Health Systems Direct

The Urban Emergency

Keeping Up With the Changing Needs of an Urban Emergency Department
Kevin D. Crook, AIA, CHC & C. Joy White

Between the popular television drama series and the nightly news, Emergency Departments are receiving constant publicity – most is negative. Not only do Emergency Departments meet emergency needs, changes in the urban environment are driving more people to use the Emergency Department as their primary care center. Even with continued managed care penetration, Emergency Department utilization has changed very little across the United States over the past five years (See Exhibit 1). However, there are regional variations (Exhibit 2) with reduced utilization in the markets with high managed care penetration. Some of this variation is due to a younger population.

Many other environmental regulatory and competitive factors are affecting inner-city Emergency Departments. For example, stiffer competition and a demand for consumer preference has increased pressure on Emergency Departments to be more patient friendly. In many hospitals the ED is the “front door” for inpatient admissions. Also, a rise in the number of gangs in urban settings calls for increased security in inner-city hospitals while a rise in infections requires better separation between public and patients. This paper will focus on four areas of change: uninsured population, consumer preferences, inner-city violence, and infection.

Uninsured Population
As reported by the US Bureau of Census 43.4 million Americans (16% of the population) had no health insurance in 1997, 36% growth since 1987. This problem is even more evident in urban and metropolitan areas where averages of 18% or more of the non-elderly population lack health coverage today. Projections show no improvement in the near future. According to a 1999 study by the National Coalition on Health Care, even with continued booming economic conditions a projected 52-54 million non-elderly Americans will be uninsured in 2009. If an economic downturn occurs, as many as 61.4 million non- elderly Americans could be without insurance in 2009 (see Exhibit 3).

So what does all this mean for the Emergency Department? More patients are using the ED as their primary source of care. The uninsured patient also tends to wait until a disease, such as diabetes or asthma, progresses to a critical point before seeking care. As a result of this delay in care, many ED’s are beginning to see an increase in the acuity of their medical patients. According to the National Hospital Ambulatory Medical Care Survey (NHAMCS) in 1996 46.2 percent of all visits were considered urgent or emergent but that number increased to 53 percent in 1997.

One way to deal with the increase in volumes is to utilize triage to move the volume of “non-urgent” patients out of the ED and to a more appropriate setting, such as a fast track clinic. This space would be staffed exclusively to handle non- urgent patients in less costly space. Frequently this area is adjacent to the ED, but it may be distinctly separate from the hospital, with a separate entrance, in order to assure it is run more like a clinic at a lower cost than a hospital setting allows. In a phone survey of urban Emergency Departments conducted by Gresham, Smith and Partners, 67% of respondents indicated a dedicated fast track or non-urgent care area with an average of 24% of their emergency beds dedicated to this space (see Exhibit 4). According to AHA Hospital Statistics, in 1997 25% of all U.S. community hospitals had a separate urgent care center.

Design is imperative when operating a non-urgent care area. Whether the area is part of or separate from the emergency department, patients must be triaged at arrival. Distinct waiting areas are also necessary to reduce disgruntled patients when a non-urgent/fast track patient is treated and sent home much quicker than an emergency patient. Exhibit 5 shows a sample of patient flow when a fast track system is implemented. Important components in a successful design include shared triage and diagnostic services (Radiology, Lab, etc.) while providing distinct waiting and exam space.

Consumer Preference
In recent years the healthcare industry has seen a rapid increase in competition. As consumers demand more choice in their healthcare plan, many hospitals are being forced to be more patient-friendly. In the Emergency Department, one simple way to be more patient friendly is to decrease the amount of time a patient waits to see a physician. The 1997 NHAMCS included a new statistic indicating the amount of time a patient spent waiting to see a physician. On average, patients wait about 38 minutes, but the amount of time varied depending on the urgency of care needed. Patients with urgent/emergent conditions waited about 22 minutes while non-urgent patients waited about 51 minutes to see a physician. Overall, waiting times were longer in metropolitan areas when compared to non-metropolitan areas with the longest waits in metropolitan government owned facilities. In order to improve wait times, some facilities have decentralized registration. Through the use of PC’s and handheld computers they now register patients at the bedside. One example is Harris Methodist Hospital in Bedford, Texas that reduced the average length of stay for their non-urgent patients by 60 percent using bedside registration. See Exhibit 6 for an example of design implementation.

Emergency Departments are challenged with a wide variety of patients on a daily basis. Each patient requires a specific treatment, which requires a specific type of space. To meet these differing needs, most ED’s have specialty areas. In a survey conducted by Gresham, Smith and Partners, most respondents had dedicated beds for Fast Track and Trauma, but less than one-third dedicated Emergency beds to Psychiatric, Pediatrics, Observation and/or Cardiac Care. Also, if you combine Cardiac and Observation, 53% of ED’s provide a dedicated space for these patients (see Exhibit 4).

It is important to the consumer for the overall length of their visit to be as short as possible. Our survey indicated the average length of stay for a non-urgent patient was 1.4 hours, urgent/emergent patients stayed an average of 2.6 hours with trauma patients out of the ED in 2.3 hours for those hospitals who track ALOS separately by patient type. For the 60% of the respondents that did not track their ALOS by patient type, the overall ALOS was 3.2 hours. In order to improve customer satisfaction and reduce average length of stay, ED’s must try to provide the most appropriate space for every patient. For example, an observation or cardiac patient who may be in the ED for up to 23 hours would be better treated in a private room with a hospital bed (not stretcher), family recliner, walls and a door as opposed to a typical treatment cubicle with curtains. It is also important to design public areas separate from patient areas in order to maintain patient privacy. Visitors should have access to hospital amenities, such as restrooms, gift shop and the cafeteria, without walking through patient care spaces. An example of patient separation in design is shown in Exhibit 7.

