This is one of a series of articles by Huddy HealthCare Solution’s experts on ED analytics, planning and design.   Each article offers insights to you as an ED physician leader on how to position your emergency department for architectural design success.

ED External and Internal Expansion

The Robert Wood Johnson University Hospital (RWJUH) is part of the RWJBarnabas Health system in northern New Jersey. This high-volume (designed for 120,000 visits), university-affiliated, urban, emergency department serves a diverse patient population including local neighborhood residents (adults and pediatrics) as well as Level 1 trauma patients from across the New Jersey, New York and Pennsylvania tri-state region. The 60,000 square foot (sf) ED project included an addition of 6,880 sf that infilled an existing ambulance drop-off bay and three phases covering 53,120 sf. An additional capacity of 45 patient spaces is delivered through 21 of the private adult ED spaces (including the 3 trauma rooms) being sized for a second stretcher for surge/overflow with additional capacity delivered through results pending spaces (vertical recliners and chairs) and imaging holding bays (designed as ED care spaces with gases, etc.) In the event of extreme surges or disasters, the RWJUH ED has a total of 126 patient care spaces to support patient care.

Clinical Leadership on Design Team

Huddy HealthCare Solutions was hired as an ED design consultant to deliver operational and design insights to the hospital design team. Jon Huddy, president, and senior ED designer, led the team and delivered the experience of over 300 ED projects. From the hospital, the project was led by ED physician and nursing leadership including an initial focus on operational redesign as part of the early planning and design process. Robert M. Eisenstein, MD, Chief of Emergency Medicine, had instituted an innovative “split emergency severity index 3 patient flow model” in the old, cramped, ED that worked to expediate the patients to the care givers. This initial “split flow” model was used as a basis for the creation of a proposed “Care Initiation” flow concept that became the basis for the RWJUH ED architectural project. Dr. Eisenstein states that “the focus on the patient flow patterns at the outset of the project allowed our clinical team to establish the expectations for rapid access to patients by the entire care team. I can’t over-emphasize the role of the ED physician and the need to lead the process from the very beginning of any architectural redesign project.” Nancy Bonalumi, clinical consultant for Huddy HealthCare Solutions, was involved in this early process analytics and workflow development and supports Dr. Eisenstein’s view point by adding “having ED physician and nursing leadership on the same page and focused on the same patient care goals is the first step in a project’s ultimate success.”

Defined Patient Flow and Care Initiation Area

Upon entering the RWJUH ED, pediatric patients and their families are rapidly separated from the adult patients and placed in a pediatric specific internal staging area for 1reception and immediate assessment. Walk-in and EMS-arriving ESI Level 1 and 2 patients are expedited to the main ED or Resuscitation Trauma suite. All other adult patients are immediately assessed in the Care Initiation Area (CIA). ESI 5s, 4s, and an estimated 40% of ESI 3s remain in the CIA area for their entire stay. The remaining 60% of ESI 3s (higher acuity) will start in Care Initiation to expedite their diagnostics, then continue to the main ED for their remaining care. The Adult CIA has 13 private assessment rooms and 15 vertical recliners in the Results Pending area. This area is adjacent to the EMS arrival corridor and non-urgent patients arriving via ambulance will be diverted to the Care Initiation Area to avoid filling the main ED with lower acuity patients. The ED includes two general radiology rooms and a CT scanner that is accessible from the main ED and directly from the Resuscitation/Trauma suite.

Communication During Design and Construction

Faith Orsini, Assistant Vice President, Construction Services at RWJBarnabas Health, led the design and construction efforts for the organization and was the link between the clinicians, design team, and construction team. She believes the success of the ED project was due to “a detailed, clear construction plan developed in tandem with the clinical staff, hospital administration, EMS, the design team, and contractors that allowed for a complex expansion and renovation project. This three-year multi-phased construction project is situated on a tight urban campus and is in a location within the hospital that encompasses five different buildings. The collaboration of the team to develop the phasing and construction plans allowed our emergency department to remain operational and to treat over 100,000 patients each year while construction was in full swing. Integrating the clinical and EMS staff into the team effort was a key to our success, allowing us to limit the impacts of the construction on our patients.”

Large ED and Wayfinding

The complexity of the interior renovations across numerous original buildings built at different times meant designing around support columns and existing pipe and mechanical shafts. Interior design was a huge part of developing recognizable wayfinding for families and patients. Nicole Cocolin, president of Interior Design: DCC Design Group, Willmington, Delaware, led the interior design effort and said the team was focused on “developing an internal design for the Care Initiation Area, and overall ED, that supports efficient patient, family, staff, and material flow while honoring the privacy and well-being of patients and their families. The use of curvature and translucent elements encourages “treatment to care station” adjacencies, strategically promoting visibility, and clarifying wayfinding. The design objective was to lower patient anxiety levels, which are otherwise elevated when they try to navigate emergency care facilities without clear direction.”2

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