RESEARCH

HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

Using Data To Drive

Emergency Department
Design: A Metasynthesis
Shari J. Welch, MD

Operational improvements have been clearly identified and

Abstract are grouped into three categories: input, throughput, and
outflow. Applications of this information are suggested.
Objective: There has been an uptick in the field of emergency Conclusion: The sentinel premise of this meta-synthesis is
department (ED) operations research and data gathering, both that data derived from improvement work in the area of ED
published and unpublished. This new information has implica- operations has applications for ED design. EDs can optimize
tions for ED design. The specialty suffers from an inability to their functioning by marrying good processes and operations
have these innovations reach frontline practitioners, let alone to good design. This review paper is an attempt to bring this
design professionals and architects. This paper is an attempt new information to the attention of the multidisciplinary team
to synthesize for design professionals the growing data of architects, designers, and clinicians.
regarding ED operations. Key Words: Emergency department, emergency department
Methods: The following sources were used to capture and operations, triage, throughput, design, efficiency, quality, safety
summarize the research and data collections available regard-
ing ED operations: the Emergency Department Benchmarking
Alliance database; a literature search using both PubMed and Aim of This Paper
Google Scholar search engines; and data presented at confer-
ences and proceedings. The universe of emergency department (ED)
Results: Critical information that affects ED design strate- operations has seen an uptick in innovations in
gies is summarized, organized, and presented. Data suggest
the past two decades (Beach, Haley, Adams, &
an optimal size for ED functional units. The now-recognized
arrival and census curves for the ED suggest a department Zwemer, 2003; Bertoty, Kuszajewski, & Marsh,
that expands and contracts in response to changing census. 2007; Chan, Killeen, Kelly, & Guss, 2005; Choi,
Wong, & Lau, 2006; Gorelick, Yen, & Yun,
Author Affiliation: Dr. Welch is a Research Fellow, Intermountain Institute
for Health Care Delivery Research, a practicing physician with Utah 2005; Richards, Navarro, & Derlet, 2000; Spaite
Emergency Physicians in Salt Lake City, UT, and a board member of the
Emergency Department Benchmarking Alliance.
et al., 2002; Thompson, Yarnold, Williams, &
Corresponding Author: Dr. Shari Welch, Quality Matters Consulting, 3267 Adams, 1996; Welch, 2010a; Wiler et al., 2010).
East 3300 South #122, Salt Lake City, UT 84109 ([email protected])
Preferred Citation: Welch, S. J. (2012). Using data to drive emergency These innovations have important implications
department design: A metasynthesis. Health Environments Research
& Design Journal, 5(3), 26–45.
for the way EDs are designed and how operations

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 PA P E R S RESEARCH
Using Data to Drive Emergency Department Design

and processes are married to design. This paper is ate. As patients age, the complexity of their acute
an attempt to synthesize for design professionals the health care needs increases (Sprivulis, 2004). As the
growing data, published and unpublished, regard- Baby Boomers reach their senior years, they will hit
ing ED operations and to suggest applications for the ED like a tidal wave. The sheer amount of infor-
ED design. mation, diagnostic and therapeutic tasks, and per-
sonnel involved in caring for these complex patients
Background will make it necessary to change space, processes,
From 1995 to 2005 the number of ED visits and operations in the ED.
increased nearly 20% to 115.3 million, even
though the number of hospitals decreased by The most common complaint about visits to the
nearly 10% (Nawar, Niska, & Xu, 2007). The ED is the perception that everything takes too much
American Hospital Association (2005) reports time (Press Ganey Associates, 2009). From the pa-
that 69% of urban EDs are over capacity, re- tient’s perspective, an ED visit is a series of seem-
sulting in crowded conditions and ambulance ingly random queues without clear communication
diversions. In 2005 the Joint Commission im- about what the patient is waiting for, what the next
plemented a new leadership standard regarding step in the process will be, and how long that step
the management of patient flow, which man- will take. The waiting has no value to the patient.
dated that hospitals “…develop and implement Emergency care providers often offer the excuse that
plans to identify and mitigate impediments to patient demands are “unpredictable” and that the
efficient patient flow throughout the hospital” sickest patients must be treated first. Although both
(Joint Commission, 2005). of these statements are founded in truth, the de-
mands on the ED are much more predictable than
The valuable effect on patient outcomes of stream- practitioners are often willing to admit.
lining ED operations has been emphasized by
the Agency for Healthcare Research and Qual- Most hospitals are capable
ity (AHRQ), the Institute for Healthcare Improve-
of providing timely care for
ment, and the Institute of Medicine. Research
demonstrating the impact of ED efficiency on sub- the sickest patients without
sequent outcomes for a number of clinical entities
delaying service for low-acuity
has been accumulating (Bernstein et al., 2009; Fee,
Weber, Maak, & Bacchetti, 2007; Joint Commis- patients. The key is using data-
sion, 2002; Magid et al., 2009; Pines & Hollander,
driven process improvements
2008; Richardson, 2006; Sprivulis, Da Silva, Jacobs,
Frazer, & Jelinek, 2006). to expedite care.
Most hospitals are capable of providing timely
Changing demographics affect the way EDs oper-
care for the sickest patients without delaying

