Help with new ER design

[GeneralVeers]

I'm on the committee giving input to help design our new ER slated to start construction early next year and I need some advice.

Our current ED sees about 58,000 patients and is level 3 trauma center. We have about 36 beds and an 8 bed fast track area.

The hospital is looking at expanding to a new 55-60 bed facility and possibly going to a level 2 trauma center.

One problem we have at all three of our current hospitals is that the doctors work areas suck. They were basically put in after the fact, and aren't functional, have no HIPPAA compliance and aren't big enough to accomodate the number of docs. I often have patients/family standing in front of my desk overhearing every word as I dictate on another chart. We will probably need space for at least 6 docs +/- 2 residents.

My director thinks that we will be doing more charting and physician order entry with either tablets or at computers at the patient's bedside, so he doesn't see the need for much designated physician space.

Do you guys think that under this scenario it's better to have one larger centralized physician work area, or several smaller areas spread out around the ED in "pods"?

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[deleted109597]

Space for 6 docs will have to be big. However, centralized is better. The problem with pods is that they design it for the nurses, so they're always using the terminals. It makes it hard to get to a computer. Also, they need to put a consultant station in as well. Nothing pisses me off more than finding some hospitalist on my terminal.

 

[WilcoWorld]

I think the ideal is a centralized work area, with specific terminals reserved for ED physicians that is sonically separated from patients while maintaining visual contact with rooms.

At my current shop we have about 4 feet of plexiglass coming up from the desk top of the work area. Patients and family knock on it and have to wait for us to come around the side and talk to them, nurses & clerks have to come up to a window in the glass to get our attention.

I love this.

 

[GeneralVeers]

Space for 6 docs will have to be big. However, centralized is better. The problem with pods is that they design it for the nurses, so they're always using the terminals. It makes it hard to get to a computer. Also, they need to put a consultant station in as well. Nothing pisses me off more than finding some hospitalist on my terminal.

Agree with everything you've said, though my Director (who rules with an iron fist) disagrees. He doesn't seem particularly interested about the comfort or work environment of the docs as a priority.

 

[docB]

ER doc work areas are unnecessary. If we have time to sit and work we're overstaffed and should be whipped harder. But the gracious, wonderful primaries who are willing to send their glorious insured patients to the ED must be given ample space to write their notes. If you point this out they might build in some space that you can sneak into when the PMDs aren't around.

As for building the 55 bed ED I suggest not doing it. More space just equals more holds in this town.

 

[RustedFox]

Disclaimer: I have no knowledge of your work area, but here are my completely unqualified two-cents.

Depending on how you do your documentation, you either want committed doc-workspace, or you don't. If you dictate.... for Dog's sake, man... have a computer screen and telephone in a closed-off area so that nobody can screw with you. Everyone else can effing wait. If its a big enough deal, a nurse will bust in to disturb you. If its all EMR, then have a big screen and desk, but sacrifice the privacy... if it's T-sheets.... then tell your director that it's not 1998 anymore, and that he should cancel his subscription to (MS) Encarta.

 

[GeneralVeers]

ER doc work areas are unnecessary. If we have time to sit and work we're overstaffed and should be whipped harder. But the gracious, wonderful primaries who are willing to send their glorious insured patients to the ED must be given ample space to write their notes. If you point this out they might build in some space that you can sneak into when the PMDs aren't around.

As for building the 55 bed ED I suggest not doing it. More space just equals more holds in this town.

I will say that the hospital is adding 150 inpatient beds including 25 more ICU beds.

 

[GeneralVeers]

Disclaimer: I have no knowledge of your work area, but here are my completely unqualified two-cents.

Depending on how you do your documentation, you either want committed doc-workspace, or you don't. If you dictate.... for Dog's sake, man... have a computer screen and telephone in a closed-off area so that nobody can screw with you. Everyone else can effing wait. If its a big enough deal, a nurse will bust in to disturb you. If its all EMR, then have a big screen and desk, but sacrifice the privacy... if it's T-sheets.... then tell your director that it's not 1998 anymore, and that he should cancel his subscription to (MS) Encarta.

Agree with you completely. Unfortunately I'm going to be overruled

I wanted a completely glassed-in, centralized doc work area. We do 100% dictation and so need a telephone, computer, and chair for each do on shift at a time.

Our past 3 ERs were designed in 2000, 2001, and 2007 respectively. All three of them just plopped the physicians at a nursing-style desk with no privacy and no separation from patient care areas. It's a HIPAA, noise, and comfort nightmare at all three campuses.

