7. Optimizing ED Flow Implications For Design

4/17/2015This presenter hasnothing to discloseOptimizing ED Flow:Implications for EDDesignJody Crane, MD, MBAApril 28, 2015,Cambridge, MA 2015, Jody Crane, MD, MBASession ObjectivesAfter this session, participants will be able to:Describe the design at Stafford Hospital to improve EDperformanceIdentify key design principles to facilitate patient flow in theED 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.com1

4/17/2015OverviewImportant ConsiderationsThe Front EndMain ED 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comTHE QuestionHow Many Beds Do I Need? 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.com2

4/17/2015Important ConsiderationsWhat exactly are you trying to achieve?More space?More rooms?Update facility?Accommodate more patients?Decrease door to doc?If you don’t ask yourself this, you will likely fix the wrongproblem (think root cause) 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comImportant ConsiderationsConsider your short and long-term growth topredict future needsConsider the next step after thisrenovation/constructionConsider your current operational metrics toarrive at target number of beds, etc.i.e. if your LOS is 10 hours, you will not be able tohandle 1500 annual visits per bedConsider benchmarks as they apply to your uniquesituationMost start with 1,400-1,500 visits per bed 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.com3

4/17/2015Important ConsiderationsYou should either have your operational issues clearlyworked out, or at least rapid cycle testedDon’t rely on a new, bigger facility to solve all of yourproblemsConsider clinical and operational functionality as primaryconsiderations 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comThe Front End - RegistrationRegistration has evolved away from the front end and tothe bedside!Most EDs have “mini-reg” function upon patient arrivalFront end check out and copay collection providespooling of front end staff who also perform mini-regShould not have separate greeter/desk 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.com4

4/17/2015 2015, Jody Crane, MD, MBA 2015, Jody Crane, MD, MBA5

4/17/2015Reception 2015, Jody Crane, MD, MBAThe Front End – ArrivalsIdeally walk-in arrivals and rescue squad arrivalsprocessed by the same registration staffShould be near triage for the availability of anurse to screen rescue squads if needed or partof your design 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.com6

4/17/2015 2015, Jody Crane, MD, MBAWalk-insEMSStaffordMedicalCenter EDLabPedsWaiting(Opening Feb ad/CTAreaWaitingAreaMain ED14 beds 1 Trauma bayWalk-inEntranceRec/QuickSecuritySquadEntrance 2015, Jody Crane,MD, MBA7

4/17/2015OtherExamplesExample #2 2015, Jody Crane, MD,MBACombined ArrivalsMain EDWaitingTriageCombinedWalk-in andRescue arrivalsEMS 2015, Jody Crane, MD, MBA8

4/17/2015Triage/IntakeIs changing from, “Who can wait?” to the initialevaluation areaMinimal nurse screening to determine most efficient pathfor patient (streaming)Incorporating physician evaluationIncorporating ancillary resources and results waiting inclose proximity 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comLatest InnovationsPivot NurseMidlevel in Triage – “Super Track”Physician in Triage ModelsRapid Medical Evaluation (RME)Intake TeamsIntake Teams 2015, Jody Crane, MD, 2012,MBAJody Crane, MD, MBA, www.X32healthcare.com9

4/17/2015Results WaitingInternalPatients don’t feelthey’re sent to WRWR is emptyCloser supervisionLess elopementMore comfortableLess spaceExternalPatients may feelgoing back to WRWR looks busyLess supervisionMore elopementLess comfortableMore space 2015, Jody Crane, MD, MBA20 2015, Jody Crane, MD, MBA10

4/17/201521 2015, Jody Crane, MD, MBAStaffordMedicalCenter EDLabPedsWaiting(Feb 2009)WaitingAreaTriage(4)IntakeTreatBaysRW (4)AreaRad/CTAreaWaitingAreaMain ED14 beds 1 Trauma bayWalk-inRec/Entrance QuickSecurity 2012, Jody Crane, MD, MBA, www.X32healthcare.comSquadEntrance 2015, Jody Crane, MD,MBA11

4/17/2015StaffordMedicalCenter EDLabPedsWaitingWaitingArea(Opening Feb 2009)TreatBaysRW essmentIntakeWaitingAreaandRapid ServiceMain ED14 beds 1 Trauma bayWalk-inRec/Entrance QuickSecuritySquadEntrance 2012, Jody Crane, MD, MBA, www.X32healthcare.comTreatBays(4)ESI 4,5RWAreaTriage(4)IntakeStaffordMedicalCenter ED(Opening Feb 2009)ESI 2,3AdmitESI 2-5EntranceESI 1,2DischargeRec/Quick 2015, Jody Crane, MD, MBA12