HERD Vol. 5, No. 3 SPRING 2012 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 27
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HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

service for low-acuity patients. The key is us- Measures of ED Performance

ing data-driven process improvements to ex- A number of metrics appear in the emergency
pedite care. medicine literature and are used by health-
care leaders as markers for quality and per-
ED operations research is often slow to reach formance (Welch, 2010a; Welch et al., 2011).
the front lines. To date there is no journal for The time interval metrics are better under-
ED operations and there is frequently a sig- stood when referring to this chart, which de-
nificant delay between operational innovation picts the time stamps/time intervals of a typi-
and widespread frontline acceptance (Welch, cal ED stay (Figure 1). In addition, a number
2010a). Every day, emergency physicians, of measures reported as percentages or rates
nurses, and staff innovate to improve ED pro- have been used to capture elements of perfor-
cesses. The 4,500 EDs in the United States mance in the ED.
are living laboratories, and each one is trying
to solve logistical and operational challenges Time Metrics (Time Intervals)
(typically constrained by physical space limi- • Arrival-to-provider time (a.k.a. “door-to-
tations). When ingenious local solutions are doc time”): Arrival time to provider contact
achieved, timely and widespread dissemination time.
of these ideas fails to occur; mechanisms for • ED length of stay (LOS): Arrival time to de-
the diffusion of innovation are lacking. The parture time.
specialty suffers from an inability to have these
innovations reach front-line practitioners let
Standard ED Time Stamps and Intervals
alone design professionals and architects. The Length of stay

result is a knowledge-action gap in ED opera-

Arrival to Provider to Decision to
tional innovation. provider decision departure

Patient Placed in a Provider Disposition Patient

arrives treatment space contact decision departs ED

The sentinel premise of this metasynthesis is

that data from improvement work in the area of Patient
identified
Triage
begins
Triage
complete
Tests
ordered
Tests
complete
Data
ready
Provider
reviews
Bed
request
Bed
available
data
ED operations have applications for ED design.
Arrival to Treatment Lab and Data to Bed
treatment space to imaging decision assignment

EDs can optimize their space provider interval time interval

Nonstandard Time Stamps and Intervals

functioning by marrying good Legend:

processes to good design. Time stamps Intervals

EDs can optimize their functioning by marrying

Figure 1. Timeline of Emergency Department time
good processes and operations to good design. stamps and intervals.

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Using Data to Drive Emergency Department Design

Table 1. ED Performance as a Function of Size

Proportion Metrics cy Department Benchmarking Alliance (EDBA)

• Left without being seen (LWBS): All patients suggests that the size (which, in ED operations,
who leave the ED before being seen by a provider. typically refers to annual volume) correlates with
• Left before treatment complete (LBTC): All performance on metrics. EDBA is a consortium
patients who leave the ED before formal dispo- of 486 performance-driven American EDs. It has
sition is made. been collecting performance and operational data
• Complaint ratio: All spontaneous written, on EDs for 7 years through its annual manda-
phone call, or spoken expressions of concern tory data survey. Data from the EDBA reveal that
brought to the attention of ED management performance on metrics is volume dependent—
or hospital staff. By convention, complaint the smaller, lower-volume EDs are operationally
ratios are tracked as complaints per 1,000 more efficient and perform better on metrics,
ED visits. suggesting that there may be an optimal size for
functional units in the ED (see Table 1) (Augus-
Patient Satisfaction tine, 2011a). These performance data are in keep-
• Patient and staff satisfaction surveys: Al- ing with a 2010 Canadian study that also found
though typically done using local survey in- that lower-volume departments functioned more
struments, Press Ganey or other professional efficiently (Hutten-Czapski, 2010).
patient survey companies may administer
these. They are usually reported as percentiles. In addition, EDBA data suggest that a new ED
be built with the assumption that approximately
Size (Annual Volume) Matters 1,500 patients a year could be treated in each
Unpublished but credible data from the Emergen- patient treatment room, in keeping with recom-

HERD Vol. 5, No. 3 SPRING 2012 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 29
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HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

Figure 2. Census and arrival curve of the Emergency Department.

