EYP| Tradewell Fellowship|Pediatrics Behavioral Health In The Emergency Department

EYP | TRADEWELL FELLOWSHIP 2019 - 2020

PEDIATRICS BEHAVIORAL HEALTH IN THE EMERGENCY DEPARTMENT LAM H. NGUYEN

MASTER OF ARCHITECTURE + HEALTH | CLEMSON UNIVERSITY

TABLE OF CONTENTS 1

LITERATURE REVIEW TIMELINE MERGING OF PEDS PSYCHIATRIC IN ED THE EFFECTS OF OVERCROWDED ED ON PSY PEDS PATIENTS CURRENT CHALLENGES IN ED TYPICAL EDs ANALYSIS

2

PROBLEMS

PRECEDENT STUDY DESIGN RECOMMENDATIONS FOR TYPICAL EDs WAITING ENVIRONMENT DESIGN RECOMMENDATIONS PRECEDENT STUDY EMERGENCY EXAM ROOMS DESIGN RECOMMENDATIONS PRECEDENT STUDY DE-ESCALATION ROOMS DESIGN RECOMMENDATIONS PRECEDENT STUDY

3

POST EMERGENCE CARE 2

Cover Page

The emergency department is a high-stress environment for the patients and medical providers due to its nature of complexity.

The public typically turns to the emergency department as the first point of contact when something happens unexpectedly; however, because of the ever-increasing demand for emergency medical services, many emergency departments are exceeding their capacities in terms of resources and staffing capabilities. This research aims to provide an overall understanding of the current challenges in the EDs in treating mentally ill children and adolescents in a typical children's hospital emergency department. Also, as the direct result of insubstantiality in federal and state funding led to limited outpatient behavioral health resources in general, and much scarce for children and adolescents specifically. Nevertheless, they were forced to come to the EDs for immediate stabilization and treatment; therefore, it presents additional burden contributing to the growing pressure on the ED system that hinders the quality of care from the healthcare standpoint and reduces patients' experience and safety drastically.

It also compromises the six quality of care principles created by the Institute of Medicine (IOM): safe, effective, patient-centered, efficient, timely, and equitable.

Because of the current research advancement, and it might seem difficult to follow as the project's development is still evolving, I have decided to structure the book into three (3) main chapters that focus – 1.The pediatrics emergency department's history and how the sub-specialty for behavioral health children & adolescents came about.

2. The impacts of high-risk and high-stress environments on the children and adolescents with morbid mental disorders are waiting in the ED. 3. Due to the nature of this research, it could potentially be expanded in a much broader study. It would be beneficial for me to develop a workable scope to stay on track. I narrow it down into two or three patients' treatment areas, such as the behavioral health exam rooms and de-escalation rooms and the waiting space. Each chapter is supported by multiple subsections and followed by EBD practices. I want to keep it at high-level findings, in the beginning, then delve into micro-level details and provide design considerations supported by best practices in the pediatric psychiatric emergency department.

Furthermore, by learning from the literature reviews, interviewing EDs expert and medical planners, and drawing from evidencebased design practices, I hope to provide some level of design recommendation and open up a discussion for future improvement and possibilities. Especially on new innovative ways that we could improve on BH exam rooms and de-escalation rooms. I have listed a few vital BH anti-ligature products often used in this setting to ensure a safe environment for patients and staff. Please feel free to add to the suggestion box. As designers and medical planners, we can become responsive to patient's and staff's needs for a safe and therapeutic healing environment within the pediatric psychiatric emergency department's realm.

3

ED Waiting Environment

Safe Effective

PatientCentered

6 Quality Aims (IOM)

Timely

Quality of Care

Growing Pressure on ED System & Lack of Resources

ED BH Emergency Room

Efficient Equitable

ED Deescalation Room

4

1

LITERATURE REVIEW

MERGING OF PEDIATRIC IN ED

OVERVIEW/ BACKGROUND/ TIMELINE

5

MERGING OF PEDIATRIC PSY IN ED

MERGING OF PEDS PSY PATIENTS IN ED

CURRENT CHALLENGES IN PEDS ED

Address

THE EFFECTS OF OVERCROWDED ED ENVIRONMENT ON PEDS PSY PATIENTS

IDENTIFY PROBLEMs

DESIGN INTEGRATIONS

6

1

L' Hopital des Enfants Malades

1802

Paris' first hospital to treat sick children

7

LITERATURE REVIEW History of Child and Adolescent Psychiatry

The idea of "How soon can a child mind go mind?

1895

Published "The Pathlogy of Mind"

Illinois established the nation's first Juvenile Court in Chicago

First Child Psychiatry Shoots

Institutional Association for Child and Adolescent psychiatry and Allied Proffesions

1899

1920

1937

Entered "Begining of Child Psychiatry"

"IACAPAP"

The American Academy of Child and Adolescent Psychiatry

The European Paedopsychiatrist later became the European Society for Child and Adolescent Psychiatry

Development of Emergency Care for Children

1937

1954

1940s 1960s

"AACAP"

"ESCAP"

"The Beginning of the Modern Emergency Care System

Established the Institute of Medicine (IOM) report Emergency Medical Services for Children. It was the first comprehensive look at the need for and effectiveness of pediatric emergency care services in the Uinted States.

1993 "IOM"

8

1

OVERVIEW/BACKGROUND Pediatrics in Emergency Department

1940s - 1960s

"The Beginning of the Modern Emergency Care System

After WWII, there was a need to develop the modern emergency room as much medical practice specialization increased rapidly. A significant decrease in physician family practice because of the private insurance plans that geared the payment towards the hospital, the people had no choice but to turn to the local hospital for treatment (Rosen, 1995). The Hill-Burton Act of 1946 was a major switch that created the emergency room development because the government is supportive of the federal grants to build hospitals across the country. To continue receiving the federal fundings, the community service obligation required hospitals to maintain their emergency room, especially in the nonprofit U.S. hospitals that still in operation today (Rosenblatt et al., 2001).

https://www.npr.org/sections/healthshots/2016/10/02/495775518/a-bygone-era-whenbipartisanship-led-to-health-care-transformation

https://www.nap.edu/read/11655/chapter/4#36 Development of Emergency Care for Children

Development of Emergency Care for Children

Development of Emergency Care for Children

1940s 1960s

1970s

1980s

"The Beginning of the Modern Emergency Care System

9

Rapid Development of EMS Systems

Pediatric Emergency Care in Its Infancy

1970s

Rapid Development of EMS Systems

In 1970, we started seeing some initial efforts to incorporate children's needs into emergency medicine and EMS system. Pediatric emergency departments (EDs) began to develop and staffed by pediatricians. They established pediatric intensive care units (PICUs) and focused their research on pediatric emergency care during this time.

In 1975, the nation's first regional pediatric trauma center was established in Maryland.

In 1993, a collaboration between physicians in Los Angeles, local professional societies, and the county EMS agency, developed a pediatric-focused training curriculum for paramedics and management guidelines for pediatric emergency care (IOM, 1993).

The level of sophistication within the emergency room was later changed to the emergency department that included many services.

Development of Emergency Care for Children

Development of Emergency Care for Children

1990s

2006

Birth of a New Subspecialty

Pediatric Emergency Care

10

1

OVERVIEW/BACKGROUND Pediatrics in Emergency Department

There were numerous of public and private initiatives to enhance and improve the medical response to accidental injuries included the national trauma system, the creation of the specialty of emergency medicine, and the enhancement of the nation's emergency care infrastructure as well as research base.

Under the Emergency Medical Services Systems (EMSS) Act of 1973 (P.L. 93-154), 300 regional EMS systems were developed and focused primarily on adult trauma and cardiac care. However, pediatric emergencies recieved little attention among all these great achievements; thus, limited fundings and development had shortened resources and expertise in pediatric emergency medicine (Foltin and Fuchs, 1991).

https://www.nap.edu/read/11655/chapter/4#36 Development of Emergency Care for Children

Development of Emergency Care for Children

Development of Emergency Care for Children

1940s 1960s

1970s

1980s

"The Beginning of the Modern Emergency Care System

11

Rapid Development of EMS Systems

Pediatric Emergency Care in Its Infancy

Image Source: https://www.rubyhospital.com/emergency-services.php Development of Emergency Care for Children

Development of Emergency Care for Children

1990s

2006

Birth of a New Subspecialty

Pediatric Emergency Care

12

1

OVERVIEW/BACKGROUND Pediatrics Psychiatry Emergency Department

In 1981, Congress passed legislation that indirectly caused a loss of funding for state EMS activities that had immediate impacts on the EMS system.

As a result, the categorial federal funding that had been dedicated to EMS was replaced by the Preventive Health and Health Services Block Grant - the idea was to shift the responsibilities for EMS from the federal to the state level.

Since the idea of EMS was relatively new during that time, the states decided to spend the fundings in other areas of need.

Because of this decision, there was a considerate reduction in total funding allocated to EMS (Office of Technology Assessment, 1989).

Conversely, attention to pediatric emergency care grew dramatically throughout the 1980s as initial data on this domain of care became available. https://www.nap.edu/read/11655/chapter/4#36 Development of Emergency Care for Children

1940s 1960s

"The Beginning of the Modern Emergency Care System

13

Development of Emergency Care for Children

Development of Emergency Care for Children

1970s

1980s

Rapid Development of EMS Systems

Pediatric Emergency Care in Its Infancy

The studies have shown that children accounted for approximately 10 percent of ambulance runs (Seidel et al., 1984).

Respiratory distress was found mainly in young children (Fifield et al., 1984) Older children were presented mainly in trauma care (Fifield et al., 1984) Associated deaths in the ED trauma care among children were reported higher than the adults (Fifield et al., 1984).

The majority of the related deaths were found in areas lacking pediatric tertiary care centers. (Fifield et al., 1984) Many problems were derived from the lack of training in pediatric care and a shortage of the equipment needed to treat children (Seidel, 1986b).

Image Source: https://www.stonybrookchildrens.org/specialties-services/pediatricspecialties/pediatric-emergency-department

Development of Emergency Care for Children

Development of Emergency Care for Children

1990s

2006

Birth of a New Subspecialty

Pediatric Emergency Care

14

1

OVERVIEW/BACKGROUND Pediatrics in Emergency Department

Moreover, there was an immediate need to establish a body of knowledge to address the pediatric emergency. We soon recognized the importance of pediatric EDs, as a result, multiple approaches were quickly developed: - Advancement in resources for emergency care.

- In 1980s, more and more dedicated pediatric trauma centers grew across the nation.

- During this time, Los Angeles developed two-tiered approach for emergency care that allowed children with critical conditions to be treated only at hospitals as long as they met the requirements and capabilities for pediatric care.

- In 1984, an EMS-C program was established for pediatric emergency care. This was probably the most significant development because the grant allowed the states to designated funding to address pediatric deficiencies within their emergency care systems.

