Emergency Blog

major ed concerns

2006-05-25T01:24:00.000-07:00

hi again. here are the images for the major concerns of the ED according to various people.

slide 1:

slide 2:

slide 3:

slide 4:

slide 5:

slide 6:

construction process - final

2006-05-24T19:51:00.000-07:00

so..... the different parts of the process didn't change in size, etc. but the staging and explanation of the process did become clearer with the following sequences of images. and the length of the boxes do correlate with time in relation to each other.

overall:

stage one - hospital administrative

stage 2: design development process

stage 3: construction process and move-in

s.

construction process - part 2

2006-05-22T08:33:00.000-07:00

hello again...
in an attempt to stick with the 3D view of the construction process, here are two versions

the first one uses really thin lines to represent the stages that require a signature before the process can proceed... not so effective:

then i tried it using a suggestion from irwin - clearer planes with darker edges. shows the blocking of the process a little better:

comments??
also, i know that the different parts need to get fatter/skinner to correlate with its importance in relation to the other parts. that'll get done soon afterwards.

s.

clearer representation of the construction process?

2006-05-17T22:30:00.000-07:00

hey guys,
i did some revisions on the construction process diagram. it's not as fancy to look at, but it probably shows the process more clearly. there are two versions that i'd like your feedback on.

the first one is a slightly 3D view...

the second one is just a flat view...

so, votes on which one to proceed with?

thanks, sharon

Transportation to th ER

2006-05-16T08:41:00.000-07:00

-Boston MedFlight (BMF) is a CAMTS accredited Critical Care Transport service
- 3 helicopters,
- Fixed wing aircraft
- 2 critical care ground vehicles.

-BMF's mission is to extend the tertiary care services of the major Boston hospitals to the citizens of Massachusetts and New England, 24/7

-Non profit organization, BMF transports patients regardless of their ability to pay.
-MedFlight is financially supported in part by a consortium of Boston hospitals including Beth Israel Deaconess Medical Center, Boston Medical Center, Brigham and Women's Hospital, Children's Hospital, Massachusetts General Hospital, and Tufts New England Medical Center.
-Established 1985

How does BMF decide which vehicle is most appropriate on interfacility transport requests?

Decision
Most appropriate vehicle to the requested hospital based on safe and efficient transportation.
Normally decided by Communications Specialists in conjunction with the BMF Medical Crew.
BMF online Medical Control is available to discuss vehicle selection with referring/receiving physicians and BMF staff.

Mission completion
1. Safety
If the helicopter is requested, the pilot must accept/reject the mission.
If helicopter transport cannot be completed safely, BMF will offer the hospital BMF's ground critical care unit or fixed wing jet service, if appropriate and available. Advantages = same crew configuration and same medical equipment.
Disadvantage = longer wait time on the part of the sending facility.

2. Patient Condition
If the patient is in need of emergent services unavailable at the sending facility, such as a cardiac catheterization lab or an operating room, BMF will triage the request to the helicopter flight team.
If the patient requires nonemergent transport, such as transport to a hospital for elective procedures, and is being maintained on therapies beyond the scope of ALS providers, BMF will triage this request to the ground critical care unit or fixed wing jet, if available and appropriate. This allows for appropriate utilization of resources by enabling the helicopter to be available for time sensitive requests.

3. Location
Long distance transfer outside of helicopter range will be triaged to fixed wing jet services.
Capable of traveling 1400 miles without refueling
Less affected by weather considerations.
In instances where travel is required outside of the immediate Boston area, fixed wing jet services provide expedited and economical transport between facilities.

MGH ER analysis 3

2006-05-16T08:32:00.000-07:00

MGH
-Massachusetts General Hospital (MGH), incorporated in 1811
-Third oldest voluntary, not-for-profit hospital in the United States
-Oldest in New England.
-Bed capacity approximately 900
-More than 37,000 patients are admitted every year.
-MGH is the original teaching hospital of Harvard Medical School
-Named in the top three hospitals in the United States by US News and World Report for the past several years.

MGH ER
- Full-service, state-of-the-art ED facility
- Provides care for over 75,000 patients annually.
- About a quarter of ED patients are admitted to the hospital.

- Acute Unit of 11 beds 4 shock-trauma resuscitation rooms
2 burn resuscitation rooms
4 cardiac acute care beds

- Major Multipurpose area
17 bays for acute adult illness.

- 4-bed Pediatric Unit

- 10-bed Minor Surgery Unit for walk-in patients.

- 7 bed Rapid Diagnostic Unit (RDU) for patients with single system acute illness.

- Acute Psychiatry Service (APS)

- Emergency Radiology Suite
3 radiology exam rooms
ultrasound suite
2 dedicated multi-detector helical CT scanners
dedicated ED MRI
All ED radiologic images are handled electronically and can be accessed within the clinical areas by computer.
2 portable bedside ultrasound devices used for trauma and acute resuscitations.

- Access to the hyperbaric chamber in the Massachusetts Eye and Ear Infirmary

- Full-weather heliport on the roof of the Blake Building allows two helicopters to access the institution simultaneously
- Frequent destination for Boston MedFlight, a multi-hospital consortium program providing air and ground critical care transport in New England and beyond, utilizing three helicopters, a CitationJet fixed-wing aircraft, and a ground critical care vehicle.