4/17/2015Get Closer to the Patient Arrival 25 2015, Jody Crane, MD, MBAIntake and Results Waiting26 2015, Jody Crane, MD, MBA13

4/17/2015Intake and Results Waiting27 2015, Jody Crane, MD, MBAGet Closer to the Patient Arrival 28 2015, Jody Crane, MD, MBA14

4/17/2015Intake and Results Waiting29 2015, Jody Crane, MD, MBAIntake and Results Waiting30 2015, Jody Crane, MD, MBA15

4/17/2015Results Waiting Areas and mentationInternalRWCT/Xray 2015, Jody Crane, MD, MBAResWaitRad/CTLabEntrance 2012, Jody Crane, MD, MBA, 2015, Jody Crane, MD, MBA www.X32healthcare.com16

4/17/2015Main EDShould articulate with triage and facilitate flowAll rooms should be clearly visible from central staff areaLab/radiology should be in close proximityTrauma area should be accessible from outside ifpossible and should incorporate “decon area” to facilitateflow of critical/contaminated patientsShould be amenable to team based careShould consider the increasing prevalence of POCtestingShould consider internal RW Area 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comFastTrackTriage 2015, Jody Crane, MD, MBA17

4/17/2015StaffordMedicalCenter EDLabPedsWaiting(Opening Feb ad/CTAreaWaitingAreaMain ED14 beds 1 Trauma S/Decon 2015, JodyCrane, MD,MBACombined ArrivalsMain EDWaitingTriageCombinedWalk-in andRescue arrivalsRescue arrivalswith decon, resuscitationseparate from Main ED 2015, Jody Crane, MD, MBA18

4/17/2015Teams/PodsAn ED I recently visited was 30,000 sf with nursing zones, but noDoc zones. The average Doc walked 7 miles per shift! Yes,true However, teams can be very effective:Decreased staff movement due to proximity of roomsGreatly enhanced communicationClear handoffs and signals due to few numbers of unique staffinteractionsThe division of the ED into teams (if desired) is an importantconsideration and should be thought through carefully.Consider team-based documentation areas as opposed toseparate nurse and MD areas 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comPhys Area 2012, Jody Crane, MD, MBA,www.X32healthcare.com 2015, Jody Crane, MD, MBA19

CombinedDocumentation AreaXPhys AreaCombinedDocumentation Area4/17/2015 2012, Jody Crane, MD, MBA,www.X32healthcare.com 2015, Jody Crane, MD, MBABoardingAdmissions outside of normal admitting timeframeshould be segregatedCare for by inpatient nurses or nurses specificallydesignated to care for themCan get the admission started and can be evaluated byHospitalistClinical Decision Unit/Obs Unit 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.com20

4/17/2015Non - ICUAdmitting -BoardingOccupancyICU 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comHolds/Admitting 2015, Jody Crane, MD, MBA21

4/17/2015Summary1. Understanding of Operations Management and flow iscritical to designing a successful ED.2. Bringing patients and staff together efficiently is thekey to front end design. Articulating reception, triage,first physician contact, and diagnostics is the key tostreamlined patient care.3. In the Main ED, facilitating communication throughproximity, and understanding your beds needs iscritically important for success.www.X32Healthcare.com 2015, Jody Crane, MD, MBA 2012, Jody Crane, MD, MBA, www.X32healthcare.comFor Further Reading 2006 Guidelines for Design & Const. ofHealth Care FacilitiesBy Facility Guidelines Institute, AIA Academy ofArchitecture for Health, US Dept. of Health &Human ServicesISBN: 157165013XAIA/FGI, 2006Paperback: 352 pagesAll the latest in healthcare design. Reorganized to be moreaccessible and updated to reflect the most currenttrends in medical practice. 2015, Jody Crane, MD, MBA22

4/17/2015For Further Reading 2015, Jody Crane, MD, MBA23

Triage (4) Intake RW Area Main ED 14 beds 1 Trauma bay Treat Bays (4) Lab Rad/ CT Area Entrance Walk-in Squad Entrance STARS Strategic Triage, Assessment and Rapid Service Stafford Medical Center ED (Opening Feb 2009) Stafford Medical Center ED (Opening Feb 2009) Entrance Rec/ Quick Triage (4) Intake RW Area Treat Bays (4) ESI 4,5 ESI 2,3 ESI 1 .