One contributing factor to patient length of stay is diagnostic response time. In larger urban hospitals it becomes more difficult to locate diagnostic departments such as Radiology or Lab near the ED. Turnaround time for X-Ray readings and Lab orders are also delayed by other hospital needs. In order to decrease average length of stay in the emergency department, many hospitals are moving some diagnostic space within the walls of the ED. The most common is General X-Ray equipment, but many ED’s also have dedicated CT and Ultrasound. Those hospitals without pneumatic tube systems often have a Stat Lab located in the Emergency Department as well (see Exhibit 8).

Inner City Violence
All you have to do is turn on the television to know that inner city violence has been on the rise. According to a 1997 study by the Bureau of Justice, the most common injury treated in Emergency Departments due to violence was bruises or similar injuries (see Exhibit 9).

In addition to treating the victims of assault, who represented 5 percent of all injury related visits in a 1997 National Healthcare Statistics study, urban hospitals must control violence within their own waiting rooms. A new focus on security is emerging. In response to this and considering that the Emergency entrance is the 24 hour entrance to the hospital, many hospitals have moved their entire security department to the ED. The use of other security measures is based on hospital preference, in part by the message they want to send to visitors. For example, metal detectors and bullet proof entrance vestibules might scare off some people, while others are reassured by the same devices. Many hospitals are choosing less aggressive security controls such as under counter silent alarms and audiovisual surveillance.

The University of California-San Francisco conducted a study in 1997 to determine the number of weapons and assaults reported in an urban county emergency department before and after the implementation of a security system. This security system included metal detectors, cameras, limited access and a manned security booth at the ED entrance. The number of weapons confiscated per 10,000 patients after installing the security system was almost double the number before the security system. This resulted in a reduction in the percentage of weapons confiscated in the patient care area from 92% to 42%. Interestingly, the reported assaults per 10,000 patients did not change significantly. This emphasizes the importance of continued training of ED personnel in the management of violent patients and potentially violent situations.

Infection Control
In recent years there has been a growing concern regarding infection control in hospitals. Tuberculosis cases grew almost 20 percent between 1988 and 1992 before numbers once again began to decline between 1993 and 1997. Given this statistic and the increase in the number of drug resistant diseases, hospitals are attempting to reduce the number of airborne infections. ED’s are providing more isolation rooms and reducing the size of large open waiting rooms that are common in Emergency Departments. For example, Sinai Hospital in Baltimore provides small enclosed waiting rooms for each of its seven separate specialty areas (Fast Track, Urgent Care, Emergent Care, Pediatric Care, Trauma, Chest Pain and Observation.) Not only does this separate critically ill from the non-urgent patient, but humidity and temperature can also be better controlled in a smaller area. However, one disadvantage of many separate areas is staffing inefficiencies.

For many years, patient treatment areas were designed as more open flexible cubicles with curtains. Now most ED’s are considering enclosed rooms or spaces with three walls and a curtain or glass breakaway doors (see Exhibit 10). This not only aids in the control of infection, but also creates a sound barrier for improved patient privacy. This is especially useful when bedside registration is occurring.

Conclusion
Planning a successful Emergency Department is now a complex problem. With continued Medicare cutbacks, increased managed care penetration and rising cost of healthcare, Emergency Departments must be prepared to provide high quality care that is timely, efficient and low cost. In addition, the healthcare industry is more competitive. Urban Emergency Departments will be under increased pressure to handle more uninsured patients while maintaining an environment that will attract paying customers. The days of the “cookie cutter” ED design are over. The future design of Emergency Departments will be based on efficient, patient and family focused care that is customized to individual community needs.

References
1. AHA Hospital Statistics, 1998

2. Emergency Departments: The New “Front Door”. The Academy of Architecture for Health, 1998.

3. Findlay, S., Miller, J. Down a Dangerous Path: The Erosion of Health Insurance Coverage in the United States. National Coalition on Health Care, May 1999.

4. Gresham, Smith and Partners: Urban Emergency Department Survey, June 1999

5. Hendey MD, G., Rankins MD, R., Effect of a Security System on Violent Incidents and Hidden Weapons in the Emergency Department, Annals of Emergency Medicine 33:6 (June 1999).

6. Levan, R, Brown, E., Lisa Lara, R. Nearly One-Fifth of Urban Americans Lack Health Insurance. UCLA Center for Health Policy Research, December 1998.

7. National Center for Health Statistics: National Hospital Ambulatory Medical Care Survey (NHAMCS): 1994-1997

8. U.S. Department of Justice: Violence-Related Injuries Treated in Hospital Emergency Departments, August 1997.

About the Authors: Kevin D. Crook, AIA, CHC has been actively involved in the healthcare industry for 16 years. His consulting experience includes participation in more than 100 healthcare facility planning and development projects for teaching institutions, psychiatric hospitals, physician office practices, ambulatory care centers, and non-profit, federal, municipal, and investor-owned general hospitals.

C. Joy White has been involved in the healthcare industry for four years. She has consulting experience in healthcare market research and strategic planning as well as facility planning and programming.