Almost every week we can find announcements of new emergency department building or rebuilding projects planned or completed somewhere in the country. While there are no official construction statistics available on just how many ED facilities are remodeled, expanded or rebuilt, it is arguably one of the most common construction projects undertaken by healthcare organizations. Almost every hospital administrator has been involved in at least one ED construction project during their career.
EDs seem to run out of space not too many years after their last rebuild is done. With the steady increase in ED visits nationally — currently around 125 million visits annually — it is likely your institution will be considering a construction project to expand your ED's capacity in the near future. Even the recent healthcare reform effort is not likely to slow the ongoing increase in ED visits anytime soon if it follows the same result seen post healthcare reform in Massachusetts. Visits will continue to rise and the number of hospitals will continue to decline leaving fewer EDs to handle more demand.
While expanding the number of beds and physical size of the ED is typically the first response to the need for more capacity, is it the best way to handle increasing patient visits?
The downside includes:
• Construction projects are expensive
• Construction projects are disruptive (and dirty)
• Funds for construction projects are scarcer today
• Borrowing costs are more expensive
• New, larger EDs may pose inefficiencies
• Larger EDs usually need higher staffing levels/costs
• The productivity per ED bed may actually decrease
Commenting on potential problems when building new, larger EDs to increase capacity, Sally Sulfaro, MSEdPH, RN, NEA-BC, emergency department operations consultant, said, "It is not uncommon for emergency departments to increase their capacity by adding space/ beds as a first-line fix only to experience reduced efficiencies post-expansion, particularly if they have not first implemented efficient processes. Less than optimal processes are transplanted into larger spaces where staff members walk greater distances between areas, patients, and for supplies."
Also, more ED space will not solve the common problem of boarding patients in the ED who are awaiting admission. ED boarding is a broader and more complex institutional issue that requires process interventions across multiple departments.
What is the alternative?
One effective alternative is improving process productivity. Handling more patients in the same space — being more productive — through process redesign. According to Ms. Sulfaro, some of the best practices that have demonstrated improvement in emergency department operations and throughput, as well as increased capacity without floor plan expansion, are:
• Triage bypass whenever a bed and a physician are available; quicker in, quicker out
• A provider who works in parallel with a "pivot," quick-look triage nurse
• Keeping low acuity vertical patients vertical; they don't need beds!
• Results-pending areas to prevent "parking" of patients in low acuity treatment spaces to await test results
• Alignment of demand, patients needing service, with capacity, space and staffing, by hour of the day based on queuing theory and takt (cycle) times
Results achieved after implementation of some, all, or combinations of the above patient flow processes include:
• Immediate reduction of the number of patients who leave prior to medical screening examination. At one ED, LPMSE (left prior to medical screening exam) fell from over 6 percent to 0.79 percent in the first couple of days.
• Door-to-doctor time was reduced from 75 minutes to 28 minutes at another ED within the first two weeks.
• Length of stay is markedly reduced for discharged patients, especially low acuity patients such as Emergency Severity Index low 3, 4 and 5 patients.
• Patient safety is improved by reducing the door-to-doctor times.
• Customer satisfaction improvement is a by-product of all the above.
Todd Warden, MD, a emergency medicine physician consultant who has led a number of ED re-engineering projects also believes capacity can be significantly increased with a combination of process changes and redesign/repurposing of existing ED space. Dr. Warden sees the two factors that contribute most to an ED's failure to effectively handle the number of visits presenting are:
• Boarding of ED patients
• The dramatic bi-modal distribution volume distributions of patients (in most EDs)
According to Dr. Warden, "Traditionally ED volume has been approached in a flat-line manner, but it is well known that every ED has a daytime volume and a nighttime volume that are dramatically different. We staff for this fluctuation, but we have not made accommodations in size or design of EDs to create adequate capacity."
He believes solutions such as these are incremental improvements and can be built upon to produce more comprehensive, high performance solutions.
• Immediate bedding
• Bedside triage
• Bedside registration
• Stretcher Turnover Strategies
• Strategies to decrease "boarders"
The more comprehensive solutions have capitalized on the good ideas contained in the limited solutions, and implemented them in a sequence that allows a number of bottlenecks to be released so that it is possible to see an improvement of patient flow. The more comprehensive solutions involve:
• Physician in Triage
• Physician Directed Queuing
• Rapid Evaluation Unit (REU/RAU/RTU)
The high performance aspects of the solutions include:
• Powerful process redesigns that focus on the existing infrastructure to maximize ED performance
• Process redesign coupled with modest to moderate construction to facilitate process implementation
• ED redesign utilizing high capacity bed model of the Rapid Evaluation Unit
• The ability to retrofit recent ED construction to newer processes reflecting high performing beds
Dr. Warden reports that for a new, real world ED currently under construction incorporating these high capacity design concepts, the construction cost is only 30 percent of a traditionally designed ED and provides 45 percent higher patient handling capacity. Also, from an operating perspective, implementation of comprehensive/high performance solutions have resulted in dramatic performance metric improvements in capture of revenue from left without treatment (LWOTs), diversions and lost admissions.
Utilizing new and improved approaches to ED processes and combining new process concepts with high performance ED design has resulted in improved ED capacity and improved operations without the traditional major construction project to expand the footprint of the ED with more space and more beds.
