Case Study: Facility Expansion for Improved Front End Flow and Better Access A Deeper Look Health systems should be designed for optimal patient flow, right-sized waiting and observation areas, as well as ease of access for ambulances and safe access for patients. Expansion and renovation are key tools to allowing facilities to remain nimble and react to patient demands, but planning and phasing logistics must be carefully developed to ensure care to critically-ill patients throughout the project.
Facility Expansion for Enhanced Flow & Safety CHALLENGE Robert Wood Johnson University Hospital needed to improve front-end flow in their Emergency Department (ED), relieve overcrowding, expand & modernize their ambulatory facilities — and maintain a cohesive exterior design in the process.
PROJECT UNDERSTANDING AND CONTEXT An extremely complex project, the expansion and renovation of Robert Wood Johnson’s (RWJ) Ambulatory building was identified as a priority for the Health System. The project occurred concurrently with the expansion of the Core building to the southwest, and it served as the kickoff to a renovation of the ED. One of 17 buildings on the Hospital’s sprawling urban campus, the ambulatory care building is situated next to the ED and houses cardiac outpatient services, EEG, stress testing and echocardiogram, vascular lab and an endoscopy suite. The purpose of the expansion was to provide a safer, more functional parking configuration and entrypoint for ambulances, to relieve overcrowding in the ED by providing space for a new observation unit and to modernize existing facilities.
SOLUTION Reconfigured ambulance parking and an 8,100 SF addition affecting both their ED and ambulatory care center help to provide additional capacity, improve flow and relieve overcrowding. New building features include a redesigned ED walk-in entrance, expanded surgery waiting area, ED waiting area, and shell space for a 21-bed observation unit.
A feasibility study was performed to identify the best course of action for reconfiguring ambulance parking and decoupling overlapping entry points for incoming ED patients and EMTs/ambulances. The study showed a need to relocate the ED entrance, provide additional EMS parking, and address exterior features that did not meet code. Apart for the external flow improvements, the project also addressed the hospital’s need for greater space in select waiting areas in the building, including surgery waiting. Thoughtful design and material selection for the infill construction were essential to unifying the campus feel and vernacular. With input from clinicians, administrative staff, and close coordination with the RWJ Facilities Department, a multi-phase construction plan was devised to allow the active ambulance bay to remain operational during the improvement process. Input
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Design Impact: Perspective from the Field
3 Questions for Leigh Anne Schmidt, Nursing Director at Robert Wood Johnson Hospital
1. WHAT DID STAFF EVALUATE DURING THE DESIGN PLANNING PHASE? We were able to look at the walk-in and the ambulance bays — and how we moved patients to the entrance of the department. One of our big concerns was the EMS arrivals. We treat the EMS just like a patient, and their ease in and out was very important to us. They were very dissatisfied with our old ambulance bay in the community. It was previously a three-bay ambulance spot underneath the building. Now, since the new design, we’re up to nine bays, it’s well-lit, easy to get in and out. There’s an electricity hook up for them, there’s a room from EMTs and administrative teams within the ED was critical to identifying the
for them off to the side and storage for their
issues the design would remedy, and planning foresight allowed the Array team to
equipment – it’s mind-blowing how we used to
provide building features that would accommodate the system’s future state.
have it compared to today.
CURRENT CONDITIONS
2. HOW HAS THE NEW ED ENTRANCE
Robert Wood Johnson’s Ambulatory Building is located on Little Albany Street
IMPACTED FLOW?
directly across from the Cancer Institute of New Jersey. With the expansion
We transformed through the new entrance
and reconfiguration of the facility, this project will reorganize the way in which
design. We used to have a process where the
ambulances park at the facility and deliver patients, provide a new walk-in entrance
patient arrives, sees the greeter, and then sees
to the ED, highlight entrypoints and landmarks and provide space to relieve ED
the nurse. Now, with this new design, we have
overcrowding in the facility’s future state.
the opportunity to have three nurses out in the ED at one time to arrive the patients and move
Prior to the expansion, ambulances entered the facility to drop off patients
them through. They’re really here to see the
underneath the building in a parking garage shared with the public. With only one shared exit point, ambulances would frequently get trapped in the garage when a second vehicle, such as a trauma delivery with multiple vehicles, came
doctor. We want to get them to the ultimate destination instead of the waiting room.
in. To remedy this problem, the facility constructed another dedicated exit for ambulances in 2008, but as ED volumes increased in the following decade, it
3. WHAT OTHER DESIGN CHANGES HAVE
became clear that the best option was to relocate the drop-off location from under
IMPACTED THE HOSPITAL?
the building to the immediate exterior of the building.