mendations put forth by Huddy (2006). are more efficient could suggest an optimal size for
functional units in an ED, even if the overall de-
The Breathing Emergency Department partment must have many more beds. Knowing
It is well recognized that the workload in an from EDBA data that EDs seeing 20,000 or fewer
ED is not level throughout the day. The ED annual visits are the most efficient (according to
goes through a 24-hour cycle that is predict- standard performance metrics) and that depart-
able regardless of volume (Welch, Jones, & Al- ments can anticipate 1,500 visits per bed per year,
len, 2007). The census in an ED, regardless of the performance-driven ED might have no more
size, is typically three to four times as great at than 13 beds in a functional unit. To be sure, these
4 p.m. as the census at 4 a.m. (Figure 2). This relationships are not fully understood, but they do
means that the ED space and operations must suggest that economies of scale are not seen in
be able to flex up and down to meet this ex- EDs; in that world, bigger is not necessarily better.
treme variation in census and arrivals through- The data are not definitive in terms of functional
out the day. unit size, but they suggest a place to start.

Applications to Design It may be that the higher-volume ED is simply

The EDBA data showing that lower-volume EDs trying to manage so many patients and tasks and

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Using Data to Drive Emergency Department Design

so much information that systems and processes 24-hour cycle with the concept of smaller operat-
break down. Therefore, designing smaller func- ing zones and a new notion is born:
tional units within a larger department may be
a design strategy whose time has come. A func-
The cyclical daily opening
tional unit requires a place for physicians and
nurses to work, a place for the health unit clerk, and closing of functional units
space for the management of lab specimens, a
according to patient arrivals
portal for the tube system, a medication room, a
space for imaging study results (a viewing area for creates the Breathing ED.
hard copies to be reviewed—or more commonly
in 2011, a digital radiography station), and both The cyclical opening and closing of func-
clean and dirty utility rooms. tional units according to patient arrivals cre-
ates the Breathing ED. The University of Iowa,
Should functional units be equivalent and act a 52,000-volume ED and Level I trauma and
as multiple smaller EDs or should they be chief teaching hospital in Iowa City, Iowa (which was
complaint or acuity differentiated? The uncon- redesigned in conjunction with Lean applica-
testable amount of research around the efficacy of tions to its ED processes), the Coxhealth ED in
the fast track would suggest that patient segmen- Springfield, Missouri, and the University of Ken-
tation based on acuity and creating functional tucky Chandler ED in Lexington, Kentucky, also
units or zones for patients with similar acuities a Level I trauma center and teaching hospital that
may be superior to creating zones that are small has 55,000 visits annually (and is part of the Peb-
ED equivalents (Cooke, Wilson, & Pearson, ble Project), are recent examples of EDs designed
2002; Hampers, Cha, Gutglass, Binns, & Krug, to be Breathing EDs (Dickson, Singh, Cheung,
1999; Handel et al., 2011; O’Brien, Williams, Wyatt, & Nugent, 2009).
Blondell, & Jelinek, 2006; Oredsson et al, 2011).
Although the definitive data on this have not As the daily surge of patient arrivals begins, the
been gathered, higher-volume EDs are gravitat- ED opens up new functional care units. The de-
ing toward increasing patient segmentation and partment is designed to accommodate the flow
differentiation of the functional zones (discussed model used by the department and in accordance
in more detail later). with the community’s needs. For instance, the
fast-track lower-acuity unit is seldom open for
In response to increasing volume, EDs are being 24 hours a day, even in high-volume EDs. The
built with increasing numbers of beds. However, University of Iowa operates its pediatric ED and
often little attention is paid to how workflow will fast track out of the same functional unit and
be adapted to the larger footprint. But combine space from late morning until midnight and then
the idea that the ED footprint should change in a closes the area down. Contrarily, departments

HERD Vol. 5, No. 3 SPRING 2012 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 31
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HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

The Emergency Department Visit

Intake Throughput Outflow

Physician in triage Patient segmentation Discharge kiosks
Team triage Med teams Express admission area
Cubicles/pods Geographic zones Clinical decision unit
Recliner intake areas Internal waiting area
Low flow/High flow Recliner units
Information technology

Figure 3. Emergency Department operational innovations.

serving high numbers of seniors often maintain ing to incorporate into its value-based purchase
one functional unit for longer periods of observa- model of payment are arrival-to-provider time
tion. Most clinical decision and observation units and LWBS, markers for intake performance (Na-
are open 24 hours and part of the “core” that is tional Quality Forum, 2008).
always open and staffed.
Improvements at Intake
Operational Research A first step in decreasing waiting times is to cre-
This review uses the intake-throughput-outflow ate an ED intake process that assesses patients ef-
model to organize and present the innovations ficiently and sends them to the appropriate area
being tested around the country (Figure 3). Most within the department.
of the operational research done in emergency
medicine has focused on patient intake (also Physician in Triage
known as the front end) because improvements One of the most common areas of operational
in the intake process can have a dramatic and innovation, both published and unpublished,
immediate impact on patient satisfaction, door- involves moving away from the traditional nurse
to-physician times, and LWBS (Welch & David- triage model that has dominated intake into the
son, 2010). There is added impetus to focus on ED for more than 30 years. Recent research has
the front end because the Centers for Medicare shown that traditional nurse triage, as currently
& Medicaid Services (CMS) has announced that practiced, fails to treat the sickest patients accord-
two of the five operational metrics it is expect- ing to recommended time frame guidelines and