Contact James DiGiorgio at jdigiorgio7@gmail.com
EDs seem to run out of space not too many years after their last rebuild is done. With the steady increase in ED visits nationally — currently around 125 million visits annually — it is likely your institution will be considering a construction project to expand your ED's capacity in the near future. Even the recent healthcare reform effort is not likely to slow the ongoing increase in ED visits anytime soon if it follows the same result seen post healthcare reform in Massachusetts. Visits will continue to rise and the number of hospitals will continue to decline leaving fewer EDs to handle more demand.
While expanding the number of beds and physical size of the ED is typically the first response to the need for more capacity, is it the best way to handle increasing patient visits?
The downside includes:
• Construction projects are expensive
• Construction projects are disruptive (and dirty)
• Funds for construction projects are scarcer today
• Borrowing costs are more expensive
• New, larger EDs may pose inefficiencies
• Larger EDs usually need higher staffing levels/costs
• The productivity per ED bed may actually decrease
Commenting on potential problems when building new, larger EDs to increase capacity, Sally Sulfaro, MSEdPH, RN, NEA-BC, emergency department operations consultant, said, "It is not uncommon for emergency departments to increase their capacity by adding space/ beds as a first-line fix only to experience reduced efficiencies post-expansion, particularly if they have not first implemented efficient processes. Less than optimal processes are transplanted into larger spaces where staff members walk greater distances between areas, patients, and for supplies."
Also, more ED space will not solve the common problem of boarding patients in the ED who are awaiting admission. ED boarding is a broader and more complex institutional issue that requires process interventions across multiple departments.
What is the alternative?
One effective alternative is improving process productivity. Handling more patients in the same space — being more productive — through process redesign. According to Ms. Sulfaro, some of the best practices that have demonstrated improvement in emergency department operations and throughput, as well as increased capacity without floor plan expansion, are:
• Triage bypass whenever a bed and a physician are available; quicker in, quicker out
• A provider who works in parallel with a "pivot," quick-look triage nurse
• Keeping low acuity vertical patients vertical; they don't need beds!
• Results-pending areas to prevent "parking" of patients in low acuity treatment spaces to await test results
• Alignment of demand, patients needing service, with capacity, space and staffing, by hour of the day based on queuing theory and takt (cycle) times
Results achieved after implementation of some, all, or combinations of the above patient flow processes include:
• Immediate reduction of the number of patients who leave prior to medical screening examination. At one ED, LPMSE (left prior to medical screening exam) fell from over 6 percent to 0.79 percent in the first couple of days.
• Door-to-doctor time was reduced from 75 minutes to 28 minutes at another ED within the first two weeks.
• Length of stay is markedly reduced for discharged patients, especially low acuity patients such as Emergency Severity Index low 3, 4 and 5 patients.
• Patient safety is improved by reducing the door-to-doctor times.
• Customer satisfaction improvement is a by-product of all the above.
Todd Warden, MD, a emergency medicine physician consultant who has led a number of ED re-engineering projects also believes capacity can be significantly increased with a combination of process changes and redesign/repurposing of existing ED space. Dr. Warden sees the two factors that contribute most to an ED's failure to effectively handle the number of visits presenting are:
• Boarding of ED patients
• The dramatic bi-modal distribution volume distributions of patients (in most EDs)
According to Dr. Warden, "Traditionally ED volume has been approached in a flat-line manner, but it is well known that every ED has a daytime volume and a nighttime volume that are dramatically different. We staff for this fluctuation, but we have not made accommodations in size or design of EDs to create adequate capacity."
He believes solutions such as these are incremental improvements and can be built upon to produce more comprehensive, high performance solutions.
• Immediate bedding
• Bedside triage
• Bedside registration
• Stretcher Turnover Strategies
• Strategies to decrease "boarders"
The more comprehensive solutions have capitalized on the good ideas contained in the limited solutions, and implemented them in a sequence that allows a number of bottlenecks to be released so that it is possible to see an improvement of patient flow. The more comprehensive solutions involve:
• Physician in Triage
• Physician Directed Queuing
• Rapid Evaluation Unit (REU/RAU/RTU)
The high performance aspects of the solutions include:
• Powerful process redesigns that focus on the existing infrastructure to maximize ED performance
• Process redesign coupled with modest to moderate construction to facilitate process implementation
• ED redesign utilizing high capacity bed model of the Rapid Evaluation Unit
• The ability to retrofit recent ED construction to newer processes reflecting high performing beds
Dr. Warden reports that for a new, real world ED currently under construction incorporating these high capacity design concepts, the construction cost is only 30 percent of a traditionally designed ED and provides 45 percent higher patient handling capacity. Also, from an operating perspective, implementation of comprehensive/high performance solutions have resulted in dramatic performance metric improvements in capture of revenue from left without treatment (LWOTs), diversions and lost admissions.
Utilizing new and improved approaches to ED processes and combining new process concepts with high performance ED design has resulted in improved ED capacity and improved operations without the traditional major construction project to expand the footprint of the ED with more space and more beds.
Contact James DiGiorgio at jdigiorgio7@gmail.com