Planning a new emergency department: One Pacific Northwest hospital's experience☆☆☆

ED community market needs 

The area population was growing at a rate of 3% to 7% per year, and the ED census had increased by 7% per year for the previous 5 years. In summer 2001 through fall 2002, we experienced a census increase of 8% to 10% per month.

Physical space needs 

At the then current 33,000 visits per year, the approximately 9000-sq ft emergency department was too small. Projected size of the new department was 16,000 sq ft at an approximate cost of $200 per square foot. This resulted in a project total of $3.2 million, including hard and soft costs of equipment and square footage. The new department was being designed to accommodate 45,000 visits per year, the calculated growth for the next 10 years, and was expected to open in summer 2004.

We used raw data, demographics, and ED visits to project growth. We then determined we needed 40 treatment rooms, based on these population predictions. We knew this was the ultimate wish and that the treatment room sizes and numbers would be subject to changes as the design process ensued because of financial and space constraints.

Resources used 

To plan the new emergency department, an ED design team was convened. ED membership included the nurse director, nurse manager, medical director, staff nurses, family nurse practitioners, staffing coordinators, unit clerks, and EMTs. Staff attendance at the meetings ranged from 5 to 10, depending on their availability. The committee used demographic population tables; architectural plans borrowed from new emergency departments; site visits to 3 new ED facilities; the medical system facility master planning documents; a human factors analysis done in conjunction with an on-site systems industrial engineer; and biweekly meetings, where ideas were discussed and needs were determined. The team reviewed plans that were working well for other emergency departments as well as samples provided by the architecture firm. Global Internet searches and literature searches about redesigning medical facilities provided additional information about ED problem areas and what to be aware of when planning a new emergency department.8

Location 

The architects developed several drawings showing possible locations for the new emergency department. Considering ambulance arrivals and departures, a patient drop-off bay, and quick access to ancillary departments, we decided to build the new department adjacent to the existing one.

Staffing model 

Using an electronic spreadsheet, the ED staffing and financial coordinator predicted staffing needs delineating a 6-year staffing model. Demographic growth and increased ED patient acuities, based on patients becoming older with increasing comorbidities, helped determine the new ED requirements. Using a predicted 7% growth rate during the first few years and incorporating a conservative projection of a possible slow down in growth, an increase of 12 to 13 full-time equivalents (ie, 2020 hours of labor per person per year) annually would be required to staff the new emergency department. These increases were spread over 6 years and varied according to position. One of the larger increases in staff was nurse practitioners as the ED medical director was creating a greater role for them. They will not only cover urgent care but will also augment the physician's role in the emergent care area. In addition, all traditional ED roles (ie, nurses, ED technicians, and clerical staff) will increase as the census grows.

Care process and patient throughput 

Through a systems analysis, the design team identified ED bottlenecks to patient throughput. These included admitting patients both to triage and to the floors in a timely manner, getting patients to and from x-ray expediently, and transferring patients to the units after being admitted. Staffing, space, and current processes were analyzed to determine size, placement of spaces, and amount and types of rooms required for the new emergency department to increase efficiency and provide quality care.

Site visits 

Several of the ED team members visited 3 new emergency departments—a not-for-profit community medical center with 77,000 visits per year, a level I city trauma center with an annual census of 45,000, and a university medical center with 90,000 visits per year. Interestingly, all 3 outgrew their new facilities within a year. This may have been partially due to the attention a new facility attracts from prehospital personnel, as well as the community in general, which can increase ED visits.

Another detriment in developing an emergency department that we learned about during our site visits was “value engineering”—saving dollars by eliminating or reducing aspects of the plan which might seem nonessential, such as the size of triage. This could result in the facility being built too small and corners being cut with an outcome of a less-than-adequate emergency department. Because none of the facilities we visited were satisfied with their triage, our design team decided to maximize flexibility and incorporated all 3 triage designs we saw into our triage area: actual triage booths, triage that follows the patient to an ED treatment room, and triage to include the waiting area when the department is extremely busy. This is to decrease waiting times and increase staff visibility with an expected improvement in customer service and patient safety.

The design team gleaned the best from the visited facilities. One facility had patient flow incorporating a double pod system of urgent versus emergent patients. Another had a nursing station with different heights for increased visibility to better control traffic. The ergonomics and acoustics were good and the department was decorated in pleasing colors. Interestingly, 1 emergency department had a communication hub, which triaged phone calls and pages electronically, resulting in a quiet, efficient atmosphere.

Written analysis 

The team discussed, analyzed, and documented a multitude of ideas and suggestions for physical space needs related to function of the planned emergency department. First, we identified physical needs contributing to patient and staff satisfaction. Next, the team used a systems engineering approach to relate frequency to functional placement. These ideas, plus group discussion and brainstorming of patient care scenarios, resulted in multiple conceptual design drawings to which the staff reacted. The end result was a formal design.

Industrial systems engineering 

We learned industrial systems engineering was the analyses of systems as well as human factors to obtain the best use of space, time, and energy.9, 10 By determining the frequency certain areas were to be used with the types of staff to provide the services within these spaces, we produced concepts which resulted in the ED schematic. This exercise provided information about functionality of space, best use of staff energy, and delivery of care. For example, closely linking the ambulance bays, hazardous material decontamination room, and trauma rooms would expedite care and limit contamination.

Schematic design 

The schematic design was a 2-dimensional drawing of the actual space. It was a drafting document that showed the placement of objects and the layout of ED rooms with dimensions. This schematic was valuable for staff who had difficulty visualizing what the new department would look like.

ED project management 

ED project management was responsible for ensuring the process flowed smoothly, the work was completed as scheduled, and project goals were attained. This required keeping the ED design team focused and on track and communicating at least weekly with the architects. For our project, ED project management was shared by the ED nurse director, nurse manager, and medical director, who worked collaboratively and managed to accomplish all the work that was needed for the project in addition to accomplishing their full-time jobs. The nurse manager and medical director worked collaboratively with the ED members of the design team as well as the rest of the staff, while the nurse director reported team progress to senior leadership.

Project timeline 

For timely completion of our facility design, we used a project management tool with time frames that had all major events placed on a timeline. Additional events not included but following this time frame included equipment planning and room detail design with furnishings and interior structure.

By using a timeline with benchmarks, the project management team was able to monitor actual progress in relation to deadlines. The tracking tool was important because it was a quick visual reference to remind team members of their responsibilities in completing tasks necessary to reach goals.

Responsibility matrix 

On the timeline a responsibility matrix showed parties responsible for completing tasks. Our timeline also showed who was needed or contacted for following tasks as the design process proceeded. Both the medical center and the architectural firm had separate and distinct responsibilities, and by the architectural firm sharing their matrix, we were able to visually see and monitor the various steps of the design process.

Timeline analysis 

We completed the ED design in July 2002, and it was taken to the state for approval in fall 2002. With state approval, required permits could be obtained and construction begun. Groundbreaking is scheduled for the summer of 2003, with the move into the new facility to occur in summer 2004 and to take 2 to 6 weeks.