- Level I Trauma Center, Level I Pediatric Trauma Center, Level I Burn Center.
- Only hospital in the United States to hold all three designations simultaneously.
- One of the busiest Level I Trauma Centers in Massachusetts,
- Internationally recognized tertiary referral center and local city hospital

Reference
http://www.massgeneral.org/ed/ED_aboutus.htm

ER Communications: Commerical Solutions

2006-05-16T08:02:00.000-07:00

Medical Personnel Communication

One interesting platform that I have come across is by MedLink Inc.

(Stud Health Technol Inform. 1999;64:93-107. "MediLink: a wearable telemedicine system for emergency and mobile applications." Koval T, Dudziak M. Medical College of Virginia, Richmond, USA)

Personnel in critical care or emergency situations have different needs from those working in other environments where telemedicine and mobile computing have been tested.

"One constructive criticism of the telemedicine initiative has been to question what positive benefits are gained from videoconferencing, paperless transactions, and online access to patient record."

Medlink offers a multipurpose mobile telemedicine applications, aiming to address the 'architecture' of the problem.

Transpac hardware
- A wearable personal computer with a smart-card interface
- Speech, pen, video input and wireless intranet connectivity.
- Structured and noise-resistant speech-to-text interfacing
- Web browser-like display
- Access through flatpanel, standard, or headset monitor,
- Beltpack TransPAC computer has functions of a complete desktop
- PCMCIA card interfaces for internet connectivity
- Secure smartcard with 16-bit microprocessor and upwards of 64K memory provides user access control for security, user custom configuration of applications and display and vocabulary, and memory to diminish the need for PC-server communications while in an active session.

"The TransPAC system with the MedLink software system is designed to provide an integrated solution for a broad range of health care functions where mobile and hands-free or limited-access systems are preferred or necessary and where the capabilities of other mobile devices are insufficient or inappropriate."

TransPAC is being implemented for EMT and ER staff usage.

Patient Information Control

MedLink also produces an 'Optical Memory Card'

Offers patients a portable, durable, high capacity storage device that can be appended but never erased for storing permanent medical history.
"Presently in use by the by the United States and other world governments, the technology embedded within the MedLink EHR card is highly counterfeit-resistant and tamper-proof, providing physicians and their patients added security and peace of mind."

_. Offers up to 4.1MBytes of digital capability
_. Store up to 1,430 pages of text or up to 465 images
_. Data can be updated thousands of times per card
_. Out performs other plastic material cards on durability & storage
_. Data can be appended, never erased
_. Automatically creates an audit trail of patient record updates & changes
_. Multiple layers of security protect data against unauthorized access
_. Most cost effective data storage card
_. Conforms to Industry Standards for optical memory cards and the Uniform Healthcare Identification Card (ANSI X3.284 1997)

Why Connect the Patient?

instant data entry (immediate admin and billing processing = receivables)
accessible (fewer redundant forms = patient satisfaction)
admin records (accurate data insurance eligibility = billable)
accurate data entry (reduced errors = administration costs)
accessible chart (fewer tests, faster accurate diagnosis = costs)
patient satisfaction (instill loyalty and marketing message to community = market share and revenues)

Reference
http://www.medlinkus.com/services.asp?p=memorycard

ER Communications Systems

2006-05-16T06:07:00.000-07:00

Emergency Room Communications

Synchronous communication (face-to-face or telephone conversations) accounted for almost 90% of communications traffic in one study of ER communications. This brings about problems of inducing clinical errors through disrupted memory process, overloaded short-tem memory because of the combination of interruptions, multitasking, and sheer volume of information that is often unwanted or irrelevant.

Efficacy of communication systems is also a problem: for example, senior personnel expects to be paged twice 'if it really is an emergency', resulting in higher levels of communication, and further time-wasting. Vincent and Wears quote an earlier study, decribing that, "despite their own disinclination to be interrupted, clinicians often initiate communication or request information without any thought of the impact of their request on the other person. This is a form of suboptimisation, in which trying to increase one's own performance results in a net decrement in performance over the entire organization."

Reference
Communication in the Emergency Department: separating the signal from the noise
Charles A Vincent and Robert L Wears
MJA 2002; 176 (9): 409-410

Communication channels in the ER
- Face-to-face
- Telephone
- Pager
- Computer
- Patient's medical record
- Forms
- Medical literature
- Test results
- Drug manual
- Letter
- Whiteboard
- Email

Communication Typologies
- Formal communication: When a message conforms to a predetermined structure (ie, is in a predefined form).
- Informal communication: When the message structure is determined solely by the conversing parties.
- Synchronous communication: When two parties exchange messages across a communication channel at the same time (eg, telephone).
- Asynchronous communication: When communication exchange does not require both parties to be active in the conversation at the same time (eg, email). The recipient can deal with communication at a time of his or her choosing.
- Interruption: A communication event in which the subject did not initiate the conversation, and which used a synchronous communication channel.
- Multitasking: A period when two or more concurrent communication events occur.