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Using Data to Drive Emergency Department Design

creates a bottleneck in the beginning of the ED send the patient to the appropriate area in the
visit (Weber, McAlpine, & Grimes, 2011; Welch department for further diagnostic or therapeutic
& Davidson, 2011). interventions, or for discharge processing.

Team Triage
One of the most common areas
More detailed intake assessments are performed
of operational innovation, both using a team triage model (Chan et al., 2005;
Mayer, 2005; McD Taylor, Bennett, & Camer-
published and unpublished,
on, 2004; Richardson, Braitberg, & Yeoh, 2004;
involves moving away from the Subash, Dunn, McNicholl, & Marlow, 2004). In
traditional nurse triage model this model, the team might consist of a combina-
tion of the following: physician, nurse, midlevel
that has dominated intake into provider, laboratory technician, ED technician,
the ED for more than 30 years. and scribe. In this model, more diagnostic and
therapeutic work is performed during the intake
Newer intake models now put a physician, either encounter.
alone or as part of a team, at the front of the ED
visit—at intake. The literature shows that a physi- Pods and Zones

cian assessment is more reliable than assessments Some centers have begun reporting the imple-
by providers with less training (Dent, Weiland, mentation of changes to the physical space to ac-
Vallender, & Oettel, 2007; Kosowsky, Shindel, commodate new intake models through case re-
Liu, Hamilton, & Pancioli, 2001; Levine et al., ports. Though not yet published in peer-reviewed
2006; Rocker et al., 2004; Rodriguez, Wang, & journals, the data from these reports are compel-
Pearl, 1997; Sinuff et al., 2006). Using an expe- ling. At Arrowhead Regional Medical Center in
rienced physician in triage allows many patients Colton, California, the ED volume more than
to be sent home with little or no testing (Sen et doubled from 50,000 visits to 110,000 visits in 5
al., 2011; Terris, Leman, O’Connor, & Wood, years. The LWBS rate had risen to an astounding
2004). It reduces the arrival-to-provider time, 20%, and arrival-to-provider time was a danger-
the overall LOS, and the LWBS rate and increases ous 4 hours. In desperation the staff trialed a phy-
both patient and staff satisfaction with the pro- sician-in-triage model made possible by bringing
cess (Choi, Wong, & Lau, 2006; Holroyd et al., in furniture modules that created small cubicles
2007; Partovi, Nelson, Bryan, & Walsh, 2001; in which physicians can see patients.
Rogers, Ross, & Spooner, 2004; Travers & Lee,
2006). There are many variations of the physi- Their experience revealed that 50% of patients
cian-in-triage model. Typically a lone physician could be discharged right from the cubicle. This
in triage will do an abbreviated assessment and opened up beds and resulted in an unexpected

HERD Vol. 5, No. 3 SPRING 2012 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 33
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HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