- In 1985, it established the first federal funding for EMS-C. The program continued to receive increased funding after that that made it possible for other services within pediatric emergency care.

https://www.nap.edu/read/11655/chapter/4#36 Development of Emergency Care for Children

Development of Emergency Care for Children

Development of Emergency Care for Children

1940s 1960s

1970s

1980s

"The Beginning of the Modern Emergency Care System

15

Rapid Development of EMS Systems

Pediatric Emergency Care in Its Infancy

Image Source: https://swlocums.com/the-social-stigma-of-mental-health-problems/ Development of Emergency Care for Children

Development of Emergency Care for Children

1990s

2006

Birth of a New Subspecialty

Pediatric Emergency Care

16

1

THE EFFECTS OF OVERCROWDED ED ON PSY PEDS PATIENTS Pediatrics Psychiatry in Emergency Department

Children with Mental Health Problems - Emergency Departments began to see a growing number of mental health disorders in children and adolescents, which led to a lot of challenges not only on the mentally ill patients but also created a burden on the emergency care providers.

- Twenty percent of U.S. children recorded to have some sort of mental disorder with at least mild functional impairment.

- 5 - 9 percent of children (9 - 17) developed a severe emotional disturbance (DHHS, 1999).

- It was imperative to address the mental health disorders in children and adolescents because it could lead to failure in school, uncooperative in the family at small and society at large, possible juvenile consequences, result in higher health care costs, and ultimately suicide.

- A study in 2002 from National Electronic Injury Surveillance System (NEISS) data, recorded that more than 200,000 children with mental health disorders reported in the emergency department annually (Melese-d'Hospital et al., 2002) - Mentally ill children & adolescent patients increased in ED visits (Santucci et al., 2000; Sullivan and Rivera, 2000: Sills and Bland, 2002).

- Furthermore, younger patients developed mental health problems such as depression, bipolar disorder, and anxiety. https://www.nap.edu/read/11655/chapter/4#36 Development of Emergency Care for Children

Development of Emergency Care for Children

Development of Emergency Care for Children

1940s 1960s

1970s

1980s

"The Beginning of the Modern Emergency Care System

17

Rapid Development of EMS Systems

Pediatric Emergency Care in Its Infancy

Children with Mental Health Problems

- There were no services or programs available for children & adolescents with mental health disorders within most of the pediatric emergency departments, according to a mid-1990 survey of hospitals (U.S. Consumer Product Safety Commission, 1997).

- A study conducted by NEISS's researchers found that three-fourths of behavioral health children received an evaluation by mental health specialists in which 69 percent of children attempted suicide, and 35 percent was related to drug and alcohol abuse (Melese-d'Hospital et al. 2002).

- Emergency care departments were unequipped and unprepared for treating mental health children & adolescent patients.

- Lack of training, skills, screening, and resources for mentally ill children & young patients created an on-going challenge in the EDs because psychiatric training was not required in emergency and pediatric emergency medicine.

- A dedicated program for mental training accounted for less than one-quarter (1/4) within the emergency services when provided.

- From the pediatric emergency staff's standpoint, many medical providers expressed concerns about treating behavioral health patients due to lack of specialty, knowledge, or adequate time for thorough evaluation in the ED setting.

Emergency setting is a high-stimulus environment for patients with morbid mental disorders. Contributing factors such as patient privacy and the high noise level made it challenging to screen and evaluate BH patients. Therefore, the ED staffs rely on psychiatrists, psychologists, or social workers to assess children & adolescents who have mental health symptoms before coming to the ED. Development of Emergency Care for Children

Development of Emergency Care for Children

1990s

2006

Birth of a New Subspecialty

Pediatric Emergency Care

CHILDREN WITH MENTAL HEALTH PROBLEMS

18

1

THE EFFECTS OF OVERCROWDED ED ON PSY PEDS PATIENTS Pediatrics Psychiatry in Emergency Department

Children with Mental Health Problems Not all hospitals have psychiatric resources available for the time of need. However, some hospitals utilize clinical nurse specialists' internal resources, mental health professionals to either provide evaluations or consultations to mentally ill patients in the emergency department (Falsafi, 2001). https://www.nap.edu/read/11655/chapter/4#36

Overcrowded psychiatric, pediatric situations in emergency departments that pose many challenges to treat/care for children and adolescents with mental health conditions due to long stays, high admissions rates, and lack of inpatient/outpatient resources.

Caring for adolescents with mental health problems: Challenges in the emergency department.

Image Source: https://www.ctvnews.ca/health/children-with-mental-

Claire Stewart, Maureen Spicer and Franz E Babl

illness-facing-long-wait-times-for-diagnosis-care-1.1656699

Development of Emergency Care for Children

Development of Emergency Care for Children

Development of Emergency Care for Children

1940s 1960s

1970s

1980s

"The Beginning of the Modern Emergency Care System

19

Rapid Development of EMS Systems

Pediatric Emergency Care in Its Infancy

- Morbid aggressive behavioral health problems are on-going challenges to medical providers in the emergency department.

The underlying mental conditions present in children may vary from mild to highly disruptive behaviors that could lead to violence. Emergency departments are often unequipped to treat mental disorder patients simply because they do not have immediate access to psychiatric services.

- The admission rate seems to be higher for pediatric psychiatric patients than the typical patient population.

- As a result of limited mental resources, most children spend extended lengths of time in hospital ED or general pediatric inpatient unit waiting to be seen/evaluated. This is particularly more challenging for children between 16 and 18 years old than most to receive psychiatric treatment because they do not meet the age criteria for adolescent or adult treatment services.

- A study found that 33 percent of pediatric psychiatric patients in the ED were admitted to a pediatric medical floor where they waited one or more days before being transferred to a psychiatric facility.

High Discruptive Behaviors

High Admission Rate

Mental Illness

Difficult for children 16-18 to get psychiatric treatment

33% of psy ped patients waited 1 or

C w u a P m t p 3 1 h a

more days before being transferred

https://www.nap.edu/read/11655/chapter/4#36 Development of Emergency Care for Children

Development of Emergency Care for Children

1990s

2006

Birth of a New Subspecialty

Pediatric Emergency Care

CHILDREN WITH MENTAL HEALTH PROBLEMS

20

1

THE EFFECTS OF OVERCROWDED ED ON PSY PEDS PATIENTS

Ten Leading Causes of Death in Children and Number of Deaths, by Age Group (in years), 2002 10 9

10 9

10 9

8

8

8

7 6 5

7 6 5

7 6 5

4

4

4

3 2

3 2

3 2

1

1

1

Age < 1 year-old

Age 1-4

10 9 8

10 9 8

7 6 5 4 3 2 1

7 6 5 4 3 2 1

Age 10 - 14

https://www.nap.edu/read/11655/chapter/4#70

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Age 5-9

Age 15 - 24

Ten Leading Principal Diagnoses for Hospital Admissions That Begin in the ED Selected States, by Age Group (in years)

10 9

10 9

8

8

7 6 5

7 6 5

4

4

3 2

3 2

1

1

https://www.nap.edu/read/11655/chapter/4#70

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1

PROBLEMS Pediatrics Psychiatry in Emergency Department

Growing Pressures on the Emergency Care System Children with Mental Health Problems The direct result of growing numbers in ED as more people turn to emergency services as the primary source of care leads to overcrowding and increases medical providers' burdens. According to a study between 1993 and 2003, the total ED visits have increased by 26 percent (McCaig and Burt, 2005). Overcrowding issues in EDs resulted in lengthy wait time before being seen between 6 to 8 hours for nonurgent patients (McCaig and Burt; 2002 NHAMCS data, calculations by IOM staff).

26%

https://www.nap.edu/read/11655/chapter/4#70

23

6 - 8 Hours

The rising number in EDs visits caused delays in transferring patients into inpatient beds. Still, emergency departments also suffered from cost-cutting measures and limited reimbursement by managed care, Medicaid, and other payers. As a result of financial impacts, hospitals were forced to consolidate and reduce their number of inpatient beds (Brewster and Felland, 2004), and unprofitable services such as trauma, burn. Especially psychiatric care became unavailable in some hospitals.

The term "boarding" has become familiar with medical providers in the emergency departments. It implies a lengthy waiting period for patients before an available exam room or treatment bay is opened. It is common for patients to wait for hours, sometime, days for an inpatient bed - the patients spend most of the time waiting in the ED waiting area or on stretchers in ED hallways. This creates logjam in the ED where staffs are required to provide ongoing care for the patients. Ultimately, medical providers in the EDs are overwhelmed by boarders.

https://www.nap.edu/read/11655/chapter/4#70

24

1

PROBLEMS Pediatrics Psychiatry in Emergency Department

1 Emergency departments have become the "first point of contact" for children & adolesecent with morbid mental disorders particularly as inpatient psychiatric beds became insufficent for the growing demands.

2 Outpatient psychiatric care become extremely scarce.

3 Evidently, the psychiatric-related ED visits, accounted for 38 percent, are on the rise compare to all other diagnoses, which made up for 8 percent, as the number of ED beds and psychiatric pediatric resources declined.

4 Nonetheless, psychiatricrelated ED vists has contributed significantly to the ED overcrowding phenomenon and create not only financial impact but also lower quality of care to all patients.

Escalating Mental Health Care in Pediatric Emergency Departments. Steven C. Rogers, MD, Christine H. Mulvey, MA, Susan Divietro, PhD, and Jesse Sturm, MD.

25

Cohort Case Study - They evaluated 13,204,293 PED visits between 2009 and 2013, and the mental health visits accounted for 11.7/1000 ED visits.

- Consistently over five years, a 40 percent increase in psychiatric visits - started from an initial rate of 9.3/1000 to 13.7/1000 in 2013.

- An average length of stay for PED visits is 1 day or less.

- Shortages of inpatient beds in EDs. - Lack of pediatric-trained professionals - Strict reimbursement policy in private and public insurance.

- Scarce resources and fragmented mental health infrastructure to accommodate the needs of children and adolescents in EDs.

Escalating Mental Health Care in Pediatric Emergency Departments. Steven C. Rogers, MD, Christine H. Mulvey, MA, Susan Divietro, PhD, and Jesse Sturm, MD.

26

1

PROBLEMS Pediatrics Psychiatry in Emergency Department

- Children and adolescents present at the emergency department with mental health problems range from 200,000 to over 825,000 visits annually.

- 2% to 5% of all pediatric emergency department visits are mental health disorders.

- All pediatric emergency department visits accounted for 5% and 10% of all psychiatric visits in rural areas.

- Specifically, in Connecticut, a six-year research study found an increase in child mental health-related emergencies by 110%.

- Overall, pediatric visits grew by 43%, and pediatric psychiatric related visits grew by 72% and 102%.