Reference
Communication loads on clinical staff in the emergency department
Enrico W Coiera, Rohan A Jayasuriya, Jennifer Hardy, Aiveen Bannan and Max E C Thorpe MJA 2002; 176 (9): 415-418

In hospitals, response times are critical and efficacy of staff-to-staff communication and patient-staff communication is vital. What is on offer on the market gives pointers to market demands, which include:

Desirables
- Enabling hospital personnel to remain fully accessible at all times.
- Immediate access
- Not interfering with hospital wireless or electronic devices.
- Easy integration with existing systems
- Single-number solutions that integrates all existing systems and numbers.

Categories
- Hospital televisions - MATV & RF Distribution
- On-demand education/information systems
- Satellite systems - entertainment, teleconferences, and programming packages
- Nurse call systems, intercom and overhead paging
- Infant abduction and patient wandering
- Access control systems
- CCTV surveillance/security systems
- In-building wireless phone systems
- Service and maintenance

Hospital personnel-Patient communication systems
- Constant contact with patient care providers, beginning from the ambulance parking lot, Enabling nursing staff to receive instant text messages through integration with nurse calls systems.
- Allowing the nursing staff to conduct initial assessment of a patient’s needs while consulting with a physician, remotely.
- Enabling the physician to consult with specialists in a ‘hands-free’ mode
- Providing family members of acutely ill patients a way to remain in close contact with hospital staff
- Permitting maintenance and security personnel to receive critical alarm and security notification via text messaging
- Accelerates access to mobile hospital staff via networking of multiple locations
Implements an effective disaster recovery solution that supports and maintains communication.

Reference
Ascom Wireless Solutions (http://www.hospcom.com/Hospcompdfs/04-PRIVATEWIRELESSPHONESYS/01%20-%20TIME%20IS%20CRITICAL.pdf)

Issues/questions?
- Is text messaging as the best means of communication within the ER and between hospital departments?
- How else can we transmit this data in a less cumbersome, more instantanaeous way? Special ER/treatment related symbols on a handset? Conventional video-confereing via cellphone? Are unita by the bedside with hands-free access for instant communication better than pager systems?

Emergency Communication Systems
- Patient emergencies
- Disorderly patients
- Wandering patients
- Code blue teams
- ED
- Chemical/Hazardous material environments

Need
An automatic system to ensure quick response times.

Process
- Automatic / user-initiated control to raise alarm.
- Notification, escalation and routing of distress signals to pre-defined team members .
- Discussion of situation via group call.
o Identify the nature of the emergency situation
o Talk to the initator of the emergency
o Ensure proper equipment and personnel are identified and gathered simultaneously
o Discuss estimated arrival times and team member proximity to emergency
o other team members can be notified by text message
- Reaction: fast and coordinated.

Reference
http://www.hospcom.com/Hospcompdfs/04-PRIVATEWIRELESSPHONESYS/12%20-%20EMERGENCY%20NOTIFICATION%20SOLUTION.pdf

One Australian study attempted to address the problem that few studies of communication between healthcare professionals exist, observing
- Time involved in communication
- number of communication events
- interruptions, and overlapping communications
- choice of communication channel
- purpose of communication
between 12 clinical staff members, comprising six nurses and six doctors in two emergency departments, one 200 bed rural hospital and one 540-bed urban tertiary teaching hospital, in New South Wales hospitals, in 1999.

“5 hours and 13 minutes were observed, and 1286 distinct communication events were identified, representing 36.5 events per person per hour (95% CI, 34.5–38.5). A third of communication events (30.6%) were classified as interruptions, giving a rate of 11.15 interruptions per hour for all subjects; 10% of communication time involved two or more concurrent conversations; and 12.7% of all events involved formal information sources such as patients' medical records. Face-to-face conversation accounted for 82%. While medical staff asked for information slightly less frequently than nursing staff (25.4% v 30.9%), they received information much less frequently (6.6% v 16.2%).

Their conclusion supports the “need for communication training in emergency departments and other similar workplaces. The combination of interruptions and multiple concurrent tasks may produce clinical errors by disrupting memory processes. About 90% of the information transactions observed involved interpersonal exchanges rather than interaction with formal information sources..”

“Several studies quantifying the impact of poor communication on clinical work suggest that communication is a likely cause of systematic error in the health system. In Australia, inadequate communication has been associated with 17% of system problems, and, of these, 84% were deemed potentially preventable.1 About 50% of all adverse events detected by general practitioners were associated with communication difficulties.2 Within intensive care units, 2% of the activity consists of verbal communication between nurses and doctors, but accounts for 37% of error reports.3 Thus, the evidence strongly suggests that poor communication wastes time, threatens patient care and may be one of the chief culprits behind preventable adverse events in clinical practice.4
The research reported here extends work begun in the United Kingdom in the mid-1990s,5,6 in which it was found that physician teams in hospital were subject to high levels of interruption. Clinical staff also appeared to bear a higher communication load than necessary, considering the many tasks that could be accomplished by accessing information sources rather than asking questions of people. It has since been hypothesised that such interruptions impose cognitive loads on clinical staff and have a negative impact on memory, leading to clinical error.7”

The following points I found of most interest:
- Nearly a third of communication events were classified as interruptions,: that they were not initiated by the observed subject, and occurred using a synchronous communication channel such as face-to-face conversation.
- Subjects were carrying out two or more overlapping conversations (multitasking) for 10% of the total communication time.
- About 90% of the information transactions observed involved interpersonal exchanges rather than interaction with formal information sources. (Their conclusion being that this suggests a low upper limit on the potential for electronic medical records (EMRs) to improve information processes within healthcare organizations, since the EMR is essentially a formal medium.)

