Improving Emergency Department Patient Flow

Poor patient flow in an Emergency Department (ED) leads to an increase in wait time and departmental crowding. There is a direct correlation to the quality of care a patient receives to wait times, which significantly impacts patient satisfaction. Increase in wait times is detrimental to patient care prolonging suffering for those in pain, and delays the assessment, diagnosis and ultimately the treatment of patients. In order to improve the overall treatment of patients coming into the ED the wait time needs to decrease; which ultimately reduces departmental crowding.

Numerous factors are associated with the performance of an Emergency Department’s quality of care. External factors, such as the lack of availability of inpatient beds increase the time patients stay in the ED and reduces the number of available beds for new patients. This correlates with the overall wait time for patients, thereby increasing the crowding in the ED. Insufficient allocation of resources are then available; the resource of both space and staff. Internal factors also influence patient flow like program adjacencies, staff workflow, and flexibility of treatment. In the Lawrence + Memorial Hospital Emergency Department Renovation and Expansion project, several design strategies were implemented with the intention to address internal factors in order to improve patient flow, and positively influence the quality, efficiency, and timely care of patients. These strategies integrated into the development of the project include the implementation of triage, vertical treatment, and sub-waiting within the intake and treatment process, and programmatic flexibility of treatment rooms.

For the Lawrence + Memorial Hospital ED Renovation and Expansion, triage, vertical treatment, and sub-waiting have been incorporated into the new design impacting the patient flow. When a patient enters the ED, they start their assessment and initial intake with the clinical staff at the reception desk. Patients will proceed through one of the two Triage rooms adjacent to the waiting area. Lower acuity patients will then continue into vertical treatment for treatment. Once treated, they will be discharged, never having taken a bed in the ED, which could be used for patients in more critical condition. In turn, this helps reduce overall wait times within the ED, decreases crowding and improves the allocation of resources.

Triage in healthcare is the initial assessment of patients to determine the severity and urgency of their condition. Vertical treatment is precisely what the name implies; patients stay vertical and designated for short term occupancy. The incorporation of the vertical treatment after the triage area enhances the assessment and treatment of patients in a timely way. Due to the proximity of vertical treatment to the general waiting area, patients do not need to go as far for treatment, reducing the time it takes to receive care. Vertical treatment has a positive impact on physical space requirements, operational processes, and patient psychology and satisfaction. The stretcher chairs in this space take up less square footage reducing the footprint requirements, which increases the number of patients treated in the same allocated square footage. When a patient’s symptoms rapidly change, the chair can recline and allow the patient to lie down completely and continue treatment.

Operationally, patients move through vertical treatment much faster than they might through a traditional treatment room within the ED. In vertical treatment, patients typically stay in their clothing and do not change into gowns. Patients who stay in conventional exam rooms will often take longer to leave as they need to change. As a result of patients going into vertical treatment, the time it takes for new patients to receive treatment is reduced. Conversely, when staff need to accommodate time for changing and other related tasks, wait time increases, as does departmental crowding. Additionally, by creating separate treatment spaces for non-urgent patients and higher acuity patients, the design works to increase efficiency and productivity. In doing so, hospital staff can more easily meet the urgent demands for the treatment of patients in critical condition.

The Lawrence + Memorial Hospital ED expansion also includes a sub-waiting outside of the Vertical Treatment space. Patients wait here for results from test or treatment to take effect. Continuing the patient flow and freeing up space for a new patient to be treated; decreasing wait times in the main waiting area. Sub-waiting also gives the patient the impression of forward movement in their treatment since they do not go back to the main waiting area. The feeling of progression through spaces improves the patient’s overall satisfaction.

In an effort to improve patient flow at Lawrence + Memorial Hospital, the team designed the treatment spaces to be flexible to accommodate surges in patient volume and varying demographics. It was essential to consider the range of patients coming in; pediatric, geriatric, high and low acuity, and behavioral patients, and allow for the treatment rooms to accommodate the ebbs and flows of these demographics. Programmatic flexibility of treatment spaces enables any patient to be treated in any room. This eliminates the need for patients to wait for specifically designated rooms and allows the full capacity of the ED to be used no matter the occupancy type.

To provide the flexibility of treatment rooms for Lawrence + Memorial Hospital, rooms were standardized and not designated for specific types of patients, i.e. pediatric, geriatric, etc. The design intention is to permit any patient to be treated in any room. Signage for all treatment rooms was elected to be non-specific, only identifying the rooms as “Treatment Room.” The uniformity in the room layouts was generated through designated zones defined in each room. With a renovated space, this can be challenging working with existing geometries. However, the equipment, plumbing, and casework in every room have been arranged in the same location with respect to the zones of the treatment room.

These designated zones are clinical, patient and family. The clinical zone is comprised of two groupings of equipment and fixtures. The first grouping incorporates a nurse server, hand wash sink, and associated accessories. This grouping is always on the sidewall when entering the room, with consistent distance from the footwall. The second grouping includes the workstation, cart, and associated accessories on the sidewall, located the equivalent distance from the headwall in all rooms. The family zone in every treatment room is on the opposite side of the room from the clinical zone. A change in flooring material marks this separation between zones. As well, creating a uniform layout for the equipment helps to increase efficiency. Staff can walk into any room and know where things are without having to take the time to realign themselves in every room. This improves the staff workflow, thereby reducing treatment time and impacting the overall patient flow through the ED.

Emergency Departments treat an extensive range of patients who all deserve a high level of care. Delays at any point in the process impact the entire department. With life expectancy rising, the impact of an aging population is higher demands on EDs across the country. This growing trend, as well as legislative changes, will continue to increase the strain placed on EDs in the future. In order to handle the increasing demands, put upon EDs the patient flow of existing and future EDs need to be evaluated and designed for.