ARCHITECTURAL DESIGN AND REDUCING WAITING TIME IN EMERGENCY DEPARTMENT

Transcription

1 Dr. Mohamed Al-Hussein DEPARTMENT OF CIVIL & ENVIRONMENTAL ENGINEERING UNIVERSITY OF ALBERTA CANADA Dr. Saad Al-Jibouri CIVIL ENGINEERING DEPARTMENT UNIVERSITY OF TWENTE, THE NETHERLANDS Presented by: Basel Abdulaal SITE MASTER PLANNER PLANNING & DESIGN SERVICES, STRATEGIC DEVELOPMENT PLANNING, CAPITAL MANAGEMENT - AHS INTERN ARCHITECT - MSC. EXECUTIVE DIRECTOR RAIC /AB LEED AP Design and Health Research ARCHITECTURAL DESIGN AND REDUCING WAITING TIME IN EMERGENCY DEPARTMENT

2 MOTIVATIONS ED waiting time impacts Medical professionals overload Access to timely patient care, and Contributes to considerable patient safety complications Factors Operational challenges Architectural design and layout Scale of the problem ED median LOS was just over 2 hours ( ) Wait time vs. time patient arrives at ED Wait time vs. severity level Correlation1 Correlation2 LOS or the median amount of time spent in the ED (Canadian Institute for Health Information, 2005)

3 OBJECTIVES Streamlined Design Scheme vs. Funnel Design Scheme Achieve a reduction in average LOS Identify the processes that add value to the patient s experience Eliminate waste Assess ED architectural & engineering standards on the basis of patient-focused environment Universal Zero Delay Treatment Instituted targeted times CTAS I Resuscitation: immediate (at 98%) CTAS II Emergent: 15 minutes (at 95%) CTAS III Urgent: 30 minutes (at 90%) CTAS IV Less-Urgent: 60 minutes (at 85%) CTAS V Non-Urgent: 120 minutes (at 80%) (David et al., 2010)

4 CURRENT PRACTICE

5 CURRENT PRACTICE Ancillary Departments DI Redundant capacity Insufficient communication Ineffective services IPU Discharge process Poor communication between on bed availability and scheduling; Bed preparations take longer than expected Inefficient tracking system to match types of available beds with types of patients for placement. The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will. (Corrigan 2001) (Huddy, 2006) / (Mickleburgh, 2010) /

6 METHODOLOGY Proposed methods a) A statistical analysis and survey of 42 ED designs b) An ED process design change c) Incorporating new design principles Standards a) Huddy, Jon (2006), Emergency Department Design-A Practical Guide to Planning for the Future, American College of Emergency Physicians b) The Facility Guidelines Institute (2010), Guidelines for Design and Construction of Health Care Facilities, ASHE (American Society of Health Care Engineering) of the American Hospital Association

7 METHODOLOGY Statistics: a) 10% has incorporated DI components within the ED. b) 12% have established direct connection with ED. c) 79% have a connection to DI through a corridor. d) 2% incorporated a pharmacy within the ED e) 14 % of EDs established a specialist to recognize psychiatric patients The current ED design practice ignores the effect of ancillary departments, specifically DI, that EDs depend on heavily in their processes.

8 METHODOLOGY Architectural a) 1154 AD b) Patient-focused environment c) Healing Garden Bimaristan is a Persian language word ( bīmārestānبیمارستان meaning hospital, (Source: (Rihawi, 1979)

9 METHODOLOGY Existing Approach Linear process Patient room size is m 2 ( sf.) **(code minimum standard) The number and size of equipment used in the design is not to today s standards New Approach Multidisciplinary team approach* Patient room size that is m 2 ( sf) The number and size of equipment have increased in the last 30 years Identical Examination room design *The team approach requires a larger patient care space. ** Code minimum standard (The Facility Guidelines Institute, 2010)

10 METHODOLOGY Segregated Trauma Rooms A non- efficient approach to excessive waiting time Curtain separation is used in approximately 25% of EDs. An ED layout that incorporates observation areas, patient holding and/or clinical decisions

11 METHODOLOGY ED Process Design Improvement

12 METHODOLOGY Patients Arrival and distribution The majority of cases (57%) were assessed as either less-urgent with CTAS IV or non-urgent with CTAS LOS is affected by both severity of illness and type of ED. The Institute for Healthcare Improvement ( Triage St. Paul s Hospital, Vancouver, BC set up screening and triage clinics staffed by six GPs to whittle down the number of patients who require surgery. Evaluating Triage Memory triage Computerized system, etraige Expert panel (Dong, 2005)