reduction in nurse staffing. Their LWBS rate redesigned its intake area, putting recliners and
dropped to 1% and their arrival-to-provider time supplies within reach of the physician and team.
was reduced to 31 minutes (Welch & David- Like Arrowhead, they found that the physician
son, 2010). At Methodist Sacramento Hospital, could discharge 45.5% of patients from triage.
in Sacramento, California, the ED was grossly This is an effective way to off-load the main de-
under-bedded seeing 42,000 annual visits in a partment when it is over capacity. This Level I
19-bed ED. The staff took a different approach trauma center, which sees an annual ED volume
to the space and layout to allow a physician and of 115,000 visits, has seen improvement in arriv-
nurse to be present at intake. al-to-provider time, decreased LWBS rates, and
an overall decrease in LOS in these trials (Welch
The staff created a six-bed triage pod, occupied & Savitz, 2011).
by contiguous stretchers with curtains. This op-
erational model articulated a goal that patients Low-Flow/High-Flow
spend less than 15 minutes in the triage pod be- Another new intake model as yet unpublished
fore being moved elsewhere in the department. but presented at an AHRQ-sponsored summit in-
The physician traverses the pod and after a quick volves the use of two distinct processes for intake,
assessment transfers the patient to one of three depending on the census in the department and
areas: the waiting room, the main ED, or a moni- the rate of arrivals. Thomas Jefferson University
tored higher-acuity ED bed. in Philadephia, Pennsylvania, a busy urban teach-
ing hospital with an annual volume of 85,000,
Although the department shrank from 19 to 13 dubbed this model the low-flow/high-flow process
beds, with new processes in place they believe model. When the ED is at a low census with open
they have smarter bed utilization. Methodist has beds, the process is the same as that employed in
seen their LWBS rates drop from 5% to 1% (Au- most traditionally run EDs. Patients are triaged in
gustine, 2011a). In Gaston Memorial Hospital the traditional manner, and each patient occupies
in Gastonia, North Carolina, $800 was spent to a room after triage. As the ED reaches capacity, the
create a care initiation area (also called the CIA) department shifts into the high-flow process. In
with a physician and team in triage. By changing this model, a processing area is opened and a team
the space and the process, this 80,000-visit ED using protocol-guided treatment plans begins the
saw its LWBS rates fall from 12% to 1.3%, and intake process and patient workups there. The
its Press Ganey patient satisfaction scores rose to first pilot of the new low-flow/high-flow model
the 99th percentile (Besson, 2009). showed a decreased LOS from 653 minutes to 158
minutes. Exit surveys of patients involved in the
Recliner Intake pilot showed extremely high patient satisfaction
In another case study in Carolinas Medical Cen- scores: 4.5 on a scale of 5 for extreme satisfaction
ter in Charlotte, North Carolina, the ED team (Welch & Savitz, 2011).

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Using Data to Drive Emergency Department Design

Applications to Design the pressure to identify cardiac patients rapidly

First, the design of the intake area will depend by quickly performing an electrocardiogram
on the process the clinicians intend to use. For (EKG) on any patient who might be presenting
very rapid physician assessments, a pod design or with acute coronary syndrome. The recognition
a bay with multiple treatment spaces that feeds of atypical presentations of acute coronary syn-
other ED areas may be appropriate. Data about drome patients has led to the new practice of per-
annual volume, admission rates, acuity, and the forming an EKG on any patient with symptoms
age of the patient populations served would in- “between the nose and the navel.”
form decisions about intake models. Recliners
could replace either chairs or stretchers for the Many older triage rooms are not big enough
first leg of the ED journey. for a patient to recline for an EKG and to ac-
commodate an EKG machine at the bedside,
nor do they have curtains to allow the privacy
The big operational change of
required for an EKG. Whether the multidisci-
putting a physician at the front plinary team selects a model employing mul-
of the ED visit needs translation tiple curtained intake bays married to a rapid
initial intake process, or separate intake rooms
into traditional ED designs. married to a comprehensive team intake pro-
cess, private space will be necesssary for EKG
The big operational change of putting a physician evaluations. This might mean an EKG alcove
at the front of the ED visit needs translation into with curtains next to the triage pod or some
traditional ED designs. other design innovation to meet this particular
need.
For a more comprehensive intake, physicians
are most effective if they have a team of person- There will be new pressures to have patients seen by
nel to assist them. In many of the new models, a physician sooner because arrival-to-provider times
the intake area could also be a site for initiating will be reportable to CMS. With this as an incen-
orders, drawing blood, and starting intravenous tive, an adequate number of intake spaces will be an
lines. This means the intake space may need to be imperative. Remembering the arrival curve already
bigger with room for supplies and clinical work mentioned, patients arrive in surges during the af-
areas. The intake model and the design of the ternoon and evening shifts. Knowing the census of
intake space must be integrated into the patient an ED can help designers plan their designs for an
flow scheme for the entire department. appropriate number of intake spaces.

Whichever model is chosen, it is important to The low-flow/high-flow model from Thomas Jef-
understand other critical factors that will influ- ferson University presents another idea for consid-
ence the design of intake spaces. Foremost is eration in ED design. Medium- and low-volume
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HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

