BENEFITS OF AN IDEAL EMERGENCY UNIT

                                                                                                                                                                 

UGWUBUJO CALEB (RN, DAEN,)

Department of Accident and Emergency

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When a man decides to build a house, he definitely needs a good plan from a good architect who will give him a nice design. Also a well constructed house gives its owner joy and an inner peace of mind. The architect of the universe, God could rejoice after creating our beautiful universe because it was well planned and designed. “After that, God saw everything he has made and look! It was very good” (Gen.1:31) A house with a good plan and design stands the test of time. This is also true of the Accident and Emergency (A$E) unit of every hospital. Proper care must be placed into consideration before designing and constructing an ideal accident and emergency unit which will meet the demands of every patient admitted into the unit. This involves adequate preparation and planning.

The A&E department is the avenue through which a significant proportion of patient enters the hospital. As well as being a route for admission, the accident and emergency unit will manage approximately 80% of its patient without admission. A thriving, well designed, forward-looking and innovative A&E unit is the key to the success of the hospital. (Sarah, 2001).

A well architectural design of the accident and emergency unit is important. Report shows that “approximately 18 million people each year seek attention in the accident and emergency unit in the united kingdom”. (National Audit Office, 2004 a,b). Accident and emergency attendance and admission continue to rise every year, as such a properly planned and designed A& E is important. “Most of the increase in emergency admission is accounted for, by acute ischemic heart disease and respiratory illness” (Edwards & Werneke, 2002)

The facility design of the hospital, with its equipment and technology, has not historically considered the impact on the quality and safety of patients, yet billions of dollars are and will be invested annually in health care facilities. This provides a unique opportunity to use current and emerging evidence to improve the physical environment in which nurses and other caregivers work, and thus improve both nurse and patients outcomes.

The internal design of an A&E department is crucial to its safe and cost effective medical, nursing and administrative management. “The physical relationship of the A&E department to the rest of the hospital is critically important for the effective management of  patients, particularly those with life threatening conditions”(David,Timothy, 2006).The planners of medical facilities must consider mans innermost needs, the aspirations of people, social structures, values and altitudes towards human life. The hospital is referred to these days as perhaps the most complex of contemporary social institutions. If we are to plan effectively to satisfy mans needs, we must face up to the complexity of the task. If not for any other reason, good health care plays an important role in stimulating economic development. This is true because a far cited sub-units of the hospital causes delay and a big threat to the life of patients in emergency situations. The A&E department should be adjacent, or close to other critical care areas as well as radiology and CT (computed tomography) scanning, all being on a ground floor (same floor) with the ambulance delivery point immediately adjacent.

According to Kelvin (2003), the essential task of a hospital is to find conditions under which humans can work together at their best in the service of others who needs help. A well planned and designed A&E unit, no doubt enhances patients care. Patients with major injuries are transported directly to the A&E resuscitation room, so that after initial resuscitation, CT scanning can be performed, before transfer to the theatre, intensive care unit or the ward. “The proximity of the critical care areas is not only beneficial to the patient but also allows cooperation and collaboration between clinicians and nursing staff, both clinically and educationally which further enhances patient’s care”.                                       

 Cognitive psychologists have identified the physical environment as having a significant impact on safety and human performance. Understanding “the interrelationships between humans, the tools they use, and the environment in which they live and work” is basic to any study of the design a health care facility and its effect on the performance of the nurses and other caregivers who interface with the facility and its fixed (e.g., oxygen and suctioning ports on the wall of a patients room) and moveable (e.g., a patient’ bed) equipment and technology. John (2005) opined that “Humans do not always behave clumsily and humans do not always err, but they are more likely to do so when they work in a badly conceived and designed health care setting.”

How the hospital sees the role and obligations of its Emergency department, determines the quality of care it renders to its citizens.

IDEAL ACCIDENT AND EMERGENCY UNIT

The lives of victims of casualties such as in road traffic accident, disaster and other injuries are threatened by poor accident and emergency facilities. Every patient that manages to get himself transferred to the hospital believes that the hospital is well equipped with facilities and personnel. The patient has the right to receive the best form of treatment under a favorable environment. The problem is that most patient come to the emergency department and develops most complications which could have been preventable, if appropriate structures were put in place. The researcher is concerned to find out the impact of a well designed Accident and Emergency unit on the patients admitted in the unit. He is not ignorant about the bad economic condition of the Nation, but something needs to be done especially when A&E units are to be designed. The next victim that may die or develop complications from a poorly designed A&E may be anyone’s “beloved”. That is why he took his time to look at what other authors have written on “the impact of a well designed A&E on the quality of patient’ care”.

The emergency department is a core clinical unit of a hospital and the experience of patients attending the emergency department significantly influences patient satisfaction and the public image of the hospital. Its function is to receive, triage, stabilize and provide emergency management to patients who present with a wide variety of critical, urgent and semi urgent medical conditions. The emergency department also provides for the reception and management of disaster patients as part of its role within the disaster plan of each region. The emergency department should be located in an area of the hospital where it is easily accessible to all. It should be on the level ground floor and has entrance from within and outside the hospital. Adequate walking access for ambulatory patients is needed as well as sufficient parking space for ambulance and automobiles. Information from Hospital Building Note (2001), states that “Accident and Emergency Department is a unit concerned with the reception of in and outpatient treatment, including follow up treatment of accident victims and patients. It also deals with immediate resuscitative care prior to admission”.  A well-designed patient room has also been found to be a factor in improving care delivery processes for clinicians by providing more clinician satisfaction, decreasing length of stay and facilitating continuity of care during a hospital stay.

