Aligning Facility Changes to Modernize and Improve Emergency Department Care

Background:We sought to implement a series of clinical improvements during a major physical renovation and expansion of our main academic Emergency Department (ED).We identified a series of prioritized improvements in the processes of care, physical design details, expansion of emergency capabilities, patient centeredness, clarifying roles and responsibilities of ED staff members, and the development of specialized zones within an expanded ED. Objective of the Review:The footprint for expansion was set in the ground level interface between the existing ED and a new 21 story clinical tower.Over the course of 5 years, facility design, multidisciplinary clinical operations, major constituency groups, patient experience, emergency oncology, observation services, and behavioral and psychiatric care met within the context of ED nursing, administrative, and physician leadership.Following a series of clinical discussions focused on identification of key challenges, recommendations for prioritized modifications in design and policy implementation were presented for endorsement by organizational leadership.Primary challenges were identified at multiple levels within and related to ED operational and quality improvements.Top challenges included long processing times for both discharged and admitted patients, excessive ED boarding of in-patients, relegation of behavioral health and other patients to hallway beds, and patient experience performance were identified.Discussion: Before and after completed renovations, total ED bed capacity increased from 52 to 109.The daily ED assignment of personnel was driven by the increased volume of ED encounters, hospital and observation admissions, and a desire to reduce left without being seen populations.Another aspect of the intent of the expansion were in the domains of designated, bedded space for cancer care, behavioral and mental health patients, observation care, and preventing patients from being relegated to hallway beds.New and existing personnel roles were modified to enhance arrival functionality in order to reduce undifferentiated waiting times and place patients in treatment spaces expeditiously.However, after 6 years of efforts, multiple metrics failed to show substantial or any improvement (ED length of stay, ED boarding).Subsidiary improvements in interdisciplinary collaborations to standardize and integrate emergency care within the larger health system included co-localization and expansion of our ED observation unit, expansion of critical care rooms, teaming of zoned ED staff together, and integration of key ancillary service providers (radiology, clinical laboratory, respiratory therapy, and others) were advanced.Improved turn-around times for radiology, lab and RT availability was evident. Conclusions:Clinical improvements in hospital metrics were advanced by space expansion, key personnel adjustments, and prioritizing the assessment of delays in the process of emergency care.Unintended consequences associated with increased hospital utilization resulted in a doubling of ED boarding, and an overall inability to meet improved processing times for emergency patients.