EDs struggle with extreme swings in census that can 2008; Nash, Nguyen, & Tillman, 2009; Rodi,
sometimes show 100% variation or more from one Grau, & Orsini, 2006; Sanchez, Smally, Grant, &
day to the next. A design that can accommodate Jacobs, 2006; Simon et al., 1996).
these extreme variations in census and arrivals with
coordinated operational changes allows the ultimate At Mary Washington Hospital in Fredericks-
in flexibility. This means that an ED might look like burg, Virginia, Dr. Jody Crane has taken pa-
a traditional department at low-flow times with tient segmentation even further. Published in
the immediate bedding of patients, in-room triage, a trade paper and not a peer-reviewed journal,
and bedside registration, sometimes called pull to Dr. Crane has used Lean processes to improve
full, described in a North Carolina ED (Colucciello, patient flow in his 100,000-visit ED. By creat-
2009). Later in the day, when the predictable surge ing even more tracks dedicated to the treatment
of patients arrives and census exceeds capacity, an of patients of varying acuity and clinical needs,
intake area with a physician-led triage team opens he has reduced LWBS, decreased LOS, and im-
up. This kind of adaptability and flexibility in de- proved patient satisfaction (Welch, 2008). At
sign and operations is cutting edge and not seen in Banner Health System in Phoenix and Mesa,
most current ED designs. Arizona, a similar “quick look” at patients and
then patient segmentation have been employed
Improvements in Throughput in a new intake model. All of the tools and a
Although there is not as much in the literature detailed description of this innovation can be
about operational improvements in the ED found on the Internet (Banner Health, 2011).
throughput domain, there are trends worth Banner calls this process “D2D SPF” (Door to
noting and considering for integration into de- Doc Split Patient Flow).
sign.
Less sick patients are not undressed or bedded;
Patient Segmentation instead they are treated as though they were in a
As EDs have experienced gains in annual census, clinic setting. The sickest patients are seen in an
the practice of patient segmentation has grown. expedient manner and treatment is begun. Ban-
The earliest example of patient segmentation (also ner implemented this new process across eight
called streaming) was the development of the fast different EDs with varying volumes and saw re-
track, an area in an ED dedicated to the care of pa- ductions in the LWBS rates of 30% to 60% across
tients with lower-acuity conditions, typically mi- the board. This concept of patient segmentation
nor accidents and injuries. The evidence support- allows for less acute patients to be moved out of
ing efficacy, efficiency, and improved performance beds after initial examination. Such accelerated
when a fast track is introduced is now exhaustive bed turnover, much like table turns in a restaurant,
and irrefutable ( Darrab et al., 2006; Ieraci, Digi- allows more patients to be seen in the same space,
usto, Sonntag, Dann, & Fox, 2008; Kwa & Blake, effectively expanding the capacity of the ED.

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Med Teams ing high-level performance on operating metrics

Knowledge about teams and their superiority in is William Beaumont Medical Center in Royal
complex work environments is well established in Oak, Michigan. This department, which sees
other service industries (Barker, 1993; Hackman, more than 120,000 visits annually in a whopping
1987; Kozlowski & Bell, 2003; Scholtes, Joiner, 110-bed ED, is divided into seven functional
& Streibel, 2003; Serfaty, Entin, & Johnston, units to improve quality, safety, efficiency, and
1998; Wageman, 1997). Beginning in the late flow (Welch, 2009).
1990s, research on med teams and formal team-
work training appeared in the medical literature, Internal Waiting Room
often applied to the ED (Barrett, Gifford, Morey, Another new and important concept relative to
Risser, & Salisbury, 2001; Morey et al., 2002; ED operations has been termed “keeping patients
Risser et al., 1999; Sexton, Thomas, & Helm- vertical.” Nationwide statistics reveal that EDs
reich, 2000). In the past decade this research admit approximately 14% of all visits (McCaig
has taken off with applications to most hospital- & Nawar, 2006); this means that 86% of ED pa-
based service lines including labor and delivery, tients go home. In addition, the majority of pa-
the ED, the operating room, and the trauma tients are ambulatory upon arrival. Thus, EDs are
suite (Awad et al., 2005; Capella et al., 2010; experimenting with keeping patients ambulatory
Guise et al., 2010; Kilner & Sheppard, 2010; and having them wait for results in an internal
McConaughey, 2008; Patel & Vinson, 2005). An waiting room, as opposed to occupying an ED
example of a med team in an ED would include a room for the entire LOS.
physician, two nurses, four techs, and a unit clerk
all assigned to the same patient care area, working At Massachusetts General Hospital, located in
together to care for the same set of patients. Boston, Massachusetts, the ED sees in excess
of 88,000 visits annually. It has implemented a
Geographic Zones complex new ED flow process that begins with
In a busy ED, a med team's approach is mar- patient segmentation by acuity. Also presented as
ried to a geographic zone to create a functional a case study at an AHRQ conference in 2010,
operating unit that improves communication the data demonstrated improvement. An im-
and clinical care (Asplin et al., 2008; Eitel, Rud- portant change in the physical plant to support
kin, Malvehy, Killeen, & Pines, 2010; Jensen & this process involved the creation of an internal
Crane, 2008; Olshaker, 2009). According to the waiting room called the post-screening area with
Studer Group, ED nurses walk 5.2 miles per shift comfortable chairs. The internal waiting room
(Leighty, 2006). This could be reduced by plac- enables less acute patients to remain vertical in-
ing staff in a large ED in one geographic area of stead of occupying bed space while awaiting test
the department for the duration of a shift. One results. The sum of these changes to the physical
of the largest EDs in the country demonstrat- plant and operations resulted in an 8% decrease

