Stafford, Virginia
X32 Healthcare
Fredericksburg, Virginia
Jody Crane, MD, MBA, Principal
Kelly McDonough, DPN, RN, Administrative Director, Nursing Practice and Nursing Operations
Opened February 2009

Key Words
High efficiency
Operational process improvement
Patient intake

Problem/Situation
Mary Washington Hospital had pioneered some changes in its main site, using patient streaming and different flows for high-, medium-, and low-acuity patients. These improvements served to reduce the time between patient arrival and the physician encounter. Operational changes in the main site were done in the context of an existing physical plant that was not optimized or expressly suited for the process that was implemented.

Mary Washington Healthcare sought to design the Stafford Hospital emergency department to integrate the discoveries from the previous 5 years of work into the physical space so that the design complemented and enabled the process. Specific goals included reducing door-to-doctor times and length of stay and enhancing patient satisfaction.

Solution
The final design with 14 treatment spaces was implemented in February 2009 and was designed for an expected demand of 30,000 visits annually. The facility was unique in that it had the ability to expand and contract treatment capacity based on peak and off-peak volume. It also had a deliberate connectivity between the waiting area and the treatment areas in the form of four intake rooms that directly opened to the waiting area and articulated with an internal results waiting area and the forward-most patient treatment rooms. This design ultimately enabled the emergency department to see over 37,000 visits annually with door-to-doctor times pf less than 30 minutes and discharged length of stay of just over 2 hours.

Specific design features included:

• Entrances for walk-in and EMS arrivals that enabled pooling of patient access to perform a mini-registration for each of these arriving patient populations from the same physical space.
• Four intake rooms articulating with the waiting area to facilitate the assessment and disposition of lower-acuity patients directly from the front of the emergency department. These rooms also facilitate the institution of workup and treatment for patients who need a treatment space when one is not available.
• An internal results waiting area was designed that articulated with the intake rooms and front four main emergency department treatment spaces. These four treatment spaces were designed with front and rear entrances so that staff could treat patients from the intake area or the main emergency department.
• A small nurses’ station was implemented in the intake area that has direct oversight of results waiting. The charge nurse is located in this nurses’ station and manages front-end flow and screens all patients arriving as walk-ins or by EMS.
• The main emergency department was designed with standard bedside supplies, carts for common and high-acuity procedures, and weight-based inventory management systems to streamline the supply chain process.

This design has proved to be very effective over time and has been able to accommodate several different staffing configurations. The emergency department has a very efficient throughput profile of 37,000 visits per year in 14 main emergency department rooms, or more than 2,600 annual visits per emergency department treatment space.

Lessons Learned

• Designing intake rooms that enable providers to see patients directly from the waiting room is beneficial in reducing door-to-provider times.
• A results waiting area can greatly facilitate throughput and maintain flow during periods when the main emergency department beds are filled. Used proactively, this strategy can preserve treatment capacity in the main emergency department for higher-acuity patients.
• Placing a charge nurse in the front end to oversee arrivals and results waiting is a very efficient use of nursing resources and an excellent way to maintain front-end flow.
• Advanced inventory pull systems can greatly reduce the time and resources needed to maintain proper inventory levels in the emergency department. This approach can reduce the amount of time required to manage inventory from hours to minutes per day.

Editorial Commentary
This is an example of operational process improvement in which the designers and consultants applied operational “lessons learned” from another facility within the same system. The operational improvements were integrated with design enhancements. In this case, careful attention to the front-end patient intake system (both operationally and physically) resulted in a very high patient throughput efficiency and satisfaction.

 

Figure 1.  

Floor plan indicating flow of patients from entrance to discharge or admitting, Stafford Hospital, Mary Washington Healthcare, Emergency Department. Copyright Jody Crane, MD, MBA.

 

Figure 2.  

Location of super track and main emergency department. Copyright Jody Crane, MD, MBA.

 

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