers for Disease Control requirements for air-filtration systems, and the Americans with Disabilities Act requirements must be considered before the design process has started. "When you interview your architect, make sure they are experienced in health care facilities and know how to conform to codes," says Huddy. "This shouldn’t be the ED manager’s job, but you need to make sure the architect has done it. Expect to see pre-design reports to explain how the department will look, and a preliminary code review should be included in that."
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