13 METHODOLOGY Current state simulation of LOW and High severity level patients processes ED Processes categorized in 2 Types of Lean Pull System: Type 1: CTAS IV & V a) High volumes b) Lead times short and stable. c) Queues between processes. d) The pacemaker discharging patients. The challenge Enhance the capability of moving patients from one stage to another to keep queues at minimum length. Lean Enterprise Institute Type 2: CTAS I, II & III a) Low volumes b) Lead time is longer c) The pacemaker stage is at the first point of examination d) Patients in downstream processes proceed (FIFO) sequence. e) Due to a low number of patients, long queues are not examined The challenge It is important to establish a system that can accommodate both types of processes.

14 METHODOLOGY Process Characteristics Allowing for process balancing Cycle times of High Severity level patient process. Cycle times of Low Severity level patient process. The demand frequency Takt = (24*60)/200 = 7 minutes Non-value added Timeline of High Severity level patient process is 32% Non-value added Timeline of Low Severity level patient process 48%

15 CONCLUSION Post-Lean Simulation - DES The Future State Model Output Count Mean Min Max Deviation Mins. Hrs. Mins. Hrs. Mins. Hrs. Mins. Hrs. LOS (from Admit to Discharge) CTAS I & II CTAS III CTAS IV CTASV The Current 8.00 State 0.13 Model 4893 Output LOS ( from Admit to Prime Assess) Count 3.10 Mean Min Max Deviation 0.00 Mins. 0.00Hrs Mins Hrs Mins. 8.65Hrs. Mins. Hrs. CTAS I & II LOS (from Admit to 4253 Discharge) CTAS III CTAS I & II CTAS IV CTAS III CTASV CTAS IV CTASV Wait time (before Prime Assess) CTAS I & II LOS ( from Admit to 4253 Prime Assess) CTAS III CTAS I & II CTAS IV CTAS III CTASV CTAS IV CTASV Wait time (before Prime Assess) CTAS I & II CTAS III CTAS IV CTASV

16 CONCLUSION Simulation Model Outcomes and Recorded Improvements Current State Future State Resource Type Utilization Resource Type Utilization Ovservation Rooms (12 rooms) 24.70% Exam Rooms (35 rooms) * 47.70% Exam Rooms (23 rooms) 83.80% Nurses (6 nurses) 83.30% Nurses (6 nurses) ** 37.60% Triage Nurse (3 nurses) 33.90% Doctors (5 Doctors) 81.10% Doctors (5 doctors) 79.80% * Exam rooms and observation rooms were combined together as one cluster in ths model ** Triage nurses were not considered in this model Current State Future State (minutes) (minutes) Improvement Average LOS % Average Wait Time % ED Capacity can be improved by up to 40% of annual visits!!

17 CONCLUSION Achieved A Streamlined Design A reduction in average LOS Value-added processes Inter- departmental process flow Waste reduction The architectural and engineering standards Future Research Universal Zero Delay Treatment. however, has not been achieved... YET

18 CONCLUSION Remember Every ED design has the potential to either increase or decrease throughput time Design should conform to functions, not the other way around Designing healthcare facilities is not a medical subject

19 REFERENCES 1. Canadian Institute for Health Information (2005), Understanding Emergency Department Wait Times, ( ) 2. David W. Warren, MD; Anna Jarvis, MD; Louise LeBlanc, RN; Jocelyn Gravel, MD; and the CTAS National Working Group (NWG), Revisions to the Canadian Triage and Acuity Scale Paediatric Guidelines (PaedCTAS), Canadian Association of Emergency Physicians (CAEP), May 2008, (Accessed: December, 2010) 3. Dong. Sandy L., (2005), Reliability and Validity of a Computer-assisted Emergency Department Triage System, A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the requirements for the degree of Master of Science, Medical Science Public Health Sciences, University of Alberta. 4. Huddy, Jon (2006), Emergency Department Design-A Practical Guide to Planning for the Future, American College of Emergency Physicians 5. Mickleburgh R., How a Vancouver hospital drastically cut its wait times, THE GLOBE AND MAIL, Tuesday, Nov. 09, :29PM EST, (Accessed: January, 2011) 6. Rihawi, Abdul Qader Arabic Islamic Architecture: Its Characteristics and Traces in Syria. Damascus: Publications of the Ministry of Culture and National Leadership. 7. The Facility Guidelines Institute (2010), Guidelines for Design and Construction of Health Care Facilities, ASHE (American Society of Health Care Engineering) of the American Hospital Association, ISBN:

20 THANK YOU Questions