August 17, 2015
Gordon Peck, AIA, LEAN Six Sigma CE

In emergency trauma centers, the name of the game is still throughput.  Speed is of the essence and having the appropriate skill sets and equipment in place to care for patients at this most crucial time is essential.  Throughout the nation, mostly in selected urban areas, but also in smaller rural communities, there are significantly more patients who have access to healthcare due to expanded Medicaid programs.  Often, these patients cannot find primary care providers who will accept Medicaid or who can take on more patients. 

Aging baby boomers are also seeking emergency care in growing numbers and frequency.  Consequently, our emergency centers are seeing surging volumes of patients.  Across the nation, nearly 75 percent of all emergency centers are reporting increased utilization over the first six months of 2015.  And while there are many reasons for this, the end result is the same … our emergency centers and the clinicians who have dedicated themselves to serving our society need help.

There are significant opportunities for improving efficiency at the front end of the process.  Delays in registering patients and inefficient triage processes often inhibit the onset of examination and treatment.  Coupled with this is the fact that many patients are not acutely ill (or injured) and may not necessarily require a significant intervention, nor a bed (or stretcher) space for the process of their examination and treatment.

Split-Flow Management

Banner Health (in particular) and many other premier healthcare systems have pioneered a process known as split-flow management.  Split-flow management identifies the acuity of patients in a quick look upon entry to the center.  Patients are identified as either vertical, meaning that they do not require a traditional examination room with a stretcher or exam table, or they are classified as horizontal, which means they need significant tests and therefore a traditional examination/treatment room.  At the quick look, the clinician must be experienced enough to determine the health status of a patient in under one minute.  Banner Health first employed highly skilled and experienced nurses in this role.  Their accuracy rate was about 65 percent.  That was not good enough, because this meant that over 35 percent of their patients had to be transferred from a chair cubicle to an exam room, or vice versa.  They modified their approach and put physicians in this role and their accuracy rose to over 85 percent.  Banner Health found that in many of their emergency centers, over 60 percent of their patients were consistently vertical patients. The other 40 percent of patients were 1 percent trauma, 33 percent main ED and 6 percent behavioral health.

Split flow (01)

The activities performed at the quick look may include:

  1. Greet patient
  2. Ask name
  3. Ask about ailment
  4. Quick inquiry about health history/chronic conditions
  5. Perform one-minute assessment
  6. Enter health insurance card
  7. Enter name and information on patient wrist band
  8. Affix wrist band
  9. Summon tech to escort patient to appropriate care zone

In some hospitals, these tasks are performed by a single person. In others, a registration clerk may be present to begin the patient record and enter the appropriate information.  Registration clerks will visit patients in rooms or chair cubicles to complete the patient record.  Working with WOWs (wireless computers on wheels), the clerks usually have sufficient time to see patients in the higher acuity portions of the emergency department, but may need to hustle to see patients in an express care or fast-track zone, where treatment and release may occur within an hour.

Express Care

Vertical patients may be seen in an express care zone, equipped with chair cubicles.  These cubicles should be 50 square feet minimum, and more often 70 to 80 square feet.  Each space is equipped with a recliner chair that can go horizontal (if necessary).  Cubicles are generally equipped with medical gases and electrical service.  Monitors may be portable and taken to where they are needed.  It is best practice to design the space to accommodate one visitor.  Because of this and because it is sometimes practical to offer positive distractions for patients who may be waiting to test results, each cubicle may want to be equipped with a flatscreen television that can be seen by both persons, but also be out of the way of clinicians.

These express care cubicles should be located near a radiographic room, as sometimes that sprain could prove to be a hairline fracture.  And of course toilet rooms need to be barrier free design and proximate to all patient care areas.  Toilet rooms should be provided at a ratio of (at least) one toilet room per eight patient spaces, but one per six may be more patient focused.

Medications and supplies in close proximity are imperative.  Again, while patients with sprains may be vertical at the quick look, it doesn’t mean they won’t potentially need splints, braces and other devices as part of their treatment.

Linear Emergency Department

Traditionally emergency departments have often addressed the need to ramp up services during the day with the addition of pods of rooms.  If you consider what would be the best arrangement of exam rooms, it might be described as just the right number of rooms arranged concentrically around a physician.  

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But that arrangement can become too large to be efficient when the design gets beyond sixteen (or so) exam rooms.  Consequently, many hospitals have added a second pod for increased patient volume.  But with that arrangement, the seventeenth patient cannot be accommodated without calling in the team to open up the second pod … and that’s not likely to happen for one patient. 

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So, emergency departments triage their patients and the person with the lowest acuity has to wait in the lounge for the next available exam room.

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But what if the entire department was reconfigured to resemble a pod that could expand and contract in response the changing patient volume over the course of a typical day?  If the center of the pod contains only clinicians and caregivers, the space could be designed to encourage more interaction and integration of care programs and activities.  To encourage the collaborative nature of this central area, the patients could access the exam rooms from the outside, which means they wouldn’t have to enter the workspace where the clinicians are working, but would meet the clinicians by entering each exam room from the other side.  We could call this the linear ED.

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Linear ED (7)

Split-flow management and the linear ED are great ways to address the need to provide expandable emergency care services in a volatile market. 

Nobody really knows what the future may hold for emergency centers.  Retail giants are pushing forward with no-waiting clinics in their shopping establishments.  Acceptance is still uncertain.  Will these facilities alleviate the burden of vertical patients from hospital-based emergency centers?  That may not be a bad thing as hospital emergency physicians and caregivers are at their best in addressing the needs of those who truly require emergency care.

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