Healthcare Design - September 2024 - 40

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Following the COVID-19 pandemic, a widely realized trend is that patients
who are seeking care at the ED are much sicker than in the past. This could
be a result of the low-acuity volume filtering out to alternative care sites or
driven by choices to delay care during the pandemic. Either way, the ramifications
are being felt in the emergency department and culminate in increased
lengths of stay as higher-acuity patients require more resources
for treatment such as additional tests, imaging services, or procedures.
Finally, while upticks in visits were seen prior to 2020, the pandemic
exacerbated the volume of patients arriving to the ED seeking mental
health emergency care. According to the Centers for Disease Control
and Prevention's Morbidity and Mortality Weekly Report, unprecedented
increases were seen especially within pediatric and adolescent populations-with
the proportion of mental health-related visits increasing
24 percent and 31 percent, respectively. The specific needs of behavioral
health patients present opportunities for improved ED planning and design
that can stand to benefit both medical and behavioral patient cohorts.
PLANNING AND DESIGN CONSIDERATIONS
The trends outlined above drive the need to think about emergency department
design in new ways, including:
Rightsizing the ED: Often the ED is the largest contiguous space needed
on a campus and drives projects when expansion is needed. Therefore, it is
crucial that the planning team thoroughly research and use all available data
to accurately inform how much space is needed. Demographic assessments,
competitor analyses, and historical volume trends pulled from electronic
health records (EHR) are the starting point for forming volume projections.
However, arriving at the right number of future care positions also requires
a critical look at current-state operational performance-namely
the average length of stay-gleaned through EHR data. The planning team
should not rely on the status quo if it is not meeting benchmarks. Alongside
emergency department leadership, current operations should be critically
analyzed to determine areas where adjustments can be made that can
improve length of stay. These targets can be combined with future-state
volume projections to inform the total number of positions, and therefore
square footage, needed to accommodate planned scenarios.
Alternative triage layouts: The conventional triage model looks like
this: after a patient arrives to the ED and checks into the waiting room, the
patient is triaged by a nurse and then returned to the waiting area. Once
called, the patient is placed in either a large or small room/bay and remains
there for the duration of their stay. While this model has served healthcare
well for many years, it may no longer be the best model for the increased
volume of higher-acuity patients as it can be error-prone in busy settings.
Several health systems are implementing other ED triage options such as
basic split flow (patient moves from check-in to horizontal or vertical care
areas), split flow with hybrid triage, rapid assessment zone (large room with
recliner bays), and pull to infinity (patients receive initial vitals and move
to a triage recliner zone for assessment and treatment or care trajectory assignment).
These approaches can use nontraditional, and often smaller, key
planning units to better leverage scarce space resources. Designing the operations
and the physical space in tandem can allow for more patient care
positions in the same square footage.
Structuring EDs for flexibility: Related to the triage process and
the mix of patient acuity within the ED, flexibility can be built into the
space by incorporating both vertical and horizontal positions.
While the right balance needs to be determined by understanding a facility's
specific acuity mix, vertical positions offer multiple benefits. For
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example, by conducting triage in recliners, care
advancement can begin immediately. These
positions also allow a more seamless flow for
low-acuity patients who may not need to be in
a horizontal position during their stay. Finally,
because these positions take up less space than
beds (requiring about one-third less space), they
can increase capacity when expanding the physical
footprint of the ED isn't an option.
It is essential that these positions are planned
for in advance, with proper space-around 80
net square feet per recliner allocated-so that
they don't interrupt flow through the department
and hinder care processes.
Dignified models of care: Nearly 15 percent
of all ED visits are behavioral health related, according
to Virtuity, a physician-owned healthcare
organization, but traditional emergency
department design is not as conducive to treating
these types of patients. The inherent risks
and stressors of the ED, such as potential access
to objects that can be used for self-harm and the
cacophony of alarms and other patients/providers,
can exacerbate their conditions.
Psychiatric patients generally are held for
longer periods of time, and with a deficit of inpatient
options to transfer these patients to, they
can occupy ED beds for a considerable amount
of time until a desired treatment setting is
found. As a result, mixing medical and behavioral
populations often results in increased lengths
of stay for both patient types.
The creation of dedicated spaces-such as
crisis units in an adjacent or dedicated section
of the ED or an EmPATH (Emergency
Psychiatry Assessment, Treatment, and Healing)
unit, which delivers acute interventions
for emergency behavioral health patients in a
therapeutic setting-can help to better serve
these patients.
INVEST IN PLANNING
The ED often serves as the front door to the
hospital, making the design of these spaces one
of the most crucial elements to get right on a facility
project.
A planning process that incorporates knowledge
of the most up-to-date trends, empirical
data, and departmental leadership and perspectives
can help to ensure that the resulting
facility provides all patients with the best healing
environment. 
Jill Barbaro, MHA, is a strategic planner at Array
Advisors (Conshohocken, Pa.) and can be reached
at JBARBARO@ARRAY-ADVISORS.COM .
http://www.HCDMAGAZINE.COM
Healthcare Design - September 2024

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