Australian hospital emergency departments have been under increased scrutiny over the past few years.
Several urban and rural based hospitals, such as Lismore Base Hospital in New South Wales and Ballina Hospital in Queensland, have been shown in media reports as not coping with patient demand and workflow inefficiencies. The areas of recent criticism and media attention listed overcrowding, extensive waiting times, lack of available senior clinicians and insufficient amenities to serve the ageing population, among other issues.
In order to improve patient and community outcomes, public and private organisations across Australia have engaged stakeholders in order to assess and analyse the main areas that require change and co-design solutions. Professional consultants and specialist architects have also been engaged to research and implement best-practices. In addition, many hospitals struggling with ED demand have now been marked for future expansions.
The set of immediate rectifications and longer term solutions presents a large challenge. These solutions are multi-faceted in nature and based on new funding models, operational improvements as well as the design and construction methodologies of modern hospitals, emergency departments and urgent care centres (UCCs). So what are the issues and solutions at hand?
Issue #1: Patients expect shorter wait times for treatment
Staffing, recruitment of doctors and nurses, technological advancements and workflow improvements are some of the main potential areas of improvement. In support of these efforts, from a building perspective, departments need to be flexible in nature, they need to expand and contract and accommodate changes in patient needs not only on a daily basis, but monthly or even on a one-off basis in the event of events such as pandemics, major accidents or other major crises.
Traditional EDs often tend to be pocketed in a section of an existing hospital and are not capable of expanding due to space constraints and lack of suitable HVAC and other infrastructure services in adjacent shells. This design inflexibility forces solutions such as major redevelopments and expansions rather than modular and scalable growth, which would have been an enormous cost saving. The ability to adapt new multi-use space is one of the most common considerations in new designs and so it should be.
Adaptable and expandable spaces allow for new multi-use beds when the need arises. Modern ED designs sometimes also incorporate upright suites, where patients sit upright in a treatment chair which can be converted into a bed only if needed. This can speed up patient waiting time, decrease their anxiety and assist in faster discharge processes. Naturally, faster discharge allows for greater throughput of new intakes. Upright suites is a relatively new concept in Australia, but has been successfully trialled and implemented in countries like the US and Canada.
Other, rather obvious internal fitout improvements relate to easy access to supplies and medical technology tools and resources. These can potentially decrease the time patient for non-critical conditions are seen and treated. It is important to engage stakeholders such as nursing staff in reviewing the workflow inefficiencies and requirements of each space – after all they will on average spend the most amount of time with emergency patients.
Issue #2: Patients expect better communication and confidentiality in the waiting room and treatment bays
A good example of how this can be achieved is showcased in the new emergency department of Epworth Hospital in Richmond, VIC designed by architects Silver Thomas Hanley.
Lounge-like waiting area allows for more intimate communication and open treatment bays have been replaced with semi open rooms allowing confidentiality. Modern, soothing interior finishes relieves some of the anxiety and promotes comfort during the patient’s often difficult and uncomfortable episodes.
Construction methods which can further assist in rectifying the issue of confidentiality involve soundproofing, use of privacy glass and other suitable materials allowing better monitoring while separating spaces. IT equipment and consumables can also be installed in locations allowing faster access and portability. Easier access to radiology should be considered as well. Diagnostic imaging equipment has gotten smaller and lighter over the last decade and by allowing faster travel times for imaging, hospitals can further speed up the patient treatment process.
Issue #3: Hospitals struggle with triaging into alternative treatment pathways
The outcomes of critical and time-sensitive conditions such as stroke or trauma are dependent of speed to access to the treatment team. These conditions continue to be treated on site and are part of the integral design and function of an emergency department. However, one of the most significant trends in the design and planning of future departments is the alternative triage approach. Less critical cases and minor injuries can be quickly assessed with patient check-in and directed to alternative modalities and treatment pathways such as an urgent care centre (UCC), which is basically an urgent treatment general practice, often adjacent to the ED. This is a major consideration for the building and design and modern hospitals.
As an example of this new way of thinking about triage, Alfred Health in Victoria has recently released an EOI for the service provision of The Sandringham Urgent Care Centre (UCC) which would be integrated with Sandringham Hospital’s 24-hour emergency department (ED).
The EOI document states “the UCC supports the treatment of patients with less urgent and minor illnesses and injuries whilst the ED treats patients requiring emergency care and continue to resuscitate and stabilise critical patients prior to their transfer or discharge.”
A different, or in some ways complementary approach to this, would be plan for building a freestanding emergency department, which is not a contiguous part of an existing hospital. This approach could work in situations where a satellite ED would then direct patients to affiliated hospitals for further critical care and UCCs for further non-critical care.
Another solution which is already being implemented in order to handle patient presentations efficiently is to direct some of the healthcare funding to day surgeries and treatment facilities with the general practice. Many of the new medical centres built over the past few years have incorporated treatment rooms with nurse’s bays into their design. A good example of a design and implementation allowing for larger number of procedures performed and a better workflow and faster turnaround is the general practice within the Vermont Private Hospital in Vermont, VIC. A centrally located, well presented procedure area is surrounded by nurse’s interview rooms, while the consulting suites are located around the perimeter of the tenancy.
Predicting the future
It is important to recognise that the growing patient demand being faced by emergency departments across Australia is not an unforeseen disaster, but simply a result of a rapidly growing population. Hospitals and departments designed and built in the 1970s and 80s most likely anticipated growth and allowed for some capacity expansion, but at that time architects and administrators could not have foreseen the actual scale of population demand growth.
We can only hope that lessons are drawn from the experience and new developments begin by analysing present and future traffic with respect to peak times, outbreaks and pandemics, as well as overall daily, weekly, monthly and yearly cycles. Emergency care centres should be planned with a 50-year cycle and take into account special population needs. Upfront capital costs should be carefully considered and weighed against the much larger cost burden of redevelopments in the future.
With the increasing cost of land and scarce resources, perhaps what the future holds is a completely new way of thinking about emergency care, incorporating innovative and creative solutions that are not reliant on new capital infrastructure. The field is already taking steps towards sharing the load with primary care centres. As construction professionals, we can immediately contribute to future solutions by always incorporating modularity into the planning, design and construction process.