Emergency departments (ED) at many U.S. hospitals have reached a critical mass, and we’re not talking about patient conditions.
Visits to America’s emergency departments are up 20 percent over the past decade, says the latest “National Ambulatory Medical Care Survey” from Atlanta-based Centers for Disease Control and Prevention (CDC).
As the number of U.S. emergency departments decreased by 15 percent, patient visits continued to grow. The CDC report logs an estimated 107.5 million visits to hospital emergency departments in 2001, compared to 90 million in 1992.
According to the American College of Emergency Physicians (ACEP), with offices in Irving, TX, and Washington, D.C., factors contributing to emergency department saturation include the lack of hospital inpatient beds, the shortage of on-call specialists to treat emergency patients, a growing elderly population with complex and chronic medical conditions, and severe national nursing and support staff shortages. Managed care and more sophisticated technologies also play a role.
Dr. Virginia Evans at Lakewood Hospital in Lakewood, OH, part of the Cleveland Clinic Health System, says increasing overcrowding in the nation’s emergency departments not only creates crowded spaces but also jams the entire treatment delivery process. “It’s difficult to move people through the system,” she says.
The CDC report found that patients on the average spent about three hours in the emergency department from arrival to discharge, with more than half spending two to six hours. Another report, issued in March by the General Accounting Office, attributes rising patient volumes with this practice of “boarding” as the major causes of ED overcrowding.
“The GAO report shed important insight into the crowding problem and how hospitals and their emergency departments have sought to manage it,” says ACEP President Dr. George Molzen. “It clearly shows that failure to move patients from the emergency department to hospital inpatient beds plays a major role in crowding.”
And while these factors causing emergency department overflow are predominantly medical related, the facility itself suffers.
Hospitals are scrambling to make more space in vital emergency departments through renovation, expansion, and new construction – a move that impacts the facilities department and the professionals with which the team works.
“We’re seeing more construction in the emergency department,” says Paul Hartwig, vice president – Healthcare, St. Louis-based McCarthy Building Cos. “Our clients are considering either expansions or new locations for their emergency departments to provide better access to the public and for better in-and-out service.”
Evans knows the scenario of stilted in-and-out service all too well. Until Lakewood Hospital opened a new ED in April 2002, she and other doctors were working in a cramped facility with 16 functional rooms designed for an average of 20,000 to 26,000 visits per year. “We were up to at least 35,000 a year,” Evans says. “It was small. It was cramped, and we were pressing the system just by volume.”
While there were days the space in the old ED was sufficient, at times it did not have enough treatment rooms available to support this volume, Evans notes. “One of the biggest challenges in the Emergency Department is what I call the elastic factor,” she says. “The yearly statistics tell you that the emergency room and urgent care clinic sees 30-plus thousand patients per year. But the daily numbers don’t average out this way. Some days are much busier than others. In even the largest emergency departments, there will always be times when space is at a premium.”
There’s more to overcrowding beyond increased patient flow and outdated facilities. Managed healthcare has changed the face of emergency medicine and contributes to overflowing emergency rooms, Evan says.
Years ago, most people who came into an emergency room were admitted for diagnostics and treatment if they were sick and injured. Today, restraints posed by the managed care system have slowed things down and eliminated many admissions. Managed care has also driven the need for more ED technology.
“In the old days, you’d look at a person with abdominal pain, decide if they were sick, and admit them,” Evans says. “Now, we really need to hone down on what is causing the abdominal pain. We need to do a work up, maybe even a CAT scan. That takes time. We then can get the patient admitted to the appropriate part of the hospital, or we might find they are fine and send them home. You just can’t admit people now. You have to have a reason. That’s good. It’s not all bad, but it does impact the evaluation process.”
This increased need for testing at an ambulatory level not only brings in equipment that takes up space, it also ties up staff and ties up the treatment process.
“Patients are being ‘boarded’ in the emergency department, which further shrinks emergency department resources to treat severely injured and sick patients,” Molzen says. “It also limits a hospital’s ability to meet periodic surges in demand, such as those from disasters.”