Purpose of communication events in the emergency department

Communication events are expressed as a proportion of all communication events, by clinical role (NOS = not otherwise specified)

Reference Communication loads on clinical staff in the emergency department
Enrico W Coiera, Rohan A Jayasuriya, Jennifer Hardy, Aiveen Bannan and Max E C Thorpe MJA 2002; 176 (9): 415-418

construction process

2006-05-15T22:02:00.000-07:00

hi everyone. just tried to synthesize some of the information that was presented last time around into one long process chain. hopefully it makes sense.

next information/graphic will be on a comparision between an RN's and architect's perspective on the most important/frequent issues for ED planning.

s.

*edit*
here is a link to a pdf of the graphic - easier to read with clearer text.

Prediction & anticipation?

2006-05-15T13:25:00.000-07:00

Excerpt from the talk by James Adams, M.D., 2002 about 'America's Hospitals: In Danger or Bouncing Back?'

James Adams is Professor and Chief, Emergency Medicine, Northwestern University/Northwestern Memorial Hospital

This is an example of a line graph that charts the numbers of patients registered, treated, and admitted to Northwestern Memorial Hospital over a 2 week period. Such a record of numbers can be used to help predict the number of patients admitted through the Emergency Department (ED).

We can predict problems tomorrow by projecting, 24 hours in advance:

* Anticipated ED volume.
* Surgical volume.
* Anticipated discharges.
* Transfers/direct admissions.
* Current hospital volume.

Why would we want to predict problems?

* If we can predict problems that will occur tomorrow, we can respond today.
* If we fail to adequately respond, at least we can:
o Know that we are optimally managing the system.
o Figure out ways to manage better.
o Know that there is simply no capacity!

Once we predict a problem, then what?

* Notify medical staff.
o What do they need?
* Notify managers and key leaders.
o What do they need?
* Prioritize work to be done:
o Labs, radiology.
o Placement, rides home.

How can we begin this process?

* The hospital system must work together as a whole.
* The demands of the ED, including bottlenecks, must be monitored.
o 5 level, ESI Triage.
o Real time process controls.
+ Information tools.

If we monitor the hospital 24 hours in advance of problems, we also must monitor the ED on a real-time basis in order to identify unanticipated problems, bottlenecks, and surges.

This is a picture of a screen showing a real-time monitoring system report. It shows what is being monitored, the status of that situation, and brief messages regarding that situation.

Emergency Department Overcrowding

2006-05-15T12:49:00.000-07:00

Excerpt of "Emergency Department Overcrowding and Ambulance Diversion." by Robin Weinick, Ph.D., 2002.

Robin Weinick, PhD., is Director, Intramural Research, Center for Primary Care Research, Agency for Healthcare Research and Quality

What is ED Overcrowding?

* Need for emergency services outstrips available resources in the ED.
* More patients than staffed ED beds, plus long wait times.
* Patients typically treated and monitored in hallways.
* Constrains ability to triage patients.

Measuring Overcrowding

* No established way to measure.
o AHRQ is developing a set of measures.
* Time from arrival to physician contact.
* Number of patients being boarded.
* Boarding time.
* Time on ambulance diversion.

Ambulance Diversion

* Closed to ambulance traffic.
o A symptom, not the primary problem.
* Results in:
o Increased ambulance cycle/response time.
o More first-time patients.
o Forced override.
* Measured by the number of hours on divert.

Percent of Hospitals 'At' or 'Over' Capacity

This bar graph provides percentages of four different types of hospitals that reported being "at" or "over" capacity in 2002. The types of hospitals and the percentage reporting capacity issues are as follows: 79% of all urban hospitals; 45% of rural hospitals; 81% of teaching hospitals; and 56% of non-teaching hospitals. Nationally, 62% of all hospitals reported capacity issues.

Source: The Lewin Group Analysis of AHA ED and Hospital Capacity Survey, 2002

The percentages of hospitals in the following groupings reported being 'at' or 'over' capacity: 34% of hospitals with less than 100 beds reported problems; 77% of hospitals with 100-299 beds were "at" or "over" capacity; 91% of hospitals with 300-499 beds reported capacity issues; and 90% of hospitals with more than 500 beds had capacity problems. In terms of trauma levels, 87% of level I hospitals reported capacity issues and 79% of level II reported capacity problems.

Source: The Lewin Group Analysis of AHA ED and Hospital Capacity Survey, 2002.

How Many ED Visits? 1992-2000

This bar graph tells how many visits were made nationwide to Emergency Departments. The number of visits by year are: 1992: 91 million; 1993: 90 million; 1994; 93 million; 1996: 90 million; 1998: 100 million; 2000: 108 million. The number of ED visits nationally has increased by 20% between 1996 and 2000.

Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1992-2000.

How Many Hospital Beds? 1992-2000

This graph highlights the reduced supply of both hospital beds and Emergency Departments across the nation. From 1992-2000 there was an overall 16% decrease in the number of hospital beds and an 8% decrease in the number of Emergency Departments.

Source: American Hospital Association, Hospital Statistics.