Child and Youth Emergency Mental Health Care: A National Problem. Janice L. Cooper, Rachel Masi. July 2017.

27

Inadequately Trained Staff Shocking data indicated that over 75% of emergency services and pediatric emergency services DO NOT require nor provide adequate psychiatric training in mental health emergency facilities. Thus, less than 25% of children hospital emergency departments staffed mental health professionals.

Inappropriate, Poor, or Nonexisting Resources An ongoing challenge that EDs are facing is insufficient resources such as unavailable or under-staff of mental health specialists, shortage of medical supplies, funding availability, and limited communitybased psychiatric outpatient services. Statistically documented, children and adolescents account for more than 27% of emergency department visits, and only 6% of dedicated resources for mentally ill children and adolescents.

Length Wait Times and Stays Many emergency department contributing factors lead to overcrowding issues based on the available resources a hospital has to provide that usually result in longer wait times for patients. Average wait time for a mental health-related visit is 5 hours before a specialist can see the patient.

Over-extended EDs lead to "boarding" According to one statewide assessment of EDs reports, children and adolescent spend appromximately 20 hours boarding in the emergency department before being transfered to an opened inpatient psychiatric bed. 33% to 60% of pediatric psychiatric patients are often admitted to general pediatric wards and waited a long time before an inpatient psychiatric bed is freed up.

Mental health adolescent patients' average wait times is between 1 to 3.6 days.

Child and Youth Emergency Mental Health Care: A National Problem. Janice L. Cooper, Rachel Masi. July 2017.

28

1

PROBLEMS Pediatrics Psychiatry in Emergency Department

The emergency department overcrowding situation results in extended wait times and stays and compromises all six (6) dimensions of quality of care, including safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity created by the Institute of Medicine (IOM).

The emergency department is considered high-risk and highstress environments for both patients and medical providers.

Potential adverse events that could lead to medical errors increase as the ED capacity increases.

Overcrowding in emergency departments creates financial burdens on the healthcare system. An hour reduction in emergency department boarding time would result in $9,000 of additional revenue to put it in perspective. The ripple effects from an overcrowding issue create a much more significant impact on the healthcare system, which could compromise the community's trust and limit an institution's ability to accept referrals and increase medicolegal risks.

Child and Youth Emergency Mental Health Care: A National Problem. Janice L. Cooper, Rachel Masi. July 2017.

29

To fully understand the overall crowding issues in the emergency department, we need to look at the throughput, clinical operational flows, and the built-environment as a whole. Let's take a look at some of the evidence build design recommendation at a high level departmental analysis that minimizes or alleviates some of the problems that cause immense challenges for EDs. However, according to John Huddy, EDs will continue facing these on-going challenges as long as we still have limited resources for post-emergence care for psychiatric patients. Although there is a growing body of study on improving throughput in the ED using various metrics to optimize the effciency, effectiveness of care and ultimately, improve patients satisfaction, the intent of this research is to use the data collected from the findings to analyze the bottleneck areas from the point of arrival to the time of discharged or admitted to inpatient beds. The design integrations will focus on the waiting place and treatment areas such as exam rooms for behavorial health patients and de-escalation rooms to treat aggressive or agitated patient's behaviors.

TYPICAL ED THROUGHPUT DIAGRAM "Generally, "throughput" refers to paitent flow, and is usually measured in minutes (Asplin et al.,2003; Jarousse, 2011). Common factors affecting throughput include patient volume, staffing, quality of communication, and availability of services and resources (Asplin et al.,2003; Hoot & Aronsky,2008; Hwang et al.,2011;Sayah, Rogers, Devarajan, Kingsley-Rocker, &Lobon,2014; Wiler et al.,2010)."

Emergency Department: Strategies to Improve Efficiency and Effectiveness of Care (Recite Correctly)

30

1

KEY PLANNING & DESIGN CONSIDERATIONS Patient Walk-In

Emergency departments must establish a clear way-finding system for a first-time visitor and accessible by ambulance dropoff. A clear way-finding system should employ multiple strategies to help patients and visitors reach the destination quickly and seamlessly, such as placing reception and triage area for situations requiring immediate attention.

Flexibility is the key driver to create a responsive and effective emergency department. The ED needs to flex between high and low patient volumes and the variety of types of cases across a diverse population.

In planning functionally efficient emergency departments, a number of key programming issues are worthy of consideration: • Intra-departmental relationships • Inter-departmental relationships • EMS Entrance • Walk-in Entrance • Security • Triage (Care Initiation Areas) • Resuscitation • Behavioral Health/ Pediatrics/ Decontamination • Flexibility The following case studies will address these key considerations within the emergency department.

Ambulance Drop-Off

Entry

Waiting Deescalation Room

Care Initiation (Triage)

Resuscitation

Exam Rooms (Areas) Imaging

Other Departments

Observation Surgery

Other Facility

Discharged

31

Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, TX: American College of Emergency Physicians, 2016.

KEY INTRA-DEPARTMENTAL RELATIONSHIPS - ADJACENCIES WITHIN THE EMERGENCY DEPARTMENT To optimize the emergency department's efficiency and effectiveness, centrally locate resuscitation or trauma room for walk-in patients or from ambulance drop-off to receive immediate care. Other key considerations include: Provide a flexible layout that maximizes flow to manage fluctuations inpatient volumes Provide common access to the same central resources from different areas within the emergency department.

Decentralize medication rooms throughout the ED allows quick access to medical supplies.

Provide flexible room sizes for clinical teamwork areas.

Create optimal travel distances from the entry to patient treatment areas.

CLINICAL OBSERVATION UNITS Potential Relationship With Clinical Decision Unit

Unstabilized patients (but may not need to be admitted into the hospital) will be kept in the Clinical observation units (COUs) until they can be discharged. Allowing extended EMS Access observation has been found to improve patient and staff satisfaction, reduce costs, shorten LOS, and reduce boarding time.

Shared resources within the emergency department need to be highly considered when designing units/wards.

Patient/Staff to Hospital Admin EMS

Admin

CT Rad/US

Clinical Support

Clinical Support

Resuscitation

Module A Split Flow Main Hospital

Open Visibility

Central Control/ Physician Work

Open Visibility Patient Access/ Public

Behavorial Health

Public to Hospital

Walk-In

Information Source: Piatkowski, Quan, Taylor. Emergency departments strategies to improve efficiency and effectiveness of care. The Center for Health Design, 2017

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WALK-IN ENTRANCE •

Easily accessible entrance from the main hospital to the emergency department is crucial for efficient functionality. It allows simplified referrals between the hospital clinics and care services provided within the ED.

WALK-IN ENTRANCE •

ED entrance needs to be visible to the patients traveling from main roads and streets for emergency services.

Provide separation between automobile drop-off/walk-in area and the ambulance drop-off area.

Maintain patient privacy by providing reflective windows into the patient public areas.

Design considerations for ED in cold weather climates: snow melting systems for automotive, EMS, and pedestrian pathways.

Design considerations for ED in cold and windy climates: double vestibule or 90 degrees turn in a vestibule to help control wind entering the waiting rooms.

VEHICULAR ENTRANCE •

Provide cover/canopy for the automobile drop-off area in front of the ED. Design considerations for parking and ED drop-off area to avoid having vehicles driving through parking lots/spaces.

ACCESS INSIDE THE ED • •

Provide wheelchair access near entrance for patient's needs.

Establish a clear and direct path for walk-in patients.

AMENITIES (WAITING ROOM) • • •

Consider placing seatings in the public waiting area to maximize comfortability and adequate areas around each chair.

The ratio for the number of chairs for each exam room is 2:1 or 2.5:1 When provided, children's play areas shall be away from the main entry vestibule and security presence.

33 Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, T

TX: American College of Emergency Physicians, 2016.

34

SECURITY •

To mitigate the unexpected physical violence situations in the emergency department, staff need to control the entrance visually. It helps with increasing awareness for security personnel and safety for clinical staff.

SITE SECURITY •

Design considerations for having bollards in front of the ED to protect the entrance from vehicular penetration.

For security purposes, the exterior of the building needs to be well-lit. It also helps to guide the patients to the entrance door at night.

SECURITY IN THE ED • • • • • • •

Consider having security at important control points such as reception desk, public waiting areas, door of public toilets, and vehicular drop-off entrance.

The security needs to have clear and unobstructed view into the public waiting area and vice versa.

Provide clear line-of-sight from the security area to the parking lot.

Provide clear views from the security to the clinical care area such as traiged/care initiation spaces.

Provide the ability to lock down the emergency department when needed.

Provide proximity from the security station to the behavorial health rooms for immediate access when situations escalate.

Provide adequate queing space infront of the metal detectors to observe and search patients bags and belongings.

CLINICAL SECURITY • •

Provide a safe passage way or area for receptionists and nurses in the receptionn, traige, and waiting room areas to escape when a situation occurs.

Provide panic alarms at the reception desk and in the behavioral health rooms.

35 Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, T

Direct to Clinical Area

Escape Path

Security Access to Clinical Area

Inner Patient Sub-Waiting

Multiple Care Initiation Rooms (Triage) Public Toilet

ED Reception

Public Toilet

Access to Auto Drop-Off

Security

TX: American College of Emergency Physicians, 2016.

Public Waiting Walk-In Vestibule

Automobile Drop-Off

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1

BASIC EMERGENCY DEPARTMENT CONFIGURATIONS

CARE INITIATION Incorporating the "care initiation process" during triage for lower acuity patients with an ESI (Emergency Severity Index) level of 4 or 5, can help to reduce the LOS (length-of-stay) for all ED patients. This process requires welltrained medical staff to evaluate, diagnose, and treat patients in triage. Research has found that when well-trained medical providers are available and involved in the triage process, one third (1/3) of ED patients can be discharged right after intake. However, depending on ED's resource availability, this strategy might or might not be practical.

PATIENT SEGMENTATION Multiple implications have been introduced to reduce the LOS (Length-of-stay), evidently in practice called "patient segmentation." Variation of the "patient segmentation" includes split flow, streaming, vertical and horizontal patient flow, quick-track, fast-track, super-track, rapid assessment zone (RAZ), and patient diversion are outlined on the next slide. Each configuration creates a fluid flow that maximizes efficiency and allows staff to prioritize patients based on the level of care and resources needed appropriately.

A combination of separate spaces, circulation paths, and rapid intake procedures in the emergency department allows lower-acuity patients to move directly to treatment areas. Pod configurations provide equipment and storage specific to different levels of need, with appropriate proximities to ancillary support. Lower-acuity patients remain dressed and upright in this particular model. They are frequently evaluated, managed, and discharged from chair-centric lower-acuity areas, which frees up beds for more critical patients. Ultimately, it helps with reducing bottlenecks and delays in the ED.