HERD Vol. 5, No. 3 SPRING 2012 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 37
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HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

in LOS and a drop in LWBS rate from 4.1% to must take into account the space that such tech-
2.4% (Welch & Davidson, 2010). nology support requires. The most advanced de-
partments (in terms of IT integrated into work-
Reclining Chair Units flow) are operating with a computer for each
The idea of using reclining chairs for intake has member of the healthcare team, including social
already been discussed. One study showed that workers and case managers. This means that com-
most patients—particularly elderly patients— puter stations to accommodate all staff members
found reclining chairs much more comfortable will need to be factored into the ED design.
than ED stretchers and had higher patient sat-
isfaction when they were allowed to sit in them In addition, banks of common-use computers
while waiting for test results and receiving care that any staff member can use are required. For
(Wilber, Burger, Gerson, & Blanda, 2005). The instance, respiratory therapists, EKG techni-
Chandler Medical Center at the University of cians, and x-ray technicians are in the depart-
Kentucky (part of the Pebble Project) is another ment transiently while involved in patient care,
example of the effective use of chairs as treatment but they need to communicate on the electronic
spaces. This new ED was built using evidence- tracking system when the encounter with the
based design (Taylor & Cheng, 2011). One of patient has both started and finished. This infor-
the design features involved the design of the fast mation is vital to the healthcare team in tracking
track area. As an evidence-based design project, patient flow in real time, and it requires com-
the multidisciplinary team trialed both stretch- puter space. To get an idea of how many com-
ers and reclining chairs for treating low-acuity puters might be needed as hospitals become ful-
patients. Their as-yet-unpublished data revealed ly invested in a comprehensive electronic health
increased patient satisfaction and decreased record, the Pebble Project at the University of
throughput times using the chair model. Reclin- Kentucky Chandler ED used predictive model-
ing chairs were employed in the final design. ing and forecasting to design a 50-bed ED with
240 computers for staff.
Information Technology
The advantages of an electronic whiteboard or
tracking system in the ED have been recognized The development and success
(France et al., 2005). Increasingly, EDs are us- of patient segmentation,
ing physician order entry and charting along
with electronic tracking systems. In addition, the med teams, and geographic
benefits of information technology (IT) that is zones once again highlight the
integrated into workflow have been reported in
the literature, but it is still an area in its infancy
benefits to workflow of creating
(Baumlin et al., 2010; Shapiro et al., 2010). EDs functional units in the ED.

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Using Data to Drive Emergency Department Design

Applications to Design Nonetheless, strategies that improve the outflow

The development and success of patient segmen- of patients who no longer need the services of the
tation, med teams, and geographic zones once ED have been identified, and they are articulated
again highlight the benefits to workflow of cre- in the following section.
ating functional units in the ED. The acuity of
the patients to be cared for will determine what Discharge Kiosks
the zone looks like. For instance, higher-acuity Driven by the dire economic situation in the
patients would likely be managed best on stretch- community that his ED served, Dr. Todd Tay-
ers in larger rooms that can accommodate a re- lor set up a discharge kiosk in the ED at Good
suscitation team, ventilator, EKG machine, and Samaritan Medical Center in Phoenix, Arizona.
portable x-ray machine all at once. These rooms When his 55,000-volume department was over-
should be directly visible from the staff work sta- run with immigrant workers with no health in-
tion. Lower-acuity patients can be managed in re- surance, he designed these kiosks to get low-wage
clining chairs in a zone of cubicles, and visibility workers signed up for any public assistance pro-
is less critical. grams for which they were eligible. He had pa-
tients pass through these discharge kiosks to help
The functional unit will need space for team usher them through the morass of paperwork in-
members to carry out both clinical and cleri- volved and to help them find clinic care for future
cal work, and adequate room for IT support is healthcare problems.
a must. Workflow should never be constrained
because a healthcare worker cannot access a com- His program, which began as a revenue capture
puter in the ED. The common practice of plac- opportunity, was dubbed the “Turnstile ED,”
ing lovely granite countertops too narrow to hold meaning patients passed through the virtual
computers and keyboards in the ED should be turnstile in the discharge kiosk. Discharge pa-
checked. All counter surfaces should be function- perwork and prescriptions were then given. This
al spaces. program proved successful and kept his depart-
ment financially viable, but it also turned out to
Improvements at Outflow be an operational success (Taylor, 2003; Welch,
The least studied area of operational improve- Viccellio, Davidson, McCabe, & Janiak, 2007).
ment for the ED is the back end. This may be
because the outflow of admitted patients has Express Admission Unit
been such a difficult area for EDs. Addressing With bed space at a premium in the ED, strate-
problems of overcrowding and boarding (holding gies that allow patients to be moved away from
admitted patients in the ED for long periods of acute care areas have proved an effective way to
time) requires hospital-wide flow solutions, and combat crowding. This has given rise to a new
these are not under the control of the ED alone. concept: the express admission unit, where pa-