How are Hospitals Staffed?

This graph shows the total number of new Registered Nurse graduates between 1995 and 2000. Highlighted on this slide is the fact that between 1995 and 2000, the number of new RNs has decreased by 26%.

Source: Health Resources and Services Administration, "Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020."
Source: American Hospital Association, Hospital Statistics.

Growing Demand for Emergency Room Visits AndThe Addition of New Hospitals

2006-05-15T12:35:00.000-07:00

On November 19, 2002, Stuart Altman, Ph.D., made a presentation in a Web-assisted teleconference at Event 1, which was entitled "The Big Picture: Hospitals in a Volatile Healthcare Environment." He mentionned the Growing Demand for Emergency Room Visits
and the Addition of New Hospitals.

Stuart Altman, PhD, is Chaikin Professor of National Health Policy, The Florence Heller School of Public Health, Brandeis University

Few elements that I have kept from his talk are:

Hospitals Face the Following Dilemma:

* Increasing Demand For Services.
o Increased Inpatient Utilization.
o Continued Growth in Outpatient Use.
o Increased ED Use.
* Accelerating Cost of Services.
* But, Inadequate Payment Rates from:
o Medicaid.
o Uninsured.
o Medicare.

Emergency Department Visits 1990-2001

This bar graph provides national estimates of the number of Emergency Department visits by year. The numbers of visits were: 1990, 92 million; 1992, 91 million; 1994, 90 million; 1996, 93 million; 1998, 96 million; 2000, 103 million; and in 2001, 110 million.

Advisory Board "We Need More Hospitals"

The projections prepared by the Advisory Board on how many more hospitals will be needed by the year 2011 based upon different sets of assumptions: A conservative estimate puts the additional number of hospitals needed at 1,023, a moderate estimate at 2,491 and an aggressive estimate at 4,914.

Individual Hospital Statistics for Massachusetts

2006-05-15T12:23:00.000-07:00

Individual Hospital Statistics for Massachusetts Staffed Beds/Gross Patient
Revenue, from the AHD

A total of 13,850 staffed beds

US national hospital data

2006-05-15T12:14:00.000-07:00

Statistics for non-federal, short-term, acute care hospitals from the American Hospital Directory.

A total of 660,558 staffed beds for 4,019 hospitals

Coordinating communication among and enhancing the efficiency of providers of EMS including ambulance services in the MA

2006-05-15T11:04:00.000-07:00

Emergency Medical Services (EMS) Regions are designated by the Massachusetts Department of Public Health Office of Emergency Medical Services (OEMS). Grouped by municipality, each EMS region is administered by a regional office dedicated to promoting patient care by coordinating communication among and enhancing the efficiency of providers of EMS including ambulance services, first responders and hospital emergency departments. Educational and training programs are also offered

Presentation for Tuesday: progress update

2006-05-13T21:00:00.000-07:00

I have been laying out the powepoint for Tuesday, here are JPEGS of the slides.

May 8th meeting recap

2006-05-08T18:14:00.000-07:00

here's a recap of what we had outlined as our plan for the ultimate presentation/submittal:

1. creating an overview of the American ER system going from the macro to micro scales

2. at each scale, flagging potential problems or issues that merit further investigation (suggested items for flagging listed below each scale)

A. national
- GIS mappings of the number of ER's from 30 yrs ago (or some other time) vs the number of ER's today
- GIS of state-run vs. private ER's
- insurance complications in healthcare in general (creating the ER as the first place of medical treatment for some, creating financial viability problems for the hospitals in other cases, etc)

B. regional/state
- GIS of transportation access to hospitals
- GIS of hospital clusters in urban vs. rural areas
- GIS or other info source outlining the demographic information (social indicators such as wealth, race, etc.)
- state funding
- private vs. public hospital

C. city
- old vs. new cities in planning hospital locations/access etc.
- case studies of demographics (wealth, race, insurance, etc.)

D. hospital
- how the facility relates to immediate surroundings (how people physically enter, how helicopters access the hospital, etc)
- transfers between the ER and other departments
- triage process

E. ER department
- planning of the ER
- renovation/upgrade
- movement within the ER
- communications
- security
- psychiatric patients
- Paula (the former RN who is now a consultant) and her comments of what are the main issues for an ER vs. the comments that an architect or facilities manager interprets as the main issues

Triage

2006-04-14T05:58:00.000-07:00

Typologies and Spatial Analysis

2006-04-13T23:59:00.000-07:00

In an attempt to understand how actual Emergency Rooms function we have consulted and visited with medical professionals immersed in the actual ER environment. While, admittedly, their design knowledge and opinions may be lacking, their understanding of the practical, actual, and utilitarian experiences can help us better understand the space. As designers it then becomes our task to decipher the design qualities that contribute to certain preferences.

Interpretations of ER Descriptions
The following three hospitals are interpretations of spaces either described by medical workers or by site visits.

University Hospital - New Jersey
This first example is of University Hospital in New Jersey as described in a conversation with Ershad Elahi, a third year medical student at the New Jersey Medical School. The unique thing about this layout is that patients are immediately separated into two different categories: trauma and medical. This allows for a specialization of care that helps make the process smoother. While such a system does require essentially two distinct and complete staff, a well thought layout can utilize shared resources such as supplies and OR rooms.