LEGENDS Central Control

Potential Imaging Location Resuscitation Room Work Zone Patient Care Areas Clinical Support EMS Entrance Public Entrance

37 Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, T

KEY PROCESSES IN THE EMERGENCY DEPARTMENT To support the flexibility and maximize visual control within multiple care zones of the emergency department, consider the following basic emergency department configurations.

Orthogonal Configuration - Scenario 2

Orthogonal Configuration - Scenario 1

“L” Configuration

Cross Configuration

“H” Configuration

Double Triangle Configuration

TX: American College of Emergency Physicians, 2016.

Orthogonal Configuration - Scenario 3

“T” Configuration

Four Triangle Configuration

38

PATIENT AREA TYPES SUPER TRACK The super-track approach is highly efficient for quick turn-around on lower-acuity patients who require low resource utilization. This approach requires rapid medical evaluation and is typically staffed by clinical staff and support personnel that determine the appropriate location to send the patients.

VERTICAL PATIENT CARE

A vertical patient care approach focuses on rapid treatment and releases to keep room capacity open for higher acuity patients. This methodology eliminates the need to place patients on the stretcher regardless of condition.

BEHAVORIAL HEALTH WAITING AREA

A Behavioral health exam room is typically designed similar to the exam room with medical gases, sinks, and storage besides medical gas covers or a roll-down shutter that protects a BH patient from getting to the medical equipment.

Clinical Work Area

Exam Room

Exam Room

Inner Waiting

Higher Capacity / Lower Acuity

39 Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, T

TREATMENT/EXAM ROOM

It is ideal for establishing a common treatment area or exam room where medical gases, sinks, and storage in the room can be designed identically at the same location.

The idea is to create an efficient and flexible environment that treats all patient types and conditions.

TX: American College of Emergency Physicians, 2016.

BEHAVORIAL HEALTH EXAM ROOM

A Behavioral health exam room is typically designed similar to the exam room with the same medical gases, sinks, and storage with the addition of either medical gas covers or a roll-down cover that protects a BH patient from getting to the medical equipment.

DE-ESCALATION ROOM

A de-escalation room is typically located near the front entrance, where aggressive behavioral health patients can quickly be removed from the November 2019 Behavioral Health Design Guide Edition 9.0 public area. Level V Level V-b. Seclusion Rooms and Restraint Rooms

Seclusion Room

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All items shall be the same as Level IV with the following exceptions: Seclusion Rooms and Restraint Rooms are very similar in design DQG FRQVWUXFWLRQ ZLWK WKH VL]H DQG IXUQLWXUH EHLQJ WKH WZR PDLQ GLႇHUHQWLDWLQJ IHDWXUHV 7KH FGI Guidelines UHTXLUH 6HFOXVLRQ 5RRPV WR EH D PLQLPXP RI VTXDUH IHHW LQ ÀRRU DUHD DQG 5HVWUDLQW URRPV WR EH D PLQLPXP RI VTXDUH IHHW LQ ÀRRU DUHD 7KH\ VKRXOG EH QR OHVV WKDQ IHHW ZLGH DQG QR JUHDWHU WKDQ feet long to avoid providing enough space for a patient to get a UXQQLQJ VWDUW DW WKH RSSRVLWH ZDOO 7KH\ VKRXOG EH GHVLJQHG WR

Lower Capacity / Higher Acuity

40

This document is intended to represent leading current practices, in the opinion of the authors. minimum acceptable conditions or establish a legal “standard of care” that facilities are re

DESIGNING FOR FLEXIBILITY

Create flexible "care zones" within an emergency department where multiple care areas can be visually connected based on the patient's care needs. These care zones are open layouts that can be flexible in delivering care for the department's future needs.

It is of utmost importance to maintain a clear visualization of all of the care areas within the behavioral health areas due to the high-stress environment's nature. Therefore, each care zone should be visually opened and linked to enhancing visual control and supporting medical providers and patients.

Avoid isolated treatment modules for different patient types or acuities within the department because that would limit the ability to flex between care spaces. The ED should be designed to flex up and down into various treatment zones as daily patient volumes rise and fall. If all zones are continuous, the staff has the ability to expand by one or two rooms as needed without adding large numbers of staff.

To provide optimal solution and flexibility within the emergency department, the operational discussion needs to happen between the designers and medical providers to figure out the most efficient strategies and approaches for a variety of testing and treatment options such as team models, pod design, point-of-care testing. It is also essential to understand the relationships between departmental adjacencies that will support the operational workflow.

Create easy access to treatment areas for staff by minimizing travel distances if possible. Furthermore, we should always plan adaptability to accommodate future growth.

41 Information Source: Piatkowski, M., Quan, X., & Taylor, E. (2017). Emergency Department Throughput: Strategies to Improve Care Efficienc

Huntington Hospital Emergency Department - Huntington, New York

cy and Effectiveness. Concord, CA: The Center for Health Design.

42

Nemours Children's Hospital Orlando, FL. Job #07200 SQ FT 630,000 GSF 95 Beds

OWNER/AFFILIATION Nemours Children's Health System

COMPLETION DATE

ARCHITECT(S) EYP Architecture & Engineering + Perkins+Will, Associate Architect

8M ILE S

SITE MAP

NORTH

Located approximately 8 miles from Olrando International Airport and off of 417, Central FLorida GreenWay, Nemour Children's Hospital provides a variety of behavioral health services including emergency care, autism, pyschology, down syndrome, and psychiatry needs for children.

HTTPS://WWW.EYPAE.COM/CLIENT/NEMOURS-CHILDRENS-HEALTH-SYSTEM/NEMOURS-CHILDRENS-HOSPITAL

43

Legend Emergency Department Emergency Waiting BH Exam Room CSPD Kitchen Imaging Imaging Waiting Administrative Area Staff Elevators Public Elevators Security Registration/Check-In Ambulance Drop-Off Walk-In Entrance Patient's Circulation Path

44

Children's Medical Center of Dallas SQ FT 328,000 SF

OWNER/AFFILIATION Children's Medical Center of Dallas

COMPLETION DATE September 2008

ARCHITECT(S) ZGF Architects LLP/ PageSoutherlandPage LLP B3

ED GENERAL OFFICE SUITE BL308

WORKRM BL308.A

MECHANICAL SHAFT #

STF TLT BL305

STORAGE BL300

STF TLT BL306

QUIET ROOM BL307

CORRIDOR BL920

LACTATION BL302

STAFF LOCKERS BL303

STAFF LOUNGE BL304

ELECTRICAL BL301

CORRIDOR BL271

CORRIDOR BL292

CORRIDOR BL296 INT. SUB-WAIT BL266

EXAM 8 BL264

STAIRWELL BL216

EXAM 9 BL233

PAT. TLT. BL268

EXAM 10 BL240

EXAM 11 BL293

FREEZER BL279 CORRIDOR BL335 CARE TEAM BL317

SOILED HOLD BL278

CARE TEAM BL333

EXAM 12 BL294 STR ALC BL227

NOUR BL338 TRIAGE 6 BL263

STORAGE BL212

EXAM 7 BL228

TRIAGE 5 BL259

HSKP BL265

SOILED WKRM BL224

CORRIDOR B1389

CARE TEAM BL299 LINEN SUPPLY ALC BL334

MECHANICAL BL214

Project Overview

TRIAGE 4 BL251

ELEVATOR SHAFT BL272

LACTATION B1401

B2

CORRIDOR BL270

UP

CORRIDOR BL298

MEDS BL332 TRIAGE 2 BL248

WAITING (83) B1413

CORRIDOR B1412

ELECTRICAL B1392

WAITING (POS ISO) BL276 MED GAS BL337

EXAM 3 BL217

CARE TEAM BL223

STAIRWELL BL213

EVS BL211

STF TLT BL336 PAT TLT BL280

CORRIDOR BL295

CTRL STATION (REG) B1410 STAIRWELL BL210

B1

CORRIDOR BL281

CONSULT RM BL288

CORRIDOR BL103

CORRIDOR BL282

EXAM 1 BL219

MECHANICAL B1394

FIRST LOOK BL101

EXAM 4 BL218 SECURITY BL277 B1404

ELEVATOR SHAFT BL273 EXAM 2 BL220

TR CLOSET B1395

EMT STR ALC B1402 TRIAGE 1 BL247

VESTIBULE BL297

STAIRWELL MECHANICAL SHAFT BL215 BL274

PUB TLT - M B1396

CORRIDOR B1411

CONCIERGE/ DISCHARGE BL269

EXAM 5 BL226

Located approximately four (4) miles from the heart of Dallas Downtown historic district and perpendicular to Harry Hines Blvd and Medical District Drive, Children's Medical Center of Dallas has integrated nature in the design patient's healing process. A 72-bed facility was initially planned on the 81-acre site and can grow into 240 beds with more than 500,000 square feet of clinic and office space.

PUB TLT - F B1399

DF B1409

TRIAGE 3 BL249

P-TUBE BL231 CLEAN STORAGE BL225

LACTATION B1408

WAITING (16) BL275

EXAM 6 BL229

TRAUMA 4 BL221

AMB ENTRY VESTIBULE BL286

MECHANICAL BL267 STORAGE BL222

WC STORAGE B1414 UP

Care Team Corridors D&T

Mechanical Public

Support

Vertical Circulation

HTTPS://PAGETHINK.COM/V/PROJECT-DETAIL/CHILDREN-S-MEDICAL-CENTER-LEGACY/59/

45 A100F LOWER LVL FLOOR PLAN NORTH

JOB NO.: DATE:

6016142.01 2017-10-03

CHILDREN'S MEDICAL CENTER OF DALLAS 3131 McKinney Avenue, Suite 340 Dallas, Texas 75204 214.468.8505 phone eypae.com

Waiting

STAFF BREAKRM

Overall Floor Plan

PHYS WORK / TELEWellness Room

STF. TLT.

CORRIDOR

ELECTRICAL

STAIRWELL B1-S12

EXAM 16

EXAM 17

EXAM 18 MECHANICAL SHAFT B1423

SECURE HOLDING 10 EXAM 23

EXAM 19

PAT. TLT. CARE TEAM

SECURE HOLDING 9 SMOKE COMPARTMENT B1623

Legend

NEG. ISO.

SMOKE COMPARTMENT B1614

CORRIDOR P-TUBE

HW

PAT. TLT.

PAT. TLT.

EXAM 20

STR ALC

NEG. ISO.