Also all three of our campuses have curtains instead of private rooms. CURTAINS IN AN ER DESIGNED IN 2007!!!! The mint green paint doesn't help with the feeling that we're trapped in the 1970's.

I have a feeling we're going to get more of the same garbage this time around.

 

[RustedFox]

Veers:

Are you really going to be overruled ? You're on the committee, man... make some NOISE !

I can't remember who it was, but there was some poster on here that recently said: "we wonder where/why we've gone wrong... but we docs have let everyone else run the show for godknowshowlong, and now we're all waaah-waaah about it."

You're in a spot to be heard man.... here's a pot and a pan. Bang 'em together. Hard.

 

[TrumpetDoc]

Just afraid if they build it...WILL THEY STAFF IT?


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[GeneralVeers]

Just afraid if they build it...WILL THEY STAFF IT?


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Doubtful. They won't even staff our current ER at the proper levels. Our biggest issue right now is holds, as we often have 20+ beds taken up by holds. More inpatient beds should alleviate that issue.

 

[EM_Rebuilder]

Its the little things....

I came to a job where the ED was essentially new (<1 year old.. 66 beds.. at least most of it anyways... they added like 30 rooms and the other 36 were renovated) so I was not part of any planning.

One thing that gets me is that many rooms are set up slightly different and that gets old... Some rooms, the otoscopes are to the left of the patient, others on the right. Also the location of the glove boxes on the wall.... Naturally, the longer I work there I begin to know which room I am in and learn where the equpiment is.... I think it would have been better if every room was essentially identical though...

Dont forget some sort of physican lounge/office and even better if you can get a private bathroom in that area. Even if its small with just a computer, fridge, maybe a sink and a TV... and mailboxes or whatever else for business 'stuff'... We have a small area and its a nice place to visit during a shift for a few mins, keep your lunch way from all the other ED staff, heat it up, catch last few mins of a game, etc.

We have two areas that are curtains over the entry, but solid walls between the room sides. One has 4 rooms, the other has 6 rooms... They actual work pretty well for 'sicker' people. Even though you have telemetry, the septic old lady should not be tucked back away in some room with a door on it. There are nurses stations in front of these areas so they can keep a close eye...

The points on the 'doctors area' are important too. We have two 'areas'.. one side is the more major area where we have the rooms above, our trauma rooms, and several other rooms. The docs set overlooking much of this area (We can see am ambulance roll through, etc); we have walls, but we face glass with about a 2 foot void about eye level so things can be passed through. With students, residents, physicans, scribes.. we can have 10+ people in this area before it starts to get crowded. The other 'doctor area' is a less acute side and its where a couple PAs set, a pediatrcian, and another MD (one shift a day).. its essentially a long hall way and is narrow. No glass, no door on either side. Its much more 'closed up' and patients are always coming up and asking you stuff since you are 'right there'.. I dont like it as well.

Specilaity rooms are nice as well.. Eye room, Sexual Assualt, prisoner cells, psych, and a casting room. Our 'cast room' is very large (size of two rooms put together) and has all the stuff for splints and such plus the C Arm. We usually do not see new patients in there, and only tuck someone in there for Ortho to mess with (we have residency in Ortho so they get called for all Fxs). Our eye room is the same way, we can walk a patient into there and use the Slit Lamp.. but the equipment was actually funded by our Opthal department (again a residency program) and they can essentially see a patient with the same equipment they have in their clinics. This room stays locked and only opened by the Opthal residents or our charge nurse. Our Sexual Assualt room is tucked in a far corner for privacy and has all the stuff needed to perform those. I think there is a tiny closet that is essentially a personal waiting room attached to it as well. Our psych rooms have nothing in them, a steel door with wire reinforced glass and a camera.... We also have 4 'jail cells' where local PD can safely stick someone or a prison system can put someone. We tend to actually see those patients in a regular room or the psych room. Occasionally I have seen a quick person in the jail cell.. they are at the ambulance entrance into our ED...

EDIT: I keep thinking of more things to add.... We work on a pod type system. During the night only one side is open (the main ED... essentially about 25 rooms), by 8AM 8 more rooms on the other side open, then 8 more at 10, and 8 more at 11, and 7 more on the main side at 3PM..each of those pods or zones are opened 12 hours. I think thats what the 'experts' say work best with flow issues? And its wise to build an ED that fits that style.

 

[StevieStud]

>so he doesn't see the need for much designated physician space.


Male Cow Fecal Matter.


>Do you guys think that under this scenario it's better to have one larger centralized physician work area, or several smaller areas spread out around the ED in "pods"?


Both.