Rochester Emergency Facilities
This second example, also described during a conversation with Ershad Elahi, is a layout of the Rochester Emergency Facilities. Unlike the linear example above, this plan is set up radially. The patient and OR rooms are placed at the perimeter of the plan to provide visual and circulatory access to the core of the building which is staffed with nurses and doctors. The supplies are central to the plan giving equal access to all those who might need it. As organized according to the conversation, it seems that this layout limits both expansion and access. However it does provide a fairly successful circulation scheme.

MGH: An Abstract Impression
Our visit to the emergency room at MGH was quick and disorienting, although quite educational. The space and layout was extremely difficult to understand in a short and furious tour through the facility. However, this layout explains the general impression of the space. This layout may be described as nodal, where particular functions and specialties pop up in concentrated cores of activity. Each core then becomes able to handle it's own nursing staff, doctors, technological support, specialty rooms, patient rooms and supplies. While as confusing to navigate as a McMansion suburban neighborhood, it is actually a very flexible system that allows for expansion in the long run.

Generic Hospital Layouts
Many of our sources often point generic plans to stress a point about trends in design and layout. The following three examples are just a sampling of the information that is out there on spatial analysis.

Generic Layout 1
This layout, taken from Design Planning for Ambulatory Care Facilities shows a typical one way circulation system. The plan has a strong orientation that explains the process through the ER. Successful aspects of this design include access to the supplies and the nurses station from the important medical rooms (such as OR or Radiology). Some of the drawbacks of such a plan include the privacy issues associated with a large patient recovery room and the relative distance from things the further you make your way through the circulation diagram.

Generic Layout 2
This plan, taken from Hospital Emergency Facilities uses some fairly typical layout strategies. First of all, it separates the patient rooms from the important activities in the hospital. In the buffer between these two you will find both supplies and the nurses/medical staff facilities. This buffer zone then allows for access of the staff and supplies both to the high resource side rooms and the patient rooms. Although the zones are clearly delineated, the segregation may be detrimental in the long run when it comes time for expansion. It might be nice to see this approach in a more "branched" layout.

Generic Layout 3
Also from Hospital Emergency Facilities this layout separates more clearly the more important rooms of the ER from the rest of the program. This can be beneficial down the road because the integration of new technological or machine heavy equipment can be a hassle to integrate fully into a fixed plan. The peripheral quality of the more significant program will facilitate expansion and changes in medicine and technology. This is also a good example of clearly delineated entrances for walk-ins and ambulatory access. Another interesting thing about this layout is the mixing of nurses stations and supply closets. It seems that this then allows for greater access to more patients when such a system is not afforded (as in a radially scheme)

Typological Layouts
We have also been investigating generic strengths and weaknesses of hospital and ER typologies. The following three examples begin to stress some of the more pressing issues at hand when planning hospitals.

The Cross
A crucifix layout is strong in it's ability to distribute double-loaded program in the shortest walking distance. However it become very important to think about where shared resource are located. For instance, if the arms of the cross become specialized then it's difficult to determine the appropriate location for supplies, nurses stations, staff resting rooms, and ORs. However expansion, if there is room, is easier in an "appendage" plan because it takes less room to add on.

The Racetrack
This plan is a good way to keep diverse programs in close proximity to each other. However, a drawback is that circulation quickly becomes long and disorienting. The strength in executing a plan like this would be to use the middle spaces as a transition space between one side of the hall and the other. This plan also allows for a certain degree of specialization.

Radial
The radial plan, as seen earlier in an interview interpretation, is straightforward in it's approach to organizing circulation and programmatic overlap. The biggest downside of such a plan is that it is limited in capacity. To add another ring increases the built area exponentially and increase circulation difficulties. Ideally a radial plan would have supplies and medical staff located centrally so as to be easily distributed to the circumference. It is also interesting to note the varying types of private and public circulation, from the external car down to private medical staff.

information for construction process

2006-04-13T21:27:00.000-07:00

here are some blocky diagrams trying to sort the information utilized in the construction process for an ED:

Emergency Department Visit Data

2006-04-13T15:39:00.000-07:00

The following figures were excerpted from McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Advance data from vital and health statistics; no. 358. Hyattsville, MD: National Center for Health Statistics. 2005.

MGH ER analysis

2006-04-13T12:06:00.000-07:00

American ER Today

2006-04-12T12:28:00.000-07:00

Here is a preliminary attempt at devising a way of presenting all the stats.

Has anyone collected information on TRIAGE, or any other ER processes as I would like to do some systems diagrams for Friday.

I have a couple of contacts at the medical school, who are happy to answer questions from the medical standpoint/recommend books from HMS library. Any burning questions that I can put to them?