Emergency Department

SECURE HOLDING 8

EXAM 21

SECURE HOLDING 7

EXAM 22

HSKP PAT. TLT. B1626

RESULTS WAITING (10) B1603 STF TLT

MECHANICAL SHAFT #

EXAM 15 B1625

MECHANICAL B1231

MEDS B1624

Emergency Waiting

EQUIP STORAGE B1611

NOUR. B1622

EXAM 14 B1623

SMOKE COMPARTMENT B1649

CARE TEAM B1620

BH Exam Room

CORRIDOR B1926 ELEVATOR SHAFT B1421

B3

SOILED WKRM B1612

Restroom C1309.A

Procedure Room C1309

CORRIDOR B1916

Procedure Room C1308

CSPD

EXAM - ASTHMA B1511

EMS TLT B1601.A

VESTIBULE B1610

EMS WORKRM B1601

CORRIDOR B1914

Staff Support Area

Restroom C1308.A MECHANICAL SHAFT BL286

CLEAN STORAGE B1602

Restroom C1305.A

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PAT. TLT. BL447

Imaging

EXAM - INFECT DIS BL445

EXAM - ASTHMA B1509

Room

ANTE BL446

EXAM 11 B1532

HSKP BL475

EXAM - ASTHMA B1508 CARE TEAM B1521

Imaging Waiting

SMOKE COMPARTMENT B1625

Family Consult C1303

Procedure Room C1305

EXAM 12 B1533

MED GAS BL469

DECON PAT BELONG BL463

DECONTAMINATION BL444

Procedure Room C1304

EXAM 10 B1531

Storage C1302

EXAM - ASTHMA B1507 CORRIDOR BL482

Restroom C1304.A

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Staff Elevators

ELECTRICAL B1701

CORRIDOR B1912

ALCOVE B1502

CT PROCEDURE B1423

PUB. TLT C1227

PUB. TLT C1218

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CT CONTROL B1424

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CT EQUIP

SMOKE COMPARTMENT B1650

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PAT. TLT. B1504

TEAM LEAD CONF B1399

STAIRWELL B1-S10

CORRIDOR SMOKE COMPARTMENT BL298

PUB. TLT C1216 TEAM LEAD OFFICE B1314

DIGITAL RADIOLOGY B1332

EQUIP B1422

TRAUMA 1 B1402

Security

STF. TLT. B1315

DENTAL/OPHTAL/ENT B1331

PUB. TLT C1215 INTERVIEW/ CONSULT B1401

CARE TEAM PHYSICIAN WKRM B1462 B1463 PROCEDURE B1384

VESTIBULE B1403

Registration/Check-In

CORRIDOR B1908

CORRIDOR EXAM 5 B1329

EQUIP ALC B1411

FAMILY ROOM B1416

SUPPLY ALC B1412

TRAUMA CIRC. B1410

Ambulance Drop-Off

NOUR B1460

PAT. TLT. B1461

TRAIGE ALC B1459 CARE TEAM B1457

FIRE CONTROL C1211

EXAM 4 B1328

PROCEDURE B1385

CORRIDOR B1904

HSKP B1458

SUPPLY ALC B1412

STAIRWELL B1-S09 EXAM 7 B1455

TRAUMA 2 B1415

ORTHOPEDIC B1386

CARE TEAM B1456 EXAM 3 B1327 CORRIDOR #

EXAM 8 B1454

TRAUMA 3 B1414

RADIOLOGY TD B1307

CORRIDOR B1905

MECHANICAL SHAFT #

Walk-In Entrance

STR ALC B1453 CLEAN STORAGE B1452

MEDS B1325

ALC B1450 SOILED WKRM B1449

Patient's Circulation Path

EXAM 2 B1326

FAMILY SEATING B1303

ANTE B1447

POS. ISO. B1448

ELEVATOR SHAFT B1341

PAT. TLT. BL392

CORRIDOR B1922

HW B1444 ANTE B1322

ANTE B1341 POS. ISO. B1342

PAT. TLT. B1323.A

CORRIDOR B1903

CARE TEAM B1340

ELECTRICAL B1302

NEG. ISO. B1321

CORRIDOR B1901

STF. TLT. B1320

PAT. TLT. B1321.A

IDF B1301

SECURE HOLDING 2 B1238 STORAGE B1236

IDF B1220.A

CARE TEAM B1235

CORRIDOR #

SECURE HOLDING 1 B1233

VESTIBULE #

PUB. TLT. B1221 ELEVATOR SHAFT B1338

SECURE HOLDING 4 B1237 PAT. TLT. B1234

SECURE HOLDING 5 B1231

PAT. TLT. B1223.B SECURE HOLDING 6 B1230 SANE CLOSET B1223.A

NORTH

JOB NO.: DATE:

6016142.01 2017-10-03

FIANCIAL COUNSELING B1404

SUB-WAITING (16) B1220

B1

SECURE HOLDING 3 B1239

A101F LVL 1 FLOOR PLAN

WAITING / RECEPTION

STAIRWELL B1-S07

C.C. ALC B1240

STAIRWELL B1-S08 MECHANICAL SHAFT #

B2

NEG. ISO. B1323

EQUIP STORAGE B1446 PAT. TLT. B1448.A

ORTHOPEDIC B1387 CODE STR B1305

EXAM 1 B1324

CHILDREN'S MEDICAL CENTER OF DALLAS

FAMILY CONSULT B1222 EXAM - SANE B1223

46

3131 McKinney Avenue, Suite 340 Dallas, Texas 75204 214.468.8505 phone eypae.com

Children's Hospital of Colorado Aurora, Colorado SQ FT

OWNER/AFFILIATION Children's Hospital Colorado

ARCHITECT(S) TREANORHL + ZGF Architects

COMPLETION DATE

Project Overview Located approximately nine (9) miles from the heart of Denver historic district and off of E Colfax Ave, Children's Hospital of Colorado provide comprehensive list of medical services for children & adolescents include but not limited to emergency care, both inpatient and outpatient services, mental health (autism and intellectual disabilities), and partial hospitalization.

HTTPS://WWW.TREANORHL.COM/DESIGN/PROJECT/CHILDRENS-HOSPITAL-COLORADO-COMPLEX

47

Overall Floor Plan Legend Emergency Department Emergency Waiting BH Exam Room CSPD Staff Support Area Imaging Imaging Waiting Staff Elevators Public Elevators Security Registration/Check-In Ambulance Drop-Off Walk-In Entrance Patient's Circulation Path

48

Children Hospital of Atlanta SQ FT Hospital: 1,547,303 SF B-Building: 324,302 SF CUP: 52,340 SF Total: 1,923,945 SF

OWNER/AFFILIATION Children's Healthcare of Atlanta

COMPLETION DATE

ARCHITECT(S) EYP Architecture & Engineering + Earl Swensson Associates, Inc.

PROVIDED SERVICES Autism Spectrum Disorder Brain Nervous System and Mental

9M

ILE

S

Emergency Care

SITE MAP NORTH

49

Overall Floor Plan Legend Emergency Department Emergency Waiting BH Exam Room CSPD Staff Support Area Imaging Imaging Waiting Staff Elevators Public Elevators Security Registration/Check-In Ambulance Drop-Off Walk-In Entrance Patient's Circulation Path

50

CHNOLA - 6016182.01 SQ FT

OWNER/AFFILIATION

ARCHITECT(S)

COMPLETION DATE

SITE MAP NORTH

51

Overall Floor Plan Legend Emergency Department Emergency Waiting BH Exam Room CSPD Staff Support Area Imaging Imaging Waiting Staff Elevators Public Elevators Security Registration/Check-In Ambulance Drop-Off Walk-In Entrance Patient's Circulation Path

52

SPARROW HOSPITAL Lansing, MI SQ FT

53

OWNER/AFFILIATION

ARCHITECT(S)

COMPLETION DATE

Legend Emergency Department Emergency Waiting BH Exam Room CSPD Staff Support Area Imaging Imaging Waiting Staff Elevators Public Elevators Security Registration/Check-In Ambulance Drop-Off Walk-In Entrance Patient's Circulation Path

54

WellStar Kennestone Hospital Marietta, GA

SQ FT

55

OWNER/AFFILIATION

ARCHITECT(S)

COMPLETION DATE

Legend Emergency Department Emergency Waiting BH Exam Room CSPD Staff Support Area Imaging Imaging Waiting Staff Elevators Public Elevators Security Registration/Check-In Ambulance Drop-Off Walk-In Entrance Patient's Circulation Path

56

COMBINED BENCHMARK - FLOOR PLAN

Waiting

STAFF BREAKRM PHYS WORK / TELEWellness Room

STF. TLT.

CORRIDOR

ELECTRICAL

STAIRWELL B1-S12

EXAM 16

EXAM 17

EXAM 18 MECHANICAL SHAFT B1423

SECURE HOLDING 10 EXAM 23

EXAM 19

PAT. TLT. CARE TEAM

SECURE HOLDING 9 SMOKE COMPARTMENT B1623

NEG. ISO.

SMOKE COMPARTMENT B1614

CORRIDOR

SECURE HOLDING 8

P-TUBE

HW

PAT. TLT.

PAT. TLT.

EXAM 20

STR ALC

NEG. ISO.