HERD Vol. 5, No. 3 SPRING 2012 • HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 39
RESEARCH
HERD Volume 5, Number 3, pp 26-45 Copyright ©2012 Vendome Group, LLC

tients can wait until their rooms are ready. It tion unit. High-volume departments might have
is also a place where admission paperwork and the numbers to support both a clinical decision
processing can take place. When ED patients unit and an observation unit as service lines with
are ready for transfer to an inpatient bed (ex- unique, dedicated space.
cluding critical care patients), they typically
are in a phase of care that requires less clini- Applications for Back-End Design
cal intensity. Diagnostics have been completed There is a knowledge deficit surrounding the
and early therapy has begun. Such patients no back end of the ED visit. Research regarding
longer need the services of the ED and often patient flow out of the ED is in its early days.
need minimal observation by medical staff. The Whether patients are admitted or discharged or
University of San Diego in San Diego, Califor- placed into observation, operational best prac-
nia, which sees 36,000 visits annually and is a tices have yet to be determined. Is an express
teaching hospital with an emergency medicine admission unit more efficacious than boarding
residency, has published the first study showing a patient in the ED? Is a discharge team more
the positive operational impact of an express ad- efficacious than primary care nurse discharge?
mission unit (Buckley, Castillo, Killeen, Guss, Relative to research on the front end, there is
& Chan, 2010). clearly work to be done.

The Clinical Decision Unit A number of factors will influence and change
There are data on the efficacy of an ED obser- discharge from the ED as healthcare reform in the
vation unit (Baugh, Venkatesh, & Bohan, 2011; United States moves forward. As mentioned pre-
Daly, Campbell, & Cameron, 2003). As pressures viously, with the aging of the population comes
to avoid hospitalization (and readmissions) grow, an increase in the complexity of the patients re-
a variation on the observation unit has evolved ceiving care. This means that more discharge
and is referred to as the clinical decision unit. Ac- planning will be needed as patients exit the ED.
cumulating studies suggest that keeping patients Healthcare reform will mean increased pressure
for 6 to 8 hours for certain clinical conditions is a to prevent readmissions for certain chronic con-
viable clinical management plan. Many patients ditions like chronic heart failure, acute heart at-
requiring prolonged diagnostic testing, observa- tack, and pneumonia (Haglund, 2011). Hence a
tion for overdoses, and other conditions, but who rebirth of interest in the observation unit concept
likely will not need 12–24 hours of care, might and its many variations is being seen. Physicians
occupy such a unit (Calello et al., 2009; Nahab et and hospitals will be deterred from admitting
al., 2011; Ross & Nahab, 2009; Ross et al., 2003; certain patients under threat of financial pen-
Schrock, Reznikova, & Weller, 2010). The lower- alty, and this will mean the involvement of a
volume ED might segment any patients in need new member of the ED team, the case manager
of 6 hours or more and send them to the observa- (Dunnion & Kelly, 2005; Kanaan, 2009). Zones

40 WWW.HERDJOURNAL.COM ISSN: 1937-5867

 PA P E R S RESEARCH
Using Data to Drive Emergency Department Design

where case managers can work with the health- were from outside the United States.
care team involving the patient and the patient’s
family are evolving. Conclusions
ED operational research has begun to capture
Concern for crowding should the attention of practitioners trying to improve
the delivery of care in the ED. Most departments
encourage design professionals
are struggling to deliver safe and efficient care in
to work with clinicians to design emergency rooms that were designed in a differ-
ent era. Most clinicians looking at the prospect of
spaces that allow patients who
a new build or redesign of their departments will
no longer need the clinical be largely unaware of this body of research and
new information. Unpublished data can help in-
intensity of the ED to be moved
form ED design; unpublished innovations dem-
quickly out. onstrate ways to improve ED operations.
Concern for crowding should encourage design
As evidence-based design concepts take hold in
professionals to work with clinicians to design
the architecture, design, research, and clinical
spaces that allow patients who no longer need the
arenas, we can look forward to EDs designed for
clinical intensity of the ED to be moved quickly
the work being done in them. This metasynthesis
out.
is an attempt to summarize the latest research and
data available involving ED operations and to ap-
Limitations
ply it conceptually to ED design. It is written in
Many of the operational innovations described
the hope that design professionals and clinicians
in this review are new and have not been vali-
can work together to design effective spaces for
dated by randomized controlled studies or for-
safe, efficient, quality-driven healthcare.
mal peer review. These process innovations and
suggested design changes may have unintended
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