The perfect ED

[erdoc61]

---

Members do not see this ad.

We are currently in the process of redesigning our ED and I've been asked to give my input. My philosophy is to dream big and then scale back slowly until we reach a realistic plan. So, let me pose this question to everyone: what would you include in the perfect ED? How would you like it organized? What elements would you want? How big should it be? Where are some places that you think are as good as it gets?

A little info on us:
Level I trauma center
Hospital-within-a-hospital Children's Hospital (so we get a lot of Peds)
About 45,000-50,000 yearly census
About 2,000-2,500 Trauma Admissions

Currently, we have 30 beds:
4 large Trauma/Medical resuscitation bays - open (patient stays in the room, NOT resus only!)
2 smaller bays (enclosed)
5 beds stuck in the hall with monitors
All the above beds are in the "Critical Care" section of the ED and have full monitor.
The rest of the beds are in the "Urgent Care" section.
5 of these are monitored
5 more are in private enclosed rooms
5 more are stuck in the hallway
the rest are either in open bays or in rooms with multiple beds separted by curtains.
We have no separate area for peds or for psych.
currently, all L&D patients are seen upstairs in L&D.

Thanks for your input!

 

[flighterdoc]

We are currently in the process of redesigning our ED and I've been asked to give my input. My philosophy is to dream big and then scale back slowly until we reach a realistic plan. So, let me pose this question to everyone: what would you include in the perfect ED? How would you like it organized? What elements would you want? How big should it be? Where are some places that you think are as good as it gets?

A little info on us:
Level I trauma center
Hospital-within-a-hospital Children's Hospital (so we get a lot of Peds)
About 45,000-50,000 yearly census
About 2,000-2,500 Trauma Admissions

Currently, we have 30 beds:
4 large Trauma/Medical resuscitation bays - open (patient stays in the room, NOT resus only!)
2 smaller bays (enclosed)
5 beds stuck in the hall with monitors
All the above beds are in the "Critical Care" section of the ED and have full monitor.
The rest of the beds are in the "Urgent Care" section.
5 of these are monitored
5 more are in private enclosed rooms
5 more are stuck in the hallway
the rest are either in open bays or in rooms with multiple beds separted by curtains.
We have no separate area for peds or for psych.
currently, all L&D patients are seen upstairs in L&D.

Thanks for your input!

Fast track / urgent care area?
labs?
radiology/CT/MRI?
get beds out of the hall routinely
separate area for peds, and psych
lots of computer capacity, and space

big break area, with good coffee, for the medics

🙂

 

[erdoc61]

Sorry, I forgot to metnion that we do have a CT scanner immediately adjacent to the dept, as well as an X-ray suite. We have a small EMS workroom that is typically used more as a staff/local FD room. The out-of-town services typically drop their patients and head out right away. (I guess they do their paperwork on the way home?)

Getting beds out and a separate area for peds and psych are my top three priorities!

Anyone with more radical ideas? I've seen some depts that have a "Surgical" side and a "Medical" side. Seems ok in theory, but how does it work? Do your triage RN's decide if a case is surgical or medical? For example, generalized belly pain could be gastritis or an appy.

 

[Febrifuge]

It's good to have at least a corner with multiple monitored beds. If you can glance at an extra computer screen and check vitals, which you've set the computer to get every 15 minutes, your techs can run around the less-acute area, and you can watch people who need to be admitted to the ICU/ the cardiac floor until "upstairs" is ready.

A nice big area for EMS and conference-type stuff is good, too.

 

[docB]

I've been a part of several ED remodels and 2 total constructions. Here's what I've found.
-Docs like rooms with doors 'cause we can do pelvics and rectals and so forth with a minimum of hassle. The RNs want curtains and bays 'cause than they can sit in one spot and watch their whole assignment without moving. I think the best comprimise is rooms with 3 walls and a curtain facing out. This seems to suit everyone.
-A radial system with central nursing areas and beds around the outside is best. If your ED is <20 beds you might even be able to see your whole dept at once.
-Try to insulate your docs in this central area, ie. don't have them sitting right behind a desk that fronts onto the corridor because pts and families will walk up and bug them all the time. Our new ED has this problem and I get asked for hot blankets and food all day long.
-Fast track can be off on its own since these are stable pts who don't need monitoring.
-Make sure there is a nook or a closet for rads to keep a portable unit in the ED. It saves everyone time.
-Give lab a small work area near the back (toward the main building or toward the main lab) it helps them out and makes them faster.
I'll jot down more as I recall them.