EXAM 21

SECURE HOLDING 7

EXAM 22

HSKP PAT. TLT. B1626

RESULTS WAITING (10) B1603 STF TLT

MECHANICAL SHAFT #

EXAM 15 B1625

MECHANICAL B1231

MEDS B1624

EQUIP STORAGE B1611

NOUR. B1622

EXAM 14 B1623

SMOKE COMPARTMENT B1649

CARE TEAM B1620

CORRIDOR B1926 ELEVATOR SHAFT B1421

B3

SOILED WKRM B1612

Restroom C1309.A

Procedure Room C1309

CORRIDOR B1916

Procedure Room C1308 EXAM - ASTHMA B1511

EMS TLT B1601.A

VESTIBULE B1610

EMS WORKRM B1601

Restroom C1308.A MECHANICAL SHAFT BL286

CLEAN STORAGE B1602

CORRIDOR B1914

Restroom C1305.A

EXAM - ASTHMA B1510 CARE TEAM B1522

PAT. TLT. BL447

SMOKE COMPARTMENT B1625

Family Consult C1303

Procedure Room C1305

EXAM 12 B1533

MED GAS BL469

EXAM - INFECT DIS BL445

EXAM - ASTHMA B1509

Room

ANTE BL446

EXAM 11 B1532

HSKP BL475

EXAM - ASTHMA B1508 CARE TEAM B1521

Procedure Room C1304

EXAM 10 B1531

DECON PAT BELONG BL463

DECONTAMINATION BL444

Storage C1302

EXAM - ASTHMA B1507 CORRIDOR BL482

Restroom C1304.A

EXAM 9 B1530 CHILD LIFE B1503

CORRIDOR EXAM - ASTHMA B1506

ELECTRICAL B1701

CORRIDOR B1912

ALCOVE B1502

SMOKE COMPARTMENT B1650

CARE TEAM B1520

PUB. TLT C1219

SOCIAL WORK B1389

EXAM - ASTHMA B1505

HUC TEAM B1501 CT PROCEDURE B1423

CT EQUIP

PUB. TLT C1227

PUB. TLT C1218

PUB. TLT C1217

CORRIDOR B1910

CT CONTROL B1424

PAT. TLT. B1504

TEAM LEAD CONF B1399

STAIRWELL B1-S10

CORRIDOR SMOKE COMPARTMENT BL298

PUB. TLT C1216 TEAM LEAD OFFICE B1314

DIGITAL RADIOLOGY B1332

EQUIP B1422

STF. TLT. B1315

DENTAL/OPHTAL/ENT B1331

TRAUMA 1 B1402

PUB. TLT C1215 INTERVIEW/ CONSULT B1401

CARE TEAM PHYSICIAN WKRM B1462 B1463 PROCEDURE B1384

VESTIBULE B1403

CORRIDOR B1908

CORRIDOR EXAM 5 B1329

EQUIP ALC B1411

FAMILY ROOM B1416

NOUR B1460

PAT. TLT. B1461

SUPPLY ALC B1412

TRAUMA CIRC. B1410

TRAIGE ALC B1459 CARE TEAM B1457

FIRE CONTROL C1211

EXAM 4 B1328

PROCEDURE B1385

CORRIDOR B1904

HSKP B1458

SUPPLY ALC B1412

STAIRWELL B1-S09 EXAM 7 B1455

TRAUMA 2 B1415

ORTHOPEDIC B1386

CARE TEAM B1456 EXAM 3 B1327 CORRIDOR #

EXAM 8 B1454

TRAUMA 3 B1414

RADIOLOGY TD B1307

CORRIDOR B1905

MECHANICAL SHAFT #

STR ALC B1453 CLEAN STORAGE B1452

MEDS B1325

ALC B1450 SOILED WKRM B1449

EXAM 2 B1326

ORTHOPEDIC B1387 CODE STR B1305

EXAM 1 B1324 FAMILY SEATING B1303

ANTE B1447

POS. ISO. B1448

ELEVATOR SHAFT B1341

PAT. TLT. BL392

CORRIDOR B1922

HW B1444 ANTE B1322

ANTE B1341

PAT. TLT. B1323.A

CORRIDOR B1903

CARE TEAM B1340

ELECTRICAL B1302

NEG. ISO. B1321

CORRIDOR B1901

STF. TLT. B1320

PAT. TLT. B1321.A

IDF B1301

SECURE HOLDING 2 B1238 STORAGE B1236

IDF B1220.A

CARE TEAM B1235

CORRIDOR #

SECURE HOLDING 1 B1233

VESTIBULE #

PUB. TLT. B1221 ELEVATOR SHAFT B1338

SECURE HOLDING 4 B1237 PAT. TLT. B1234

SECURE HOLDING 5 B1231

PAT. TLT. B1223.B SECURE HOLDING 6 B1230 SANE CLOSET B1223.A

57

A101F LVL 1 FLOOR PLAN 6016142.01 2017-10-03

FAMILY CONSULT B1222 EXAM - SANE B1223

CHILDREN'S MEDICAL NORTH

JOB NO.: DATE:

FIANCIAL COUNSELING B1404

SUB-WAITING (16) B1220

B1

SECURE HOLDING 3 B1239

NEMOURS' ED

WAITING / RECEPTION

STAIRWELL B1-S07

C.C. ALC B1240

STAIRWELL B1-S08 MECHANICAL SHAFT #

B2

NEG. ISO. B1323

EQUIP STORAGE B1446 PAT. TLT. B1448.A

POS. ISO. B1342

CHILDREN'S MEDICAL CENTER OF DALLAS

3131 McKinney Avenue, Suite 340 Dallas, Texas 75204 214.468.8505 phone eypae.com

CHILDREN'S HOSPITAL OF

CENTER OF DALLAS

COLORADO

DGSF:

DGSF:

DGSF:

BGSF :

BGSF :

BGSF :

TYPICAL EXAM ROOM SF:

TYPICAL EXAM ROOM SF:

TYPICAL EXAM ROOM SF:

TYPICAL BH EXAM ROOM SF:

TYPICAL BH EXAM ROOM SF:

TYPICAL BH EXAM ROOM SF:

CHILDREN'S HEALTHCARE

CHILDREN'S HEALTHCARE OF NEW ORLEANS

OF ATLANTA DGSF:

DGSF:

BGSF :

BGSF :

TYPICAL EXAM ROOM SF:

TYPICAL EXAM ROOM SF:

TYPICAL BH EXAM ROOM SF:

TYPICAL BH EXAM ROOM SF:

58

2 I.

PROBLEMS ED Waiting Environment/Situation

"Overcrowded U.S. emergency room have become a place of last resort for psychiatric patients. Psychiatric boarding, defined as psychiatric patients’ waiting in hallways or other emergency room areas for inpatient beds, is a serious problem nationwide"

Image Source: https://health.usnews.com/health-news/patient-advice/articles/2015/05/08/enduring-really-long-waits-at-the-emergency-room

Poorly equipped emergency departments with limited resources, specifically for typical exam rooms, often cannot treat mental health needs. Overall, the quality of care reduced dramatically for boarded patients with exceptional care needs and increased pressure on medical providers and staff in the ED. Furthermore, hospitals can not be reimbursed for the boarded patients that utilize extensive resources and staff on the financial side.

However, the level of complexities within the ED would be challenging to comprehend without understanding the fundamental concepts of its entirety from a departmental planning level to specific treatment rooms.

59

A Plan to Reduce Emergency Room ‘Boarding’ of Psychiatric Patients. Vidhya Alakeson, Nalini Pande, and Michael Ludwig.

Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, TX: American College of Emergency Physicians, 2016.

2 I.

PROBLEMS ED Waiting Environment/Situation

background photo - show a typical playroom

Interview With Expert - John Huddy

In order for me to understand more about the current challenges in the ED waiting area, I have reached out to John Huddy - an expert in emergency department designs. He has written multiple articles on ED design recommendations such as "Design Considerations for a Safer Emergency Department" and a book on "Emergency Department Design: A Practical Guide to Planning for the Future." He is experienced in working with hospital EDs across the nation and internationally.

Questions

Answer

Where do MH patients stay in the ED?

The patients staying right into the ED until they can be transferred to another facility. Not many adult psychiatric facilities and even less adolescent BH facility. Recently, we are developing a unit now that most rooms don’t have toilet and shower in them because they want to maintain visibility. However, in the sample I sent you, they have toilet & shower because it was design to inpatient standard now because they might stay there for 8 – 10 days.

The ED is a high stress environment especially in the waiting area. For children/adolescent with mental health, how can we create a calming waiting area that helps deescalate the episodic ED situations?

Stay away from the TV - no loud noise. There is some interactive touchscreen but usually muted colors so that we not excited patient – the most consideration that it can be used by clinical personnel. A lot of time we use 1- or 2-ways glass so that staff can watch into the room and patients don’t feel like they’re being watched.

The FGI requires a playroom or play area in the waiting room for pediatric emergency services.

Are there any other similar requirements/areas specific to pediatric emergency?

Playroom still in the FGI guidelines but the problem in the section control doesn’t allow any toys or anything to be in this room any more so it is a useless room.

It usually has some recliners and chairs, and some books (Huddy can send me de-escalation room, inner playroom *the play room is the same as the waiting room).

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• • • • • •

2

BEHAVIORAL HEALTH AREAS

Design Considerations for Waiting Area in the ED

Behavioral health care zones should be accessible from both the Walk-in and EMS entrances.

Provide a direct visual connection between the main ED nurse station to the behavioral health nurse station for additional support when needed.

Avoid dead-end corridors and provide at least two (2) safety escape options for staffs in the behavioral health care areas.

Avoid having staffs back facing the patient spaces for safety reasons.

Implement anti-ligature solutions in the exam rooms such as rolling shutters to cover medical gases, sinks, supplies and other care zones within the behavioral health area.

Provide seperation between agressive behavioral health patients and non-violent BH patients in the waiting area perhaps provide an inner-waiting for patients waiting to be discharged away from the main public area.

PEDIATRIC AREAS • • • • •

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Separate pediatric entrance from the main/adult ED entrance.

Isolate "sick" and "injured" children within the pediatric waiting area.

Provide adequate space to accommodate up to two (2) family members within the pediatric treatment/exam rooms.

Provide patient's privacy by locating consultation room near or in the pediatrics area.

Avoid over-decoration within the pediatric area.

Recommend soothing and warming colors for the interior design.

Information source: Huddy, Jon, and Michael T. Rapp. Emergency department design: a practical guide to planning for the future. Dallas, TX: American College of Emergency Physicians, 2016.

Overall Goal WAITING AREA

Create a healing & calming environment in the ED waiting area for BH patients and staffs

Waiting Children 3-17

ts

Multipurpose Room Flexed Space

Waiting Adolescent 18-21

Co n

ce p

p ce

ts

n Co

Safety for patients & staffs

Access to nature

Calming environment

Calming environment

Optimizie Visibility Control

Co n

Psychological Resillience

STAFF CONTROL

Psychological Resillience

n Co

ts cep Con

Con cep t

s

Flexed Space

ts

p ce

ce p

ts

Access to nature

HEALING & CALMING

HEALING & CALMING

Concepts

Concepts

Safety for patients & staffs

Safety for staffs

Waiting Area for Adolescent Waiting Area for Children

Concepts

Goals Function to achieve goals Design Concepts

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2 II.

Design Integration Precedent Study/Evidence Based Design ED Waiting Environment/Situation

CORRIDOR A-0C06

Legend Emergency Department Emergency Waiting Staff Elevators Public Elevators Security Registration/Check-In Walk-In Entrance Patient's Circulation Path

NEMOURS' CHILDREN HOSPITAL - EMERGENCY DEPARTMENT DGSF:

63

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Children's Medical Center of Dallas

LACTATION B1401

LACTATION B1408

PUB TLT - F B1399

WAITING (16) BL275

PUB TLT - M B1396

DF B1409

Legend Emergency Department

CORRIDOR B1411

Emergency Waiting TR CLOSET B1395

EMT STR ALC B1402 WAITING (83) B1413

CORRIDOR B1412

Public Elevators

ELECTRICAL B1392

TAIRWELL BL213

EVS BL211

Security

CTRL STATION (REG) B1410 STAIRWELL BL210 CORRIDOR BL103

IDOR 82

MECHANICAL B1394

Patient's Circulation Path

AMB ENTRY VESTIBULE BL286

WC STORAGE B1414 UP

CHILDREN'S MEDICAL CENTER OF DALLAS - EMERGENCY DEPARTMENT

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Registration/Check-In Walk-In Entrance

FIRST LOOK BL101 SECURITY BL277 B1404

DGSF:

Staff Elevators

HTTPS://PAGETHINK.COM/V/PROJECT-DETAIL/CHILDREN-S-MEDICAL-CENTER-LEGACY/59/

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Children's Hospital of Colorado Aurora, Colorado Waiting Space

Legend Emergency Department Emergency Waiting Staff Elevators Public Elevators Security Registration/Check-In Walk-In Entrance Patient's Circulation Path

CHILDREN'S HOSPITAL OF COLORADO - EMERGENCY DEPARTMENT DGSF:

67

68

Waiting Space Children Hospital of Atlanta 6018101.01 3,075 SF

Legend Emergency Department Emergency Waiting Staff Elevators Public Elevators Security ED WAITING

5 3075 SF

Registration/Check-In Walk-In Entrance Patient's Circulation Path

CHILDREN'S HEALTHCARE OF ATLANTA - EMERGENCY DEPARTMENT DGSF:

69

70

CHNOLA - 6016182.01 WAITING

Legend Emergency Department Emergency Waiting Staff Elevators Public Elevators Security Registration/Check-In Walk-In Entrance Patient's Circulation Path CHILDREN'S HEALTHCARE OF NEW ORLEANS - EMERGENCY DEPARTMENT DGSF:

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2 I.

