Healthcare Design - January 2014 - 70

OPERATIONS | 02.14

Rethinking the ED
An innovative renovation of Lehigh Valley Hospital - Muhlenberg's emergency
department manages patient volumes and improves performance
By John F. Wheary
Emergency departments across the nation are
constantly faced with increasing and unpredictable patient volumes. At the same time, there's the
constant need to improve quality and efficiency while
providing more value to patients. Lehigh Valley Hospital - Muhlenberg (LVH-M), a community hospital in
Bethlehem, Pa., was in this predicament, challenged
by volumes that exceeded its ED capacity.
The 23-bed department, which included a fourbed fast track, was completed in 1994, built to
accommodate 30,000 patient visits a year (the annual
census at the time was 25,000). Between 2004 and
2009, LVH-M experienced rapid overall growth at an
average rate of 8 percent, followed by a 4 percent
growth between 2009 and 2010. Patient visits surpassed 52,000 annually, a volume that exceeded the
hospital's 2,000 patients/bed threshold and pressed
the need to increase capacity.
The ED renovation
Goals for a new emergency space were not only to
manage volumes but to transform both space and operations. ED leaders, providers, nurses, and ancillary
staff worked collaboratively with consultants including
Todd Warden, MD, of Emergenuity (Woodbury, N.J.),
in-house project managers, and architects including NBBJ (Seattle) to develop an innovative design
solution. The group adopted a model designed for
the rapid assessment and evaluation of emergency
patients: a rapid assessment unit (RAU). Using this
model, developed by Emergenuity's Warden, a patient
would arrive at the ED and be seen in the RAU by
an intake team composed of a nurse, registrar, and
provider who would quickly evaluate the patient and
provide immediate treatment.
The renovation of the department provided the
opportunity to develop a dedicated space to support
the RAU function. This new unit and method allows
the ED team to improve throughput metrics, safety,
and quality of care. For example, by minimizing the
waiting room experience, a more immediate connection between providers and patients improves patient
satisfaction and value. In fact, the RAU was constructed in the footprint of the ED's existing waiting room
space, with a smaller waiting room designed for the
RAU. Typically, patients are seen within 20 minutes
of arrival. After the rapid assessment is complete, the
patient is moved to another section of the ED for fur70

HCDmagazine.com 02.14

ther care, creating a constant stream of patient flow that
keeps the RAU beds available to incoming patients.
Another important aspect of the ED renovation was
the differentiation between "vertical patient flow" and
"horizontal patient flow." The RAU team decides whether
a patient would be better served by remaining seated
(vertical) or by taking a recumbent position (horizontal),
as opposed to placing all patients on a stretcher regardless of need. Vertical patients remain seated in a chair or
recliner while they receive minor treatment and/or wait
for test results prior to discharge. This occurs in a space
designated "internal disposition area" (IDA). By eliminating the need for stretchers, the IDA can accommodate
a greater number of patients per square foot than a
traditional ED design. Furthermore, these patients can
flow through the system faster. Sicker patients, who require a more intense or thorough workup, are placed on
a traditional stretcher and moved to the main emergency
room for more in-depth testing and treatment.
Keys to success
The ED changes at LVH-M have led to a net increase in
capacity and significantly improved metrics, quality of
care, and patient satisfaction. The arrival-to-physician
time decreased from an average of 60 minutes to 20
minutes. Volume increased by 5 percent, while the number of patients leaving without being seen decreased
from 2.4 percent to 0.2 percent. Overall length of stay
also decreased. Patient satisfaction scores have risen,
too, moving from the 40th percentile to the 90th percentile, while hours of ambulance diversion decreased from
approximately 700 hours per year to 0 hours over the
past 11 months.
The LVH-M project illustrates that by creating smaller,
more efficient units within the ED, operations were
improved, as process linearity was eliminated and
replaced with the more efficient parallel method of the
RAU. As we approach the challenges and uncertainty
of healthcare in the 21st century, it's clear that improving patient care will be driven by innovative thinking and
redesign. Ultimately, we can achieve better outcomes in
patient care through this type of approach. This is one
example of how thoughtful spatial redesign can lead to
operational excellence. HCD
John F. Wheary, DO, MBA, FACEP, is the site director
for the department of emergency medicine at Lehigh
Valley Hospital-Muhlenberg. He can be reached at john.
wheary@lvhn.org.

John F. Wheary

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Healthcare Design - January 2014

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