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David Vincent, AIA, ACHA, LEED AP designer and director of HKS Team ED

EMERGENCY DEPARTMENTS: Are they affected by the Patient Protection and Affordable Care Act (PPACA)?

Emergency Departments

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and the link to the U.S. Supreme Court decision to uphold the individual mandate of the PPACA

Over the last decade, ED visits are up 32 percent but capacity is down 7 percent. Universal care

coverage

increase

will

demand

likely

because

of the lack of primary care access.

Healthcare

leaders

need to focus on meeting the needs of physicians, staff and patients, and creating EDs that are adaptable for the future.

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There definitely are fewer practitioners accepting Medicare and Medicaid patients because of the declining reimbursement rates and red tape surrounding reimbursement. According to the Texas Medical Association, this was not addressed in the PPACA. EDs likely will see a significant increase in this insured population that will place a burden on both human and physical resources.�

Marysol Imler, RN BSN, Strategic and Operations Planner, HKS Clinical Solutions Group

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Wake Forest University Baptist Medical Center Pediatric Emergency Department Expansion, Winston-Salem, N.C.

The PPACA:

Will it affect ED operations and design?

When the U.S. Supreme Court decision to uphold the individual mandate of the PPACA was announced at 10:30 a.m. on June 28, an HKS team was speaking at the Center for Health Design Conference’s “The Emergency Department: Considerations for Innovation and Strategic Design Workshop” in Washington, D.C.

Suddenly, the conference took on a new importance.

Less than two hours later, a panel discussion ensued on the decision’s impact on emergency departments in the U.S. The panel included nationally recognized design and healthcare experts including HKS’s David Vincent, Marysol Imler and Shannon Kraus, as well as Michael Pietrzak, Frank Zilm, Jim Lennon and others.

Although there was lively debate, the general consensus was that the addition of a major population of covered patients not matched by an increase in primary care access would, for several years, create additional pressures on emergency departments (EDs) in terms of both numbers and patient types.

The group voiced their opinion that emergency departments would continue to be default access points for years to come.

The bottom line: ED design will need to adapt to this increased population of ambulatory patients unable to secure appointments in primary care settings.

Marysol Imler, RN BSN, strategic and operations planner, HKS Clinical Solutions Group, observed, “There definitely are fewer practitioners accepting Medicare and Medicaid patients because of the declining reimbursement rates and red tape surrounding reimbursement. According to the Texas Medical Association, this was not addressed in the PPACA. EDs likely will see a significant increase in this insured population that will place a burden on both human and physical resources.”

David Vincent, AIA, ACHA, LEED AP, designer and director of HKS Team ED, added, “With the anticipated increase in ambulatory patients seeking care in the emergency room, resulting in over-capacity conditions becoming common, the need to address medical consequence management will become essential in ED planning. Designers need to carefully evaluate and better understand the ED’s staffing and operations in order to create a safe and efficient environment.”

According to Shannon Kraus, AIA, ACHA, LEED AP, healthcare practice leader/ senior planner, HKS, Inc., “While it is too early to know the specifics, it is not a stretch to believe the PPACA will have a significant impact on healthcare design, particularly on the emergency department.

While the FGI Guidelines for the Design and Construction of Healthcare Facilities do not specifically address the act itself, there already is a shift toward requirements based on functional program needs.

The functional program, in part, would be informed by a threat assessment, the market being served, the primary care providers in the marketplace, and the services offered (or not) by competitors. Radical alterations in these factors will drive changes in requirements for new ED facilities, or those areas undergoing renovations. Examples of potential requirements based on functional program and the accompanying threat analysis could include those relating to surge capacity, behavioral health facilities, pediatric facilities and bariatric accommodations.”

While it is too early to know the believe the PPACA will have a sig design, particularly on the

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e specifics, it is not a stretch to gnificant impact on healthcare e emergency department.

Shannon Kraus, AIA, ACHA, LEED AP Healthcare Practice Leader | Senior Planner HKS, Inc.

Parkview Regional Medical Center, Fort Wayne, Ind.

Designing Today’s ED:

6

Steps to Improve Patient Care

1. Sitting Down for Care

2. Scaling Up and Down

3. Keeping Care Safe

Eighty percent of patients can be treated in a seated position because they are not critically ill.

They are considered ambulatory patients. Instead of occupying valuable space in a hospital bed, consider treating patients who are seated. One potential solution: a chair-centric format that requires less space due to a vertical, versus horizontal, configuration.

EDs exceed capacity just 10 percent of the time. It’s crucial to design EDs that are scalable to flex with patient volume fluctuations. Examples: scale from a one- to a twobedroom configuration to maximize treatment spaces. Accordingly, medical utility provisions also need to be right-sized.

More and more people are having difficulty receiving acute mental health intervention. In turn, they are relying on EDs for care. Any disruption could cause security issues for hospital staff. Planners must develop appropriate, secure and safe space for acute mental healthcare.

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The emergency department (ED) is a healthcare system’s 24/7 front door. Over the last decade, ED visits are up 32 percent but capacity is down 7 percent. Universal care coverage will likely increase demand because of the lack of primary care access. Healthcare leaders need to focus on meeting the needs of physicians, staff and patients, and creating EDs that are adaptable for the future. The architecture must also provide sufficient flexibility to accommodate wide variances in patient flow and emerging technologies. Consider the following six key issues when designing your next ED.