PROBLEMS Emergency Exam Room

Poor Emergency Room care factors to treat Behavorial Health Patient: Agitated behavioral health patients need a quiet and calming environment to de-escalate during sudden episodes or the ability to be removed from the scene. However, it is challenging to accommodate that due to the emergency rooms' chaotic nature with a high level of noise and hectic environments.

Lack of psychiatric resources in the emergency department leads to inadequate assessments, and most of the time, treatment is provided in the form of medication that helps calm the patients.

An increasing liability pressure on untrained medical providers to treat and ensure safety for behavioral health patients .

Exposed medical gases and equipment

Image Source: http://lawrenceemergencymedicine.com/employment

A Plan to Reduce Emergency Room ‘Boarding’ of Psychiatric Patients. Vidhya Alakeson, Nalini Pande, and Michael Ludwig.

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2 I.

PROBLEMS Emergency Exam Room

Interview With Expert - John Huddy

The conversation with Mr. Huddy revolved specifically around treatment areas and challenges from the design stand point and operational stand point for behavorial health patients in the emergency rooms. He has expressed concerns on various of care areas and provided design considerations to improve patients and staffs' safety and experience particularly for this patient type. The following questions and answers indicated a few design implications to address flexibility and safety in the behavorial health exam room.

Questions Is a typical emergency exam room well-equipped to treat children/adolescent with behavioral health problems?

Chair with windows into two rooms

BH Room

Answer NO. It is not but the staffs have to be able to separate patients visually.

Integrate all the anti-literature stuffs. Many countries in the world are going away from the electronic camera - it means they still have camera to watch patient, but now it does not legally count as a visual sitter. These rooms need to have sitter outside that can be viewing into the room. There should not be any hidden corners nor any where anyone can hide. These rooms need doors that can swing out because people will barricade themselves in & out. Hard ceiling needs to be implemented because patient will try to crawl up into the ceiling and try to escape.

BH Room

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Psychiatric exam room shall comply with 2.1-3.2.2 2.1-3.2.2.1 Space Requirements 1. According to the FGI, behavioral health exam room shall have a minimum of 120 SF with a clear dimension of 10 feet.

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ED clinicians should always have visual into de-escalation rooms or private areas such as toilets and showers to make sure patients cannot harm themselves. It is of utmost critical for staff to see into the room through unbreakable windows with integral blind built-in between behavioral health exam rooms.

3'-0"

12'- 0"

Flexibility has become the main focus for smaller emergency departments to serve various patients' demographics and conditions and the ability to separate or remove aggressive patients from the general public safely within the care areas. Conversely, a typical exam room could be flexed into a tamper-proof or suicide-proof behavioral health exam room by having an automatic rolldown shutter over the medical gases, sink, and supplies. If an electronic rolldown shutter is not feasible for an ED, consider alternative options such as place sinks outside of the room, use portable equipment only, install stainless steel over medical gases and cover electrical outlets inside the room to avoid harms for patients.

3'-0"

2. Clearances:

(a) Provide a clear minimum of 3 feet at each side and the foot of the patient exam table.

(b) when angle the patient exam table, one side of the exam table needs to be closer to the wall than another or against a wall to accommodate the type of patient being served.

120 SF

3'-0"

10'- 0"

• Lower level

•

• Moderate level

• •

Exam rooms, private offices, and concilliation rooms (always supervised) Staff and support areas (not accessible by patients)

Activity spaces, group rooms, and treatment spaces (supervised with good visibility) Dinning rooms and recreation spaces, both indoor and outdoor corridors (always visible) Anna Shaw Children's Institute

• • Highest level

•

Seclusion rooms (where patient acuity poses an increased risk) Patient bedrooms and toilet rooms (areas where patients spend long periods of time out of direct supervision of the staff) Psychiatric emergency department (comprehensive psychiatric emergency program, or CPEP, an area under good supvision but dealing with unpredictable patients under initial evaluation and often under heavy medication)

Image Source: https://mises.org/ wire/pseudo-psychiatrist-diagnosestrump-supporters-mental-disorders

Image Source: https://blog.array-architects.com/kc/revisions-to-the2014-guidelines-for-psychiatric-hospitals

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Safety

Durability

Flexibility

ED Exam Room Behavioral Health Guiding Principles

Dignity

Visibility

Behavioral Health Design Guide: Design Guide for the Built Environment of Behavioral Health Facilities.

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Anti-ligature Hardware considerations: Openings: Doors: In a behavioral health exam room, the door needs to swing outward to ensure patient safety and allow staff to get to the patient quickly.

If the door turns inward, this creates a peril situation where patients might accidentally or intentionally barricade themselves in the room in which further harm might happen to the patient. It would be difficult for staff to enter the room from the other side. This risk can be mitigated by employing various door swing configurations: Windows: Specialized windows with strong adhesive ability that holds broken sharp shards within the frame, so patients cannot use it as weapon to endanger themselves and others. Reference 2018 edition of the FGI Guidelines for additional regulations and requirements on glazing system for behavorial health care areas.

Out-swinging doors

In Swing - Doubleacting doors

Ceiling: Avoid having ceilings lower than nine-foot-high (9'-0") because the patients might be able to reach and tamper with the ceiling and ceiling-mounted devices. Refer to Safety Risk Assessment for each area of the unit to determine the appropriate ceiling height requirements.

In Swing - Wicket doors

Unequal pair of double egress doors

Behavioral Health Design Guide: Design Guide for the Built Environment of Behavioral Health Facilities.

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Anti-ligature Fixtures Anti-ligature Hardware Surface and Materials Wall Base: Special wall base finishes need to be cohesive and seamless throughout. Avoid adjoining gaps between the wall and floor with flexible rubber or vinyl baseboards because behavorial health patients will tamper with it and use it to hide or conceal unwanted items.

Flooring: Consider class A rating flooring materials such as carpet or sheet vinyl. Patterns and color combinations are proven to have negative impact on behavorial health patients because they might appear disturbingly and animatedly that lead to misperceptions by patients.

Anti-microbial sheet carpet has proven to work effectively in the behavorial health facilities due to its properties of having moistureresistant backing and solution-dyed yarn. This material also works incredibly well in controlling ambient noise.

Lighting Fixtures: Lighting fixtures need to be desisgned for patients' safety with tamper-resistant type. A minimum of a quarter inch (1/4") thick polycarbonate lenses is required to be securely fixed in the frame

Medical Gases: Typical behavioral health facilities are not required to have medical gases; however, to create flexibility for behavorial health exam rooms in the emergency department, it is highly reccommended to provde medical gases covers or lockable panels with tamper-resistant screws to ensure patients' safety.

Staff Hand-washing Stations: The FGI Guidelines do not mandate or require hand-washing sinks in the Psychiatric Hospital patient rooms.

with covers and mounted to the ceiling surface with tamperresistant screws.

79 Behavioral Health Design Guide: Design Guide for the Built Environment of Behavioral Health Facilities.

Flexibility There are several approaches in providing safety to behavorial health patients in an exam room: 1. Medical gas cover and other anti-ligature products 2. Particularly in this case study, there is an overhead rolling door installed over the medical gas, counters, sink, and other equipment to provide flexibility for other intended purposes.

Medical Gas Covers

SecuRoom: Modular Services Company

Cookson: MGH Motor Operated Rolling Door

Behavioral Health Design Guide: Design Guide for the Built Environment of Behavioral Childrens Hospital New Orleans, LA

Health Facilities.

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Visbility Visibility is the most critical design consideration in the behavioral health care areas where staff and nurses need simple, clear visuals into the treatment areas and corridors. Installing cameras into these areas can also help the team to enhance their monitoring capability. Consider providing large windows between behavioral health exam rooms with integral blinds for patients' privacy.

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Behavioral Health Design Strategies: Providing a safe and therapeutic ED environment by Anne M. Cox, AIA, ACHA, EDAC

Dignity

Durability Durable products used in the behavorial health care areas are not only highly preferred in order to maintain its intended architectural design but also ensure patients' safety. Breakable products can be very dangerous to the patients because they will use parts and pieces as weapons for selfharms and endanger others.

Behavioral Health Design Strategies: Providing a safe and therapeutic ED environment by Anne M. Cox, AIA, ACHA, EDAC

Behavioral Health Design Guide: Design Guide for the Built Environment of Behavioral Health Facilities.

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2

II.

Design Integration

Typical Emergency Exam Room Nemours' Children Hospital

83

Exam Room (BH)

84

2

II.

Design Integration

Typical Emergency Exam Room Children Medical Center of Dallas

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Secure Holding /Exam Room (BH) (not sure if the SH is used for BH patient)

Stretcher

Roll-down Shutter Sink

86

2

II.

Design Integration

Typical Emergency Exam Room Children Healthcare of Atlanta

140 SF

87

Exam Room (BH)

146 SF

88

2

II.

Design Integration

Typical Emergency Exam Room Children Healthcare of New Orleans

Headwall Elevation

132 SF

89

Hand-washing Elevation

Exam Room (BH)

Headwall Elevation

140 SF

Hand-washing Elevation

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2 I.

PROBLEMS: Why Do We Need De-Escalation Rooms Agitated Behavioral Health Patients Require A Safe Place to De-escalate

Agitated behavioral health patients often present with comorbid mental disorders in the emergency department where immediate action(s) needs to take place to remove patients from the general public and for staff to resume control of the situation. Typical and traditional methods of subduing an agitated patient are to issue medication to avoid further escalation. However, according to Leslie Zun, MD, applying medication too early might negatively affect behavioral health patients in ways that would make them feel dismissive, rejecting, or humiliating. Thus, it could potentially exacerbate more agitation and violence. Noncoercive approaches require experienced and trained practitioners to achieve optimal results in treating and calming down agitated patients. The practitioners need to follow a 3-step approach to ensure safety for themselves and agitated patients: 1. Initiate a verbal engagement with a patient to establish a connection.