Principal Design Issues in the ER

2006-04-11T13:11:00.000-07:00

PRINICIPAL DESIGN ISSUES

- Helicopter access
- Triage
- The waiting area
- Treatment spaces
o Triage area
o Trauma room (s)
o Cardiac resuscitation room (s)
o Urgent exam room/treatment room (s)
o Non-urgent exam room/treatment room (s)
o Geriatric treatment room (s)
o Suture/minor treatment room (s)
o Quiet room (s)
o Secure isolation room for psychiatric emergencies (s)
o Paediatric treatment/examination room (s)
o OB-GYN room (s)
o Eye examination room (s)
o Cast/ortho room
o Decontamination room (s)
o Observation room (s)
o Chest pain observation room (s)
o Fast-track room for primary care (s)
o Emergency dental treatment room (s)
- Staff and support spaces
- Accommodation of data and diagnostic technologies
- Flexible design for flexible response
- Specialty emergency treatment areas
- Security
- Convenient parking
- Prominent signage and entryways

OTHER GENERAL ISSUES TO CONSIDER IN ER DESIGN

- Layout: satellite vs. ballroom vs. corridor vs. pods etc.
- Are the patients observing what is going on more than the staff is able to?
- How to prevent patients being ‘forgotten about’
- How to improve the experience for the patient
- Enormous waiting times: 5 hours
- Overcrowding
- 30% of the population are without medical insurance
- ER as primary care facility (esp. for those without insurance)
- ED running at a deficit in most cases: how can profitability be improved?

BIBLIOGRAPHY

Chapter on Boston City Hospital
Vogel, M. J., The Invention of the Modern Hospital, University of Chicago Press, 1980
Miller, R. L. and Swensson, E. S.. Hospital and Healthcare Facility Design, W.W. Norton and Company, 2002. Chapter 5
Guidelines for Design and Construction of Hospital Facilities, AIA Press, 1997
Zimring, C. A Guide to Conducting Healthcare Facility Visits, The Centre for Healthcare Design, 1994
Lennon, J. A Workshop for Designing the ER of the Future Journal of Healthcare Design, Volume XIII 1996 p. 139

The ER today

2006-04-11T13:01:00.000-07:00

In 1965, there were 30 million visits to the ER; in 1999 there were 103.7 million visits to the ER.
US hospitals in the same period dropped from 7,123 to 5,890.

According to the American College of Emergency Physicians, Americans made more than 115 million visits to hospital emergency rooms in 2003. Some of the most common complaints were stomach pain, chest pain, fever and cough. About 12 percent of those seen in the emergency room are admitted to the hospital.
The National Hospital Ambulatory Medical Care Survey found in 2002, the average duration of a visit to the emergency room was 3.2 hours. However, the actual range of waiting time varied, with some patients waiting as long as 6 hours.
More...

FACTS ON US HOSPITALS FROM AHA HOSPITAL STATISTICS
The American Hospital Association conducts an annual survey of hospitals in the United States. The data below is from the 2004 annual survey.

Total Number of All U.S. Registered* Hospitals 5,759
Number of U.S. Community** Hospitals 4,919
Number of Nongovernment Not-for-Profit Community Hospitals 2,967
Number of Investor-Owned (For-Profit) Community Hospitals 835
Number of State and Local Government Community Hospitals 1,117
Number of Federal Government Hospitals 239
Number of Nonfederal Psychiatric Hospitals 466
Number of Nonfederal Long Term Care Hospitals 112
Number of Hospital Units of Institutions (Prison Hospitals,
College Infirmaries, Etc.) 23

Total Staffed Beds in All U.S. Registered* Hospitals 955,768
Staffed Beds in Community** Hospitals 808,127
Total Admissions in All U.S. Registered* Hospitals 36,941,951
Admissions in Community** Hospitals 35,086,061
Total Expenses for All U.S. Registered* Hospitals $533,853,359,000
Expenses for Community** Hospitals $481,246,587,000

Number of Rural Community** Hospitals 2,003
Number of Urban Community** Hospitals 2,916

Number of Community Hospitals in a System*** 2,669
Number of Community Hospitals in a Network**** 1,464

*Registered hospitals are those hospitals that meet AHA's criteria for registration as a hospital facility. Registered hospitals include AHA member hospitals as well as nonmember hospitals. For a complete listing of the criteria used for registration, please see Registration Requirements for Hospitals .
**Community hospitals are defined as all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are nonfederal short-term hospitals. Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries.
***System is defined by AHA as either a multihospital or a diversified single hospital system. A multihospital system is two or more hospitals owned, leased, sponsored, or contract managed by a central organization. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more, and at least 25 percent, of their owned or leased non-hospital preacute or postacute health care organizations. System affiliation does not preclude network participation.
**** Network is a group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Network participation does not preclude system affiliation.

Visit to Massachusetts General Hospital ER

2006-04-11T12:28:00.000-07:00

MRI Image from General Electric Healthcare

Interview with Dr. Gonzalez, Chief of Neuroradiology at the Massachusetts General Hospital and Associate Professor of Radiology at Harvard Medical School.

QUESTIONS

1. How do patients transfer to specialists in two hypothetical situations?
a. Clear-cut situation such as a broken limb
b. Less obvious situation: how many steps before radiological imaging is called for?
2. What is the head radiologist's dream ER and how would it function?
3. How does the ER interface with other departments within the hospital (such as the psych dept)?
4. What are the major security issues and patient privacy issues?
5. What is the actual protocol for triage?
6. Is the head radiologist more of a clinical or administrative position at the hospital?
7. How much interaction does the radiology department have with the ER?
8. What types of comments come back from staff and patients?
9. How are patients physically transferred between departments?
10. What are the time constraints? What are the time limits to treatment options?
11. How much does the clinical staff rely on patient questionnaires vs. observation?
12. What is the protocol for repeat patients?
13. How does MGH's ER compare to ER's in other hospitals?

