Data-Driven Design Strategies to Address Crowding and Boarding in an Emergency Department: A Discrete-Event Simulation Study

Abstract

Objective: To address prolonged lengths of stay (LOS) in a Level 1 trauma center, we examined the impact of implementing two data-driven strategies with a focus on the physical environment. Background: Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen. Methods: Using ED historical data and expert estimates, we created a discrete-event simulation model. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care) instead of the exam rooms and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of LOS, time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate. Results: The hallway care scenario resulted in significantly lower LOS and exam room time only for EMS patients but when implemented along with the EMS triage scenario, a significantly lower LOS and exam room time was observed for all patients (EMS and walk-in). The combination of two simulated scenarios resulted in significant improvements in other flow metrics as well. Conclusions: Our findings discourage boarding of admitted patients in ED exam rooms. If space limitations require that admitted patients be placed in ED hallways, designers and planners should consider enabling hallway spaces with features recommended in this article. Alternative locations for boarding should be prioritized in or out of the ED. Our findings also encourage establishing a triage area dedicated to EMS patients in the ED.

How the Coronavirus Pandemic Has Changed Healthcare Design

“…Cubicles with curtains between patients, hallway bathrooms shared by multiple patients, small waiting rooms with the thought we would eliminate waiting with improved patient flow, lack of backup space for a surge in admissions, and multistation triage areas simply do not work with pandemics or even major trauma events. Airborne infections do not honor cubicle curtains as an effective barrier; epidemics with bodily fluid transmission (Ebola) require individual toilet areas; and multiple admissions simultaneously and crowding in the ED because of lack of intensive or acute care beds require contingency care settings adjacent to the ED (Valipoor et al, 2021). The design of “soft” spaces that can be rapidly deployed to increase surge capacity and maximizing adaptability of all spaces must be designed into new hospitals.…”

Leveraging discrete event simulation modeling to evaluate design and process improvements of an emergency department

“…The findings from this study displayed that the application of DES provides a cost-effective instrument to assess and inform future design decisions using current process data. Similar to previous studies (Cai & Jia, 2019;Han et al, 2010;Oh et al, 2016;Shim & Kumar, 2010b;Swan et al, 2019;Valipoor et al, 2021b), DES was notably worthwhile in evaluating the impact of multiple processes, design solutions, and proposing optimal scenarios for the ED.…”

“…These techniques include directing lowacuity patients to a co-located outpatient facility, public education, or increasing the working hours of primary care centers (Dolton & Pathania, 2016;Morley et al, 2018;Sharma & Inder, 2011). Other investigations have focused on expediting the patient flow within the ED system (Amarasingham et al, 2010;Bal et al, 2017;Copeland & Gray, 2015;Han et al, 2010;Valipoor et al, 2021a).…”

Toward Building Surge Capacity: Potentially Effective Spatial Configurations in Emergency Departments

“…Integration of isolated waiting room areas for potentially infectious patients who were otherwise stable allowed for a two-tiered approach to patient throughput. In addition, some studies that were published after the initiation of this study suggested other configurations (Franklin et al, 2020; Payne et al, 2020) or found other advantages of the retrieved strategies in the present study (Ahmadpour et al, 2021; Anderson et al, 2020; Martin et al, 2021; Valipoor et al, 2021) that provide insight for the future studies.…”