The centralized work area is great.... for sharing common tasks and information. But there are so many times that a private area (with a locking door, damnit) is needed.

 

[8654Marine]

We have a new ED. 43beds. CP/obs beds as well. Dedicated crisis/psych rooms.

We dictate. We have a dedicated room w/ 4 computers, phones, PACS. ED docs only. Glass sliding doors.

There's another private room for the consultants, hospitalists, residents.

But we also have workstations all over in various pods as well.

GV, hopefully your Director listens.

 

[Apollyon]

I'm on the committee giving input to help design our new ER slated to start construction early next year and I need some advice.

My director thinks that we will be doing more charting and physician order entry with either tablets or at computers at the patient's bedside, so he doesn't see the need for much designated physician space.

Agree with everything you've said, though my Director (who rules with an iron fist) disagrees. He doesn't seem particularly interested about the comfort or work environment of the docs as a priority.

Agree with you completely. Unfortunately I'm going to be overruled

I agree with Rusted Fox - if you have "no responsibilities whatsoever" (quoting A Few Good Men), then what are you doing? Is the director on the committee? If he is, you don't need to be. If he isn't, yet he is directing the way the committee goes, when all is said and done, he'll get the praise, and you the poison. Every fault will be yours, and any fame will be his.

 

[GeneralVeers]

I agree with Rusted Fox - if you have "no responsibilities whatsoever" (quoting A Few Good Men), then what are you doing? Is the director on the committee? If he is, you don't need to be. If he isn't, yet he is directing the way the committee goes, when all is said and done, he'll get the praise, and you the poison. Every fault will be yours, and any fame will be his.

The hospital system we work in is very bureaucratic, and extremely officious. The decisions they make are often made at higher up levels without the input of the people they actually affect (like nurses and doctors).

I've come to the conclusion that I'll have little input into the layout, curtains versus walls, and mint green paint. I'm trying to influence the design process in terms of the doctor work areas, which I think is reasonable. The process is still early, and if it appears that I have no input and stuff will be done regardless of what the docs want, then I won't waste my time on it.

 

[EM2BE]

We had a recently renovated ED. The above comments are helpful, but I will give a few pet peeves. It is a smaller ED, but still may help.

No desk at an extreme of the ED. You have no idea what is going on on the other side and it is a lot of wasted time walking to and from the desk.

We have basically arms from the main desk where physicians sit, so you are walking 3-4 rooms down a hall at most. With your number of beds, you may need to split the ED into pods to make it less annoying. Not saying walking is bad, but if you have to run back to your work station for orders all the time, you don't want to have to go that far. Especially if you do not have computers in each room. Which brings me to the next point - put computers in each room so that you can do order entry on a patient while you are in there and the nurses can also document while in the room. Cuts down on fighting for computers outside the rooms. I usually only use it if it's a critical patient to throw in the orders quickly or if a pt wants to know the specifics of their results. Much easier than trying to commit everything to memory.

Have more computers in the physician area than you anticipate needing. Students, off-service residents, and change of shift times can cause a problem with computers. Have space for even more just in case you underestimate. With everything on the computer, you can't work too much without one.

Definitely do not underestimate the size needed in rooms. We have rooms made for resuscitations and we still run into the issue of not enough room for all the people / equipment. You have to allow for an ultrasound machine in the room with all the normal things as the ultrasound is becoming more and more widely used.

Have storage space in the rooms for items used on most patients (IV access / labs / gauze / flushes, etc). Have a cart in the room for the nursing / phlebotomist things. Also, space for extra blankets / towels / urinals / basins / etc in a cart or built-in cabinets. Storage for IVF bags is also really handy to have. Also having techs to restock the carts regularly helps quite a bit. They are useless when not stocked.

 

[Danbo1957]

Triage Bays, at least two of them.

http://hfwebmedia1.health-first.org/vtours/ed/vh/vtour/tour.html

Edited to add:

The flow: patient presents to the sign-in booth which is manned by a clerk from the registration department. They sign in on a form which gathers the basics - name, DOB, C/C. Clerk assembles chart and places it manually in a basket. Pt then waits to be called (wait of 20 minutes or less.) Pt is called to one of two triage bays by an ED tech who gathers vitals, allergies, meds, bands the patient, and field dresses anything dripping blood.

Nurse takes over patient while ED tech takes next patient in the other bay. Nurse completes triage and returns the can wait patient to the waiting room. Chart goes in a needs to be registered box. Registration completes insurance, L&I paperwork, etc. Clerk will enter triage bay and do interview when necessary. When registration is complete, chart goes into the "fully registered" basket.