 

[ERMudPhud]

Allowing for virtually every bed to be monitored gives you lots of flexibillity and is becoming more common. Several of our newest ED's in town are virtually 100% monitored

 

[beyond all hope]

-Esophagoscope
-Nasal fiberoptic (look for nosebleeds)
-Slit lamp
-At least one ultrasound, preferrably 2, with vaginal probes
-CCTV for isolation room for psych patients (also good for videotaping your own H&Ps for improvement)
-computerized orders, H&P, lab results, radiology, which connect to wireless PDAs
-base phones (cell phones that only work in the ED. Much better than pagers!)
-Hazmat decontamination showers in parking lot
-metal detector at entrance (only one entrance!)
-call room with refrigerators (at least 2), microwave, TV, computers, couch, separate small room with bed, copy machine, etc
-really good ventillation (for smelly folks)

 

[Scrubbs]

- I second the base phones (makes call-backs from admitting teams/PMDs/Consultants so much easier!).
- Also the fish-bowl setup... Doc/Nursing station in center with rooms around the outside. If you can divide the central station so that your floor people have an area to work on admits/consults with their own computers, even better!
- PACS system is oh-so-helpful if your hospital is equipped.
- Definately agree that seperating peds/psych is nice... or at least having 1 psych room that can be monitored and 1 room with cutesy kiddie decorations.
- DocB's suggestion of rooms with 3 walls and a curtain is good, but you need at least a few rooms with doors to do pelvics. We have convertable beds at one of our hospitals that look normal, but the foot rest pulls out and they become gyn beds (yes, they are TRANSFORMER BEDS!!!!)
- As many computers as possible (assuming you get labs on computer) 😉

 

[erdoc61]

We've currently got a few rooms that are "cutsie kiddie" decorated. The two big problems are:
1) If there are a lot of adults and no kids, adults get put in there and then when kids come in they get put somewhere else.
2) (The BIG one in my opinion) When you get a kiddo who needs conscious or deep sedation (face suturing, fracture reduction etc.) they have to go up to one of our trauma/critical care beds (recently we've gotten the nurses to agree to do sedation in a lower acuity bed with a monitor) and often they find themselves next to an angry druck who flipped his car. Mom and Dad are often upset as junior recieves quite an education on the latest swear words and finger gestures while he is waiting to go to sleep.

Separate peds facilities is definitely the way to go IMO!

 

[deleted6669]

Portable Fluoroscopy Unit In Dept For Fb Removal And Quick Looks To See If Fxs Are Completely Reduced. Saves Lots Of Time As Pts Don't Have To Go Back And Forth To Xray Multiple Times.

 

[docB]

We've currently got a few rooms that are "cutsie kiddie" decorated. The two big problems are:
1) If there are a lot of adults and no kids, adults get put in there and then when kids come in they get put somewhere else.
2) (The BIG one in my opinion) When you get a kiddo who needs conscious or deep sedation (face suturing, fracture reduction etc.) they have to go up to one of our trauma/critical care beds (recently we've gotten the nurses to agree to do sedation in a lower acuity bed with a monitor) and often they find themselves next to an angry druck who flipped his car. Mom and Dad are often upset as junior recieves quite an education on the latest swear words and finger gestures while he is waiting to go to sleep.

Separate peds facilities is definitely the way to go IMO!

I like exposing the kids to the drunks and the hookers. It's a subtle way of saying to mom, "Maybe you should have gone to your PMD or even given Jr some tylenol at home before you came to the pit."

 

[basementbeastie]

as a 10 or 11 year old, i broke my arm being stupid. this brought me to the local ER where a thin curtain separated me from a loud drunk who hootin' and hollerin' about how "that bitch nurse better bring him a damn bed pan" or he was going to piss all over the room, along with other choice curses. to this day, this a humorous story in my family oft repeated at christmas and other holidays. i often cite it as creating the foundation for my desire to be an EM physician.