by Jerald D. Peters, AAA AIBC MAA OAA SAA FRAIC LEED AP
Link to the Grace Hospital Emergency Department Project
Grace Hospital Emergency Department
The existing emergency department was deemed to be overcrowded, cramped and inefficient. Wait times and Length of Stay (LOS) track record scored amongst the worst in Canada, gaining notoriety for all the wrong reasons, including patient care occurring in designated hallway beds.
Prior to design, operational data and processes were analyzed and scrutinized. Anomalies, such as extreme length of stay for patients were identified and questioned. Operational processes, such as ambulance offloading, triage, registration, testing protocols, provider assessments, discharge protocols, room turnover, etc., were documented and analyzed for efficiencies during a LEAN 3P Kaizen five day event.* At the end of the five day event a plan was developed for the future design of the Grace ED, a plan which remained intact throughout the course of design. Simulation models were developed using existing data and the old and new layouts, allowing improvements to be measured accurately against the baseline of existing conditions.
- Old: Complete registration at intake.
- New: Quick registration at triage, followed by registration at the bedside.
- Old: Comprehensive triage.
- New: Streamlined and focused triage.
- Old: Batched and retrieved hourly lab tests.
- New: Protocols on demand with results in under 60 minutes.
- Old: Nurse followed by provider assessment process.
- New: First available assessment process.
- Old: Individualized staffing schedule.
- New: Nurse, technician, and registration clerks to work in teams, resulting in 12 additional hours RN time.
- Old: Specialist consultations occurring periodically (sometimes twice daily).
- New: Process will target consultant evaluations in less than 90 minutes.
- Old: Patients waiting for admission or unable to go home were relocated to an observation zone within the old ED.
- New: Patient remains in the ED bed without transfer and consultant evaluations are more timely.
- Old: Overnight CT imaging was completed offsite.
- New: CT Imaging will be available 24/7 with results in under 90 minutes. Also, X-ray is in the department with dedicated equipment and resources.
Minor Treatment Area:
- Old: Department utilized a one room, one nurse practitioner from 10 am to 6 pm.
- New: Department has a seven room MTA intended to operate from 8 am to 10 pm and provides flex space for the main ED 24/7.
‘Can’t Go Home’:
- Old: Historic data indicates patients could remain in the emergency department for days as they were not sick enough to be admitted, but not well enough to be discharged (with adequate supports in place).
- New: More appropriate protocols in place to address observation patients.
Admitted Patient Stays:
- Old: Similarly, historic data also illustrates that patients who are to be admitted are often awaiting test results for over 24 hours, creating underutilized ED beds for observation.
- New: The new process limits admitted patient stays to 10 hours.
- Old: 77% of patients arriving by stretcher remain on the stretcher and in the care of the EMS worker for longer than one hour.
- New: Process will enable EMS workers to offload 90% of patients in under 60 minutes, improving their availability to service additional patients.
Baseline Length of Stay in 2014 was 12 hours, 39 minutes. The new design, based on simulation results, will have a LOS of 5 hours, 10 minutes. A reduction of nearly 60%.
The new emergency department is visually open and flexible, able to accordion up and down to suit the patient load. There are 31 treatment rooms, including bariatric, isolation, seclusion and gyne with seven rooms designated for minor treatment in a fast track format. Rooms are standardized with segregated clinical and family zones, improving travel distances, turnover efficiencies, and reducing transfers between rooms for specialized care. Triage is designed to initiate protocols and treatment and expeditiously move patients forward in the process. There are two resuscitation rooms with a central equipment and support area allowing movement between the two rooms for multiple case coverage. Radiology and lab functions are located within the ED to expedite protocols and testing, reducing wait times and LOS. Four subwaiting areas strategically located within the ED along with two interview rooms improve patient flow, room turnover, and results waiting / discharge processing.
WRHA tracks the Wait Times and publishes monthly and annual reports. Across the region wait times are improving with consolidation from six EDs to three EDs. With consolidation, improved and timely access to testing and specialist consultation is impacting wait times and LOS. Improvements for the Grace ED indicate a nearly 12% reduction in wait times since last year. Overall, the WRHA reports a 16% improvement. Further review of the results data will occur later in 2019.
The design team recently completed a Post Occupancy Evaluation in conjunction with the WRHA and Grace Hospital staff in January 2019. The results of the POE indicate:
- Bed side registration is not currently implemented due to technology challenges and further work is needed to improve wait times with this task.
- The Sub-wait areas through-out the department are very well utilized and would be larger with more seating options if the staff had been able to foresee the utilization. The Grace team refers to these areas as Care Zones. Two of the Care Zones are utilized differently than planned and observation responsibilities should be revisited.
- Coordination of supplies in the best possible locations remains an ongoing challenge and some of the originally planned design locations have changed, partly due to new staff members.
- Due to the quiet and calm atmosphere of the new ED, many patients believe they are not busy even though the ED may be fully occupied.
- Staff love the natural light, spacious and visually open environment – ‘A beautiful facility and I am proud to work in it!’ – staff survey comment.
Author: Jerald D. Peters, AAA AIBC MAA OAA SAA FRAIC LEED AP
Architect / Principal
Jerald Peters brings more than 23 years of experience creating vibrant, functional spaces, and has provided leadership and technical expertise on an extensive array of projects in healthcare, institutional, housing, commercial, and religious environments.