KEY RESPONSES

TRIAGE

MGH - patient arrive mainly by ambulance rather than as walk-ins, but the ER caters to both.

The EMT makes decision where the patient should go, and assesses the situation. After the patient arrives at the ER, the Triage nurse evaluates the patient, determining whether the problem is routine or critical.

If further investigation is necessary, the patient will undergo CT scans and/or MR studies.

A hypothetical situation illustrates the breadth of response: a patient comes in with a headache, after an accident. After triage: the patient is sent home having been evaluated and given some painkillers, or will be sent to have a CT scan which may show an aneurysm and will then have to be treated. The patient will be admitted to the appropriate part of the hospital.

ISSUES OF COMMUNICATION

There is no substitute for talking face-to-face; it is the best means of communication in the ER. This includes both doctor-to-patient and especially doctor-to-doctor communication.

Transfer of information is done face-to-face.

ISSUES OF OWNERSHIP OF THE PATIENT

The ER is the entryway to the hospital. If the patient is admitted, then - for example - neurosurgeons and other specialists will take over management of the patient from the ER. The patient will not return to the ER, but will be transferred around other parts of the hospital as necessary.

ISSUES OF LEGACY OF BUILT FORM

One of the main problems is that the ER inhabits an old building. The ER is a hybrid system, which has evolved over a century, but is becoming more streamlined. The built form however, creates issues of legacy. How do you fit new machines, new ways of treating patients etc into the existing shell, whilst continuing functional operation of services within the hospital?

CARING FOR THE PATIENT IN THE ER

The main business of the ER is vital care.

Support systems: a problem is all the extra kit following patients around: trolleys and wires with IV/machines etc that have to be maneuvered individually whilst still connected to the patient.

Scanning/Docking CT/MRI procedures now take only a few minutes (CT scan possible in just 5 minutes), but the whole process can take an hour to get the patient onto and off the scanner.

The scanning machines are in use 24/7. On average, 2 patients per hour on the CT scanner, 1 per hour on the MRI scanner. Patient has to change cart due to the magnets, all needles etc have to be changed so that there is no ferrous material in the scanning room.

Issues with CT/MRI machines– placement in building, special building materials etc.

Overflow spaces (staging areas) for scanning. Scanners constantly in use.

The ER at MGH has an ER Radiology Department within the ER which is one part of a larger radiology department.

THE DREAM ER

Easier interventions and upgrades.

Patient focus/patient-centric platform

Vertical connection to the rest of the hospital from the ER.

Communications systems: face-to-face, paging, telephone instant access is important in the ER. The ideal would be to have instant video conferencing, however, this is still not a substitute for face-to-face communication, and would only be useful if was instantaneous.

GENERAL ISSUES AT MGH'S ER

Bottlenecks and tight corners. Legacy issues in every ER.

Control rooms scanning reading room (very dark).

Issues of cross-talk– privacy screen in tight spaces such as CT control rooms.

Issues of getting lost and mobility

ER's are not 'designed', at the most, they are space planned. How quickly do they go out of date? How do you upgrade them? Should equipment rooms such as scanning facilities be placed around the edges for easy upgrading of large equipment? Are things already out of date by the time they are built and start to be in use?

Trolleys that automatically cart medical supplies/medical records etc around follow coloured lines on floor.

Patient exposure to other patients in the entryway.

Problems with bringing in new machinery to the new Stroke Department on the 2nd floor. New machines had to delivered by helicopter in after part of the ceiling was removed, the building had to be strengthened.

Security? Privacy?

THE TECHNOLOGICAL REVOLUTION IN THE ER

Revolution in radiology (Computers, then CT and MRI) has completely changed the way problems are diagnosed and the ability to diagnose. It is rare to have an MRI scanner in the ER.

Everything is digital now, even X-Ray no longer uses film.

Speed of information transfer 15 mins, can take longer, so radiologist will be present to look at the results as they appear on the screen as an initial check to make sure nothing serious is happening there and then.

In 1975, MGH installed the second CT scanner in the country (?), which was able to scan 4 slices per hour, and then took 1 hour to reconstruct the data. We saw the scanner processing and displaying enormous amounts of detail of the entire body in around 1 minute.

We thought about issues of power and also issues of server space and information storage. With its 6 CT scanners alone working 24/7, MGH must require extraordinary IT systems as well as the generators etc required by all hospitals. What happens if these go down?

The entire ER area has been rebuilt in the last 5 years in stages, (what complexities and compromise does an ongoing upgrade system like this entail

Future advances: biopsy– digital intervention, data/biological instead of cutting patients open to examine. How will this affect the ER of the future?

E.R. with GIS

2006-04-07T16:19:00.000-07:00

We have researched on the location of emergency rooms and hospitals within MA

ER in MA

Purple H Hospital with ER

Pink H Hospital without ER

Previous research

2006-04-07T16:18:00.000-07:00

During the GSD product design research course, we researched and prototyped an integrated dropped ceiling.

Research goal

2006-04-07T12:49:00.000-07:00

The optimal goal of the class is to have a better understanding of the emergency rooms in US hospitals.

This blog will discuss our current research on E.R.