2. Establish a collaborative relationship with a patient through conversation.

3. De-escalate the patient out of the agitated state once the patient remains calm.

Verbally engaged patients informing that collaborative relationship are incredibly crucial because it is a successful determining factor for the positive outcomes in evaluating and treating agitated patients. Furthermore, there are some exceptional circumstances where voluntary medication and environment planning proven to be acceptable to treat agitated patients. According to West J. Emerg, the de-escalation process has four (4) primary objectives: (1) Ensure safety for staff, patient, and others in the area; (2) Help the patient to manage his or her emotional distress or regain control of their behavior; (3) Discourage any restraining methodologies because it will worsen the situation; (4) Eliminate any coercive interventions because it will escalate more agitation and violence.

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Supervising Section Editor: Leslie Zun, MD Submission history: Submitted July 29, 2011; Revision received September 6, 2011; Accepted September 26, 2011 Reprints available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2011.9.6864

Psychiatric evaluation is not always available in the emergency department due to a lack of psychiatrists and other resources to treat patients that present with agitated behavioral problems.

To safely and calmly help the agitated patients, diagnostic interventions need to proceed with caution. To quickly and accurately provide symptom relief on the patient's evaluation, it is critical for emergency department physicians to have a rapid assessment and decision-making skills. Taking these preventative approaches such as verbal de-escalation or medication if necessary, it could potentially reinforce positive engagement with the agitated patients.

Thus, it decreases or eliminates the need for seclusion, restraints, and hospital admission; ultimately, it reduces the length of stay for hospitalization. The study has found the direct correlation between LOS and restrained approach.

Emergency department physicians are encouraged to implement non-coercive approaches to de-escalate patients out of their agitated state. Successful outcomes increase overall patients' satisfaction and prevent unnecessary physical confrontation. Keep in mind that physical restraints and/or premature medication could create a misinterpretation that violence is necessary to resolve conflict.

According to the Centers for Medicare and Medicaid Services, one of the critical quality indicators is a low restraint rate because incident

https://www.moneralo.com/adolescent-counseling-importantreasons/ The physical environment also plays an essential role in providing ED physicians and staff safety in managing agitated patients. Arguably, moveable furniture allows for flexible arrangements within the space where the same egress is considered for both patients and staff. Fixed furniture is sometimes preferable by other emergency departments because they are concerned that agitated patients may use moveable furniture as objects for self-harms and endanger others. However, there are design integrations that could accommodate both strategies to achieve an optimal solution. Noise level, wall color, and temperature of the environment should be considered to minimize abrasive, sensory stimulation.

Supervising Section Editor: Leslie Zun, MD Submission history: Submitted July 29, 2011; Revision received September 6, 2011; Accepted September 26, 2011 Reprints available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2011.9.6864

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2 I.

PROBLEMS De-escalation Room

What is a de-escalation room?

Some states call it holding room/safe room.

These rooms smaller 60/80 SF. They’re the one called rubber room – the room with nothing in it. This room can’t be more than 9 feet so the patients can be picking speed to run across the room and throw them into the wall hurt themselves. Old fashion put MH patients into the room and see if they calm down. Some states still allow it.

These rooms are Claustrophobic and look like 1900 mental health.

These rooms are not required. You need to look into state regulation, they may say if you are treating MH patients you need to have safe room. We don’t put them very often at all in unless the state regulated it to be in. We are doing more de-escalation room.

Mr. Huddy mentioned in his article after he toured a large number of emergency departments where he saw behavioral health patients sitting in hallways in chairs among the general patients without any barrier seperations. It was a horrifying scene for any emergency departments. He expressed great concerns for governing authorities and healthcare system leaders to address this problem. Unfortunately, with the increasing behavioral health volumes and limited community resources outside of the ED for patients, it is an on-going burden on the EMS. "...A staff member in an emergency department behavioral health unit was pinned against an exit door by an aggressive patient. Two issues put her in greater danger even after being grabbed by a violent patient and thrown against a door. First, the door to the behavioral health unit had an in‐swinging door, meaning, instead of the door releasing and swinging out for an easier escape, the door hardware was developed for the door to swing in. So, the staff member was pinned against a door that could not open outward. Second, the door was locked electronically and could be unlocked only with the staff member’s badge. But, the electronic pad that could deactivate the lock was on a wall more than 5 feet away – too far to respond to her frantic attempts to get free by waving her badge in front of the sensor. Within days, facility engineers changed the direction of the doors to open outward and started the work of relocating the electronic pad immediately next to the exit."

John Huddy. Design Considerations for a Safer Emergency Department

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Level V-b. Seclusion Rooms and Restraint Room

Typical ED behavioral examination rooms tend to be buried deep within the

emergency department. This leads to problematic situation for some emergency departments when transporting agitated patient with disruptive behavior across multiple care areas before reaching a degsinated behavioral health exam room. One of the approaches that ED could take is to move the behavioral health examination room close to the entry points for easy access. However, if an ED does not have the capability to do so, an alternative option is to have de-escalation rooms near walk-in entrances, triage and initial assessment areas, or EMS entrances. Design recommendation for de-escalation room shall comprise all of the anti-ligature fixtures and locked panels or covers for medical gases should ED decide to convert one of their existing exam rooms into a de-escalation room. Deescalation rooms are closely monitored on the cameras from clinical areas, security desks, or by a sitter outside the room.

Design Considerations for ED Seclusion Room Level V: b. Seclusion Rooms and Restraint Rooms.

Seclusion Rooms and Restraint Rooms are often intertwined in terms of design and construction. The only differentiating factos

are in size and furniture arrangement for each room typology. According to the FGI Guidelines recommendation, Seclusion Rooms' clear floor area shall be a minimum of 60 square feet with no less than 7 feet wide and no greater than 11 feet long. The reason for this is because they do not want the room to be large enough for the patients pick up a running speed at the opposite wall.

Seclusion Roo

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Ceiling needs to be a minimum of 9 feet. Avoid hidden corners or blind spots within the room for the staff to observe the patients from the outside of the room.

items bethe theroom same as Level IV with following A proximity between Seclusion Rooms and nurse station is very important for staff to All be able toshall access when needed.

Doorthe swing exceptions:

direction need to be outward and open directly into an anteroom to separate these activities from other patients and give the patient access

Seclusion Rooms and Restraint Rooms are very similar in de DQG FRQVWUXFWLRQ ZLWK WKH VL]H DQG IXUQLWXUH EHLQJ WKH WZR PD GLႇHUHQWLDWLQJ IHDWXUHV 7KH FGI Guidelines UHTXLUH 6HFOXVL Figure 4. Sitter station near behavioral health room, as printed in Emergency Department Design: A Practical Guide to Planning for the 5RRPV WR EH D PLQLPXP RI VTXDUH IHHW LQ ÀRRU DUHD DQG Future, 2nd Edition 5HVWUDLQW URRPV WR EH D PLQLPXP RI VTXDUH IHHW LQ ÀRRU D 94 7KH\ VKRXOG EH QR OHVV WKDQ IHHW ZLGH DQG QR JUHDWHU WKDQ feet long to avoid providing enough space for a patient to ge

to a toilet wihout entering the corridor.

REFERENCES 1. Read "Emergency Care for Children: Growing Pains" at NAP.edu. (n.d.). Retrieved July 20, 2020, from https://www.nap.edu/read/11655/chapter/4 2. Stewart, C., Spicer, M., & Babl, F. E. (2006). Caring for adolescents with mental health problems: Challenges in the emergency department. Journal of Paediatrics and Child Health, 42(11), 726-730. doi:10.1111/j.1440-1754.2006.00959.x 3. Rogers, S. C., Mulvey, C. H., Divietro, S., & Sturm, J. (2017). Escalating Mental Health Care in Pediatric Emergency Departments. Clinical Pediatrics, 56(5), 488-491. doi:10.1177/0009922816684609 4. Child and youth emergency mental health care: A national problem. (1970, January 01). Retrieved July 20, 2020, from http://www.sprc.org/resources-programs/child-youth-emergency-mental-health-carenational-problem 5. Piatkowski, M., Quan, X., and Taylor, E. (2017). Emergency Department Throughput: Strategies to Improve Efficiency and Effectiveness of Care (Research brief). Concord, CA: The Center for Health Design.

6. Huddy, J., Rapp, M., & Haley, L. L. (2003). Emergency Department Design: A Practical Guide to Planning for the Future. Annals of Emergency Medicine, 41(5), 768-769. doi:10.1016/s0196-0644(03)90207-8 7. Alakeson, V., Pande, N., & Ludwig, M. (2010). A Plan To Reduce Emergency Room ‘Boarding’ Of Psychiatric Patients. Health Affairs, 29(9), 1637-1642. doi:10.1377/hlthaff.2009.0336 8. Guidelines for design and construction of hospitals and outpatient facilities. (2014). Chicago, IL: American Society for Healthcare Engineering.

9. Hunt, J. M., & Sine, D. M. (2014). Design guide for the built environment of behavioral health facilities.

Washington, DC: National Association of Psychiatric Health Systems.

10. Cox, A. M. (n.d.). Behavioral Health Design Strategies: Providing a safe and therapeutic ED environment.

Lecture presented at AIA,ACHA,EDAC. 11. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. (n.d.).

Retrieved July 20, 2020, from http://escholarship.org/uc/uciem_westjem 95

IMAGE SOURCES 1. https://www.npr.org/sections/health-shots/2016/10/02/495775518/a-bygone-era-when-bipartisanshipled-to-health-care-transformation 2. https://www.rubyhospital.com/emergency-services.php 3. https://www.stonybrookchildrens.org/specialties-services/pediatric-specialties/pediatric-emergencydepartment 4. https://swlocums.com/the-social-stigma-of-mental-health-problems/ 5. https://www.ctvnews.ca/health/children-with-mental-illness-facing-long-wait-times-for-diagnosiscare-1.1656699 6. https://www.eypae.com/client/nemours-childrens-health-system/nemours-childrens-hospital 7. https://pagethink.com/v/project-detail/Children-s-Medical-Center-Legacy/59/ 8. https://www.treanorhl.com/design/project/childrens-hospital-colorado-complex 9. https://mises.org/wire/pseudo-psychiatrist-diagnoses-trump-supporters-mental-disorders 10. https://www.bwbr.com/portfolio/umn-masonic-childrens-hospital-child-adolescent-mental-health-program/ 11. https://blog.array-architects.com/kc/revisions-to-the-2014-guidelines-for-psychiatric-hospitals

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