Through the design of the waiting room, we
A second critical issue for patient inflow was a shared entryway. The ED entrance
also strategically positioned security. They
was previously shared with the public and EMTs, so it was important to get the
are now able to see outside and in the waiting
ambulances out of the way of foot traffic. The entrance previously consisted of a
room, giving them a better vantage point.
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canopy and a door but lacked sufficient design elements for wayfinding and welcoming visitors. Similarly, sight lines from select areas in the ambulatory building were not conducive for wayfinding or comfort straying from areas such as surgery waiting.
AMBULANCE REORGANIZATION Improving the existing ambulance approach and parking required pulling the operation out of the shared public parking garage. A dedicated entrance was established for this purpose, and what was once a shared entrance to the ED was broken into two. Surface-level parking was added, now providing eight
IMPLEMENTATION Phasing and logistics were critical for this project’s delivery. The ambulance bay could not be closed, and in order to provide street-level drop-off/parking, the access road to the ambulance bay needed to be lowered 30 inches, in stages. 24/7 police presence posed additional difficulties.
ambulance bays so that EMTs have eight ways in and out. This new building feature prevents ambulances from getting trapped, readies the hospital for higher ED volumes and removes risk associated with a shared entrance. RELIEVING OVERCROWDING, CALLING ATTENTION TO ENTRYPOINTS The public ED entrance moved to the corner, was designed to
“The rule was that we could never close the ambulance bay during construction —even during steel erection. Working with those logistics was a challenge.” -Faith Orsini, Assistant VP of Construction Services, RWJBarnabas Health
feature much better signage and lighting, and was expanded to include a larger waiting area for patients. An existing stairway leading to the ED entrance was demolished as it did not meet code. Expanding the entrance opened the door for the facility to implement new triage bays which lead directly to trauma. The new waiting area, redesigned entrance, and reconfigured ambulance system operate in tandem to provide the hospital improved front-end flow.
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Who We Are ARRAY-ARCHITECTS.COM
“By creating a more open surgical waiting, it allowed families to feel more comfortable with traveling to Starbucks, Walgreens, or the gift shop and still be within eyeshot of surgical waiting.” -Faith Orsini, Assistant VP of Construction Services, RWJBarnabas Health
As part of the building’s expansion, the surgery waiting area was enlarged, and the balcony on which in sits was enclosed. The space redesign strengthened the line of sight between the waiting area and coffee shop and pharmacy in the courtyard below, allowing families to feel more comfortable with traveling short distances as they remained within view of surgical waiting. Acoustical panels were added to the courtyard directly below surgery waiting to curb noise, and a new exit area, new public toilets, and new information desk were added to improve the facility’s
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The infill construction above an active ambulance bay
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amenities, bring it up to code, enhance patient experience and facilitate wayfinding.
needed an exterior that would unify the hospital’s design. In the absence of a façade treatment, and without enough
was able to ring that entire edge of campus with pops of
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glass and metal and incorporate it with brick to tie it all
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support to use heavy brick as a primary unifying element, creating a continuous look and feel was a challenge. Array
together, allowing for one modern, clean and cohesive design. FUTURE-READY SPACE To provide further relief from ED overcrowding in the future,
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a shell space for a 21-bed observation unit was established in the ambulatory building. A pathway to the Core pavilion was also constructed to connect the ambulatory building to provide direct access to the new intensive care units currently under construction, the existing surgery suites, and the respiratory care unit. A dedicated trauma elevator was added to directly link the ED, ORs and ICU overbuild.
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Published: January 2019
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