As an ED nurse for over 25 years, Innova Senior Consultant Janet Woods has worked in several Emergency Departments (EDs) each with a unique departmental design and often undergoing an expansion or renovation to accommodate an increase in patient volume or to improve patient processes and staff workflow. Now, as a clinical consultant for the Innova Group she visits a variety of EDs and provides input into optimal design and patient flow on projects ranging from large medical centers to community clinics.
Read below for Janet’s insight on overall design and potential changes to consider in pandemic planning.
There are a variety of design concepts to consider when planning or initiating a new project – patient safety, patient throughput, and patient/ staff satisfaction. Equally important is the adaptability of the space to support operational needs or unforeseen challenges such as the current pandemic. Some of the design considerations are protocol or policy driven while others are government, regulatory or accreditation agency requirements. It is even more imperative with the COVID-19 pandemic to include adaptability in the ED design and workflow. The following sections highlight considerations by departmental areas.
Entrance / Triage
The main entrance to the ED should be visible from triage. Triage is the beginning of a screening process that may include point-of-care-testing, first aid, or rapid intervention. This task is usually performed by an RN who, along with a registrar or technician, has oversight of the waiting room as well. Some triage models may include a physician or mid-level provider to expedite care.
In the case of a pandemic, outdoor screening may be used to identify symptomatic patients. Remote registration prior to going to the ED can be done online for most metropolitan area hospitals or rural facilities associated with a healthcare or hospital system. During a pandemic, triage and registration may occur simultaneously using the patient’s phone.
Consider separate entrances for triaged patients who are symptomatic or suspected of being infectious. If a decontamination room or area exists, this could be the entrance by which symptomatic patients are routed prior to entering the designated treatment area. Remember parking and traffic flow might be affected by a pandemic testing / screening queue. Ambulance and patient vehicle access to the ED by other patients should not be hampered.
Even during a pandemic, the ED provides acute care for major and minor medical conditions, illness and injuries or trauma. In the current healthcare environment, patients may await treatment in their cars or in reconfigured separate waiting areas – one reserved for possible infectious patients and one for those with an injury or medical complaint not pandemic related. Family or patient escorts may be allowed to wait with them or instructed to wait in their vehicle. Either way, most modern hospitals have a guest website and patient phones are becoming a method for keeping patients and family informed of their place in “line” or other expectations during the visit. Chatbots are another option to keep patients informed and answer common questions.
A hospital main lobby or designated sub-waiting areas can be used for additional information gathering prior to moving a patient to a treatment room. Wherever patients wait, it is important that staff have oversight of the area in-person or remotely in case of a deteriorating patient condition.
Patient Care / Support Areas
Much has been researched and written regarding improving the throughput of ED patients, which includes streamlining processes and protocols to expedite care. Emergency planning and guidelines for managing throughput when experiencing a heavy influx of patient from a pandemic, natural disaster, mass shooting, or other causes is equally important.i Improving patient flow during a pandemic may be accomplished by designing the ED with flexible patient care areas. Organizing the ED into pods with the ability to add beds or quickly convert to negative pressure would allow less critically ill patients to isolate together.ii
In addition, there are design considerations that could help decrease a length of stay and increase treatment space for another patient. Having a discharge lounge where patients wait for their instructions and prescriptions would accomplish this goal.
All the healthcare workers in the ED, from physicians to registration clerks, need a place to debrief, take a moment to eat, or contact family. Constructing an ED where staff support rooms, breakrooms, and offices have windows, preferably with a view of nature, helps support the healthcare workers caring for the rest of us.
Hospital and community efforts need to be on-going to ensure patients needing emergency care recognize that services are available for all types of patients during a pandemic and that measures have been implemented to protect everyone’s health. Incorporating new safe distancing triage options, maintaining visibility in waiting and sub-waiting rooms, optimizing patient throughput, and designing the ED with a layout flexible to meet patient care and support staff are important considerations. When renovating or designing an Emergency Department for the future, consulting with ED staff members who interact with patients and provide bedside care is essential for understanding staff concerns related to an optimal ED design.
How well has your ED layout been able to adapt to new and changing processes?
What spaces have you reconfigured to support patient and staff precaution guidelines during COVID-19?
Janet Woods, RN, BSN is a former ED / Critical Care nurse who is currently planning patient care environments as a Clinical Consultant with The Innova Group, Austin, Texas.