In traditional EDs built even 15 or 20 years ago, space is at a premium when you combine staff, patients, and the equipment needed for treatment and diagnoses – factors planners, designers, and administrators of the past did not necessarily count upon.
McCarthy’s Hartwig says it’s crucial to try to predict how much more an ED will grow in so many years in order to anticipate possible needed space down the road rather than having to build it in during a space crisis.
One such designer is Tom Van Landingham, an associate at St. Louis-based architect Christner Inc., who has worked with Hartwig on several emergency department construction projects.
“Built-in flexibility is key to anticipating future needs,” says Van Landingham, adding that in the planning and design processes, it’s imperative to build in the potential adaptability of “soft” spaces, such as offices, skilled support areas, and conference rooms, for other uses.
At Lakewood Hospital, the new emergency department boasts 30 rooms plus a decontamination suite. Nine of the rooms have built-in monitoring equipment, but the department also has portable systems that can be used in the other spaces. Two of the rooms serve as seclusion rooms for psychiatric admissions, but any of the rooms can be used for multiple functions, if needed, according to Evans.
“There’s flexibility,” she notes. “We’re not locked in. We can use a seclusion room as a treatment room. That’s not a problem.”
Construction put an ambulatory surgery department in the ED’s former space, which is adjacent to the new emergency department. After 3:00 p.m. each day, it is used as a holding area and provides the department with room to expand if the evening gets crowded
“We have a buffer zone,” Evans explains. “Not every patient goes there, just those on their way up to a floor. It has made a huge impact for us. Also, by having the ambulatory surgery area contiguous to our department, we can increase our area on an episodic basis in a disaster or on a permanent basis down the road if we are required to do so at some point in time. It gives you flexibility down the road.
“It came out of long, hard-thought-out, critical thinking and planning.”
Robin Suttell, based in Cleveland, is contributing editor at Buildings magazine.
Taking proper infection control measures during any health facility construction project is crucial as pathogens are easily carried throughout a facility within the dust generated from the work.
“You have to think about all of the possible scenarios and control and minimize those,” says Shawn Wolfe, senior project manager at the Seattle-based environmental consulting firm Clayton Group Services. “You need to consider what you are doing, who is going to be in the area, and what you are introducing into the area’s environment.”
The American Institute of Architects and Facility Guidelines Institute’s 2001 edition of Guidelines for Design and Construction of Hospital and Health Care Facilities requires that a healthcare facility perform an infection control risk assessment (ICRA) prior to construction activity. According to Wolfe, many facilities have done this in the past, but it was more prevalent in acute care environments.
“ICRAs should be performed during the project planning stage, and there should be infection control standards instituted within the facility to address maintenance activities,” Wolfe says.
In performing any risk assessment, Wolfe suggests asking the following questions:
What are the construction activities?
What are the patient risk groups?
What are the impacts to the building systems of the facility?
What will be the flow of materials in and out of the construction zone?
What phasing requirements are there?
What housekeeping issues are associated with entering and exiting the construction zone?
What are the risks of water damage?
On its website, the American Society of Healthcare Engineers (ASHE), Chicago, offers a sample matrix using some of these questions to classify the construction or maintenance project in order to properly determine the level of infection control requirements.
At Lakewood Hospital in Lakewood, OH, seven miles west of downtown Cleveland, infection control professionals take construction projects seriously. The hospital most recently completed construction of a new emergency department, which opened in April 2002. Dr. William Riebel, director of Infectious Diseases and Infection Surveillance, says all contractors placing bids must fill out an action plan that states what work will be done, what kind of dust will be generated, and what measures will be taken for protection.
“They are then put into a risk category,” Riebel says. “The form we give them requires their signature at the end and informs them of their liability.”
Riebel says it is imperative to get an infection control plan in writing from a contractor before construction work begins. He also suggests designating a team member to focus solely on facility-related infection control issues.
“It’s not a bad idea to keep track,” he says. “And if you don’t want to do it in-house, contract out for advice. Infection prevention advice is available. Sometimes, the costs seem hard to justify, but if a patient gets sick because the environment isn’t clean, you’re going to lose money.”