Wake Forest University Baptist Medical Center Pediatric Emergency Department Expansion, Winston-Salem, N.C.

4. Technology on Tilt

5. Controlling Contaminates

6. Securing Spaces

Leverage technology on all counts.

Design for today – but keep in mind emerging technologies such as self-decontaminating materials and touchless sensors. Advanced telecommunications devices allow staff to make triage decisions long before the patient arrives. Handheld advanced imaging devices are allowing clinicians to bring technology directly into the room, versus designing the environment around the imaging equipment.

Mechanical, electrical and plumbing concerns are paramount to planners when designing EDs. An integrated team approach allows technical professionals and planners to investigate space, barriers and opportunities to mitigate infection and other airborne contaminates.

It is important to perform a threat assessment before, not after, the ED is designed to review natural, industrial and deliberate threats.

Securing a portal entry, installing various scanning technologies and developing a lock-down plan are critical planning and design aspects.

Washington Hospital Center Project ER One Study, Washington, D.C.

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Dreams Really

Do Come True...

Although over a decade has passed since the initial ER One technical report publication was released, the innovations, concepts and thought processes of this leading-edge project continue to influence and affect ED and hospital design today. During the peak of the Project ER One development, HKS Team ED Leader Dave Vincent stated, “We may, in fact, be forwarding design concepts that are not ready for adoption today but likely will be adopted 10 to 15 years from now.�

This statement proved to be true. Technology and design thought have caught up. Design concepts developed by HKS and the Project ER One team are now commonly in use in EDs around the world.

Design Link with David Vincent, AIA, ACHA, LEED AP, HKS Team ED designer and Director

Designing from the Parent’s Perspective Having a child injured or in pain is one of the most stressful situations a parent can experience. After coming home from the hospital post-surgery for a football injury, my son started to have what appeared to be a panic attack. I did not know what was happening to him and when he told me “I don’t want to die,” I went into another level of emotion.

Paramedics arrived and determined it was, in fact, a panic attack and they took him to the emergency room. Even though I knew exactly where the hospital was, having been there many times, I got lost on the way. My concern for my son took over and I was not thinking clearly. After my son got through his panic attack, I realized the importance of ED wayfinding and design.

People want to get their loved ones into care quickly.

From the visual cues that get them to the right place to seeing a physician instead of sitting in a waiting room, design plays an essential role in creating a comforting experience for patients and family. ED design also is important for clinicians and staff. They need an environment that is efficient and safe, as well as provides them an opportunity to de-stress.

As an ED designer for many years, I am excited to continue to explore new ideas in ED design and see how other ideas have evolved over time. Concepts we developed for the Washington Hospital Center ER One study are now being put into place, thanks to anticipated advancements in technology.

Another design concept that I hope to see become a reality involves large, urban EDs. The idea of an ED having multiple entry points, similar to an airport terminal, would positively affect ED operations.

Imagine having the ability to drive up to an entry based on the type of emergency or the immediate availability of treatment. Patients would travel less once they arrive, treatment areas would be equipped based on the entrance point, and staffing would be appropriate for the level of emergency and capacity. I believe this one change could have multiple, positive results for patients and ED efficiency … something that is important to parents like me.

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HKS Team ED is a specialty practice that provides healthcare clients with services concentrated on emergency department design including pre-design consulting, space programming, simulation modeling, operational and strategic planning, and design.

Team ED has designed more than 75 major emergency departments in the last 10 years. Team ED leaders include: David Vincent, AIA, ACHA, LEED AP Designer and Director, HKS Team ED | dvincent@hksinc.com David has programmed, planned and designed numerous emergency departments throughout the country. His experience developing EDs – from community hospital renovations to academic medical center replacements – has enabled him to effectively and efficiently define the designspecific challenges unique to each project. Through his award-winning work with Washington Hospital Center ER One, David developed vital experience in contingency planning and design for event-based medical consequences. Additionally, he has collaborated with nationally recognized patient safety and human factors experts to develop advanced planning concepts that reflect the latest theories in patient safety planning.

Shannon Kraus, AIA, ACHA, LEED AP Healthcare Practice Leader, Senior Planner, HKS, Inc. | skraus@hksinc.com Shannon has been an integral part of the design and planning of more than 20 million square feet of healthcare projects of all sizes and scopes. His projects have been honored with design awards from the AIA, Symposium on Healthcare Design, Modern Healthcare and IIDA. Shannon is an ACHA board-certified healthcare architect, was a contributing author of the FGI 2010 Guidelines for Healthcare Construction, and teaches seminars on hospital design as a faculty member of the American Hospital Association. He also has worked with the Center for Healthcare Design, the Academy of Neuroscience for Architecture, and AIA on various research and design initiatives related to improving healing environments through more effective facility design and planning.

Marysol Imler, RN BSN Strategic and Operations Planner, HKS Clinical Solutions Group | mimler@hksinc.com Marysol is a licensed registered nurse with experience in providing quality, patient-centered care with expertise in emergency and surgical care, strategic business planning and operations planning. She has worked in Level 1 Trauma settings, as well as in specialty surgical settings such as orthopedic and plastic surgery. Her solid credentials and diverse experience include a comprehensive background in healthcare process, performance management and information technology strategies.

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