You should see one patient every five minutes during peak times with the triage tech and ER doc alternating back and forth between the two triage bays; room a patient every 7 minutes.

It does get brutal is when waits start hitting 2 hours-- then we interview in the waiting room, "60-second eyeball" and added components of blood draws, EKG's, radiology studies and preemptive lab work. Those are the times a second tech and another curtained overflow bay needs to be available.

 

[Farmer2DO]

EMS triage.

In 3 of the 5 hospitals where I work, EMS was an afterthought. In the busy, tertiary care level I trauma center, it's in the middle of the busiest hallway in the ED (100,000 pts per year.) In another, any more than 2 gurneys literally means they are lined out the door. None of them have a HIPAA compliant place to do triage. I've actually had nurses tell me to go back to my ambulance with my patient and wait there because they didn't have any room.

 

[Old_Mil]

Our current ED sees about 58,000 patients and is level 3 trauma center. We have about 36 beds and an 8 bed fast track area.

as I dictate on another chart. We will probably need space for at least 6 docs +/- 2 residents.

My director thinks that we will be doing more charting and physician order entry with either tablets or at computers at the patient's bedside, so he doesn't see the need for much designated physician space.

Do you guys think that under this scenario it's better to have one larger centralized physician work area

You dictate charts? In a level 3 trauma center with 58k visits? I'd get this fixed before I spent another minute worrying about the physical plant of the ED. Dictating is for family medicine and internists in a clinic setting - if that. An electronic medical record allows you to accurately and quickly pull up prior visit information about ED patients who may be obtunded or you know next to nothing about and that alone makes it the right documentation system for an emergency department.

 

[GeneralVeers]

You dictate charts? In a level 3 trauma center with 58k visits? I'd get this fixed before I spent another minute worrying about the physical plant of the ED. Dictating is for family medicine and internists in a clinic setting - if that. An electronic medical record allows you to accurately and quickly pull up prior visit information about ED patients who may be obtunded or you know next to nothing about and that alone makes it the right documentation system for an emergency department.

I agree with you. Dictating is the least favorite part of my job. I love places that have T-sheets or electronic T-sheets. All of our dictations are transcribed within 24 hours and end up in the EMR, so if a patient was seen in our ED yesterday, I can pull up the complete text of the visit within a few seconds and see what was done.

Unfortunately most of the members of my group (approx 35 guys) don't want to move away from dictation. They feel it protects them from added liability.

 

[gutonc]

Unfortunately most of the members of my group (approx 35 guys) don't want to move away from dictation. They feel it protects them from added liability.

Totally OT here but I'm curious as to why they think that. Documentation is documentation whether you write it down or somebody else does. I'm probably missing something obvious though...the last time I dictated something was 5 years ago.

 

[GeneralVeers]

Totally OT here but I'm curious as to why they think that. Documentation is documentation whether you write it down or somebody else does. I'm probably missing something obvious though...the last time I dictated something was 5 years ago.

With dictation it's easier to see a doctor's intention from dictation, which often doesn't come out on the T-sheets.

As far as protection from liability, I don't think anything protects us....

 

[docB]

I have heard the same thing about dictation being better in court than Tsheets as well. I have heard that jurors see a long list of checks and think you just checked boxes rather than doing what you said but if you "typed" it (they don't understand dictation) that you really did it.

Just my $0.02 but I really like the 3 walls and a curtain type of lay out. It gives a good comprimise between privacy and access/visibility. At my main hospital we use those roomes primarily and fortunately for us they're big enough to comfortably run a code or do procedures.

 

[RustedFox]

I'll jump in here to say that the perceived protection of "dictation" comes from the fact that the dictation is basically a blank canvas for the chart-writer. You can paint a picture as intricate as "Starry Night" or as obscure as an autistic child's fingerpaintings. EMR doesn't always allow you to express your thought process/differentials/intents as eloquently as it tends to box you in to its linear style of "I ask you this question, you give me an answer from this list, or you don't get to move on to the next question and your charting goes nowhere."

Dictation FTW, especially with complex cases.

I just wrote an article on some quick tips as to how to 'shore up your charting, medicolegally speaking'. Gonna try to get it published in one of our scandal rags here soon.

 

[gutonc]

With dictation it's easier to see a doctor's intention from dictation, which often doesn't come out on the T-sheets.

As far as protection from liability, I don't think anything protects us....

See...I knew I was missing something. I wasn't even thinking T-sheets. I was just thinking dictating my stream of consciousness vs typing my stream of consciousness, in which case, there is no difference (aside from who does the typing). Thanks.