According to Kelvin (2003) standard Accident and Emergency Room has been defined as “a facility that will normally serve a population of not less than 150,000 in other to justify a 24hours serve and a high level of staffing”. An emergency department should be sited in hospitals with existing supportive services like central Sterilizing and supply department (CSSD), intensive care unit, radiological Department, emergency laboratory etc. “The sites of all the types of health care unit should be well chosen to allow for expansion which is one of the major requirement for building that will have to meet the changing demands throughout their life span”.(Sarah,2001). The A&E department needs a well designed plan which will make way for adjustment when the need arises. A well designed A&E contributes to recovery of the patient. “The physical relationship of the A&E department to the rest of the hospital is critically important for the effective management of patients, particularly those with life threatening conditions” (David etal, 2006).

In a review of the literature by Henriksen and colleagues 2001, the following design elements were identified as critical in ensuring patient safety and quality care in the emergency unit, based on the five quality aims of the Institute of Medicine’s report, Crossing the Quality Chasm: A New Health System for the 21st Century: They include,

• Safety which encompasses-

Ø  Applying the design and improving the availability of assistive devices to avert patient falls

Ø  Using ventilation and filtration systems to control and prevent the spread of infections

Ø  Using surfaces that can be easily decontaminated

• Effectiveness, including

Ø  use of lighting to enable visual performance

Ø  Use of natural lighting

Ø  Controlling the effects of noise

. Efficiency, including

Ø  Standardizing room layout, location of supplies and medical equipment

Ø  Minimizing potential safety threats and improving patient satisfaction by minimizing patient transfers with variable-acuity rooms

• Timeliness, by

Ø  Ensuring rapid response to patient’ needs

Ø  Eliminating inefficiencies in the processes of care delivery

Ø  Facilitating the clinical work of nurses.

• Equity, by

Ø  Ensuring the size, layout, and functions of the structure meet the diverse care needs of patients.

Most A&E departments have evolved within existing hospital and there are relatively few examples of purpose –built facilities. Furthermore, the A&E department is continuously changing. There is therefore no ideal A&E department. “In general terms however, various requirements must be satisfied in order to provide the best services. (Andrew, 2009)

Ø  Easy access for the ambulances and the general public.

Ø  Distinct, ideally separate, access for the ambulance and ambulant cases.

Ø  A close physical relationship between the accident and emergency unit (particularly the resuscitation room) and other critical care areas.

Ø  A clear distinction between major and minor sides of the accident and emergency unit, arranged so that the nursing and medical staff can move freely between the areas.

Ø  The resuscitation room must be close to the ambulance entrance, the route from the resuscitation room to the CT scanning and other areas should not pass through the minor treatment or waiting areas.

Ø  The nursing station should be positioned in a place where the nurse can see the patient and vice versa.

Ø  Minor cubicles must be easily supervised.

Ø  The patient waiting areas should be welcoming and open-plan, allowing easy surveillance by the nursing and security staff.

Ø  There should be readily identifiable nursing triage areas for the initial assessment of cases of a minor side.

Ø  There should be a clear designated reception area, affording adequate protection for staff and space for the storage of A&E record.

Ø  There must be fully equipped suture and fracture Manipulation Theater.

Ø  There must be adequate offices for the senior medical and nursing staff, as well as for a departmental secretary.

Ø  The department must include a distressed / patient interview room with telephone.

Ø  There must be a rest room for the A&E staff.

Ø  There must be a seminar room for A&E staff teaching and meetings”. (Andrew, 2009)

Design Goals

Lincoln W.C (2003) opined that the design of a hospital emergency department must include goals of efficiency, cost-effectiveness, flexibility, expandability, cleanliness and accessibility. The department must also control patient circulation to enhance patient safety and security.

Site Selection

Decisions regarding site location have a major influence on the eventual cost and operational efficiency of the department and should be made in conjunction with emergency department staff. The site of the emergency department should, as much as possible, maximize the choices of layout. In particular, sites of access points must be carefully considered. (Nelson V. 2005)

Bed Spacing

In the Acute Treatment area there should be at least 2.4 metres of clear floor space between beds. The minimum length should be 3 metres. (Nelson V. 2005)

Patient Call Facilities

All patient care areas including toilets and bathrooms require individual patient call facilities.

Emergency department bed spaces should have call buttons that can be easily reached by a patient on the emergency department trolley.

Staff Room

At least one room should be provided within the department to enable staff that is distressed during working hour to have some rest during break periods. Food and drink should be able to be prepared and appropriate table and seating arrangements should be provided. It should be located away from patient care areas and have access to natural lighting and appropriate floor and wall coverings. The staff room should be based upon the number of staff working at any one time and their anticipated needs.

Distressed Relatives' Room

All emergency departments should have a distressed relative’s room. Departments with more than 25,000 yearly attendances should have 2 rooms for the relatives of seriously ill or deceased patients. They should be acoustically insulated and have access to beverage making facilities, a toilet and telephones. “A single room treatment area should be in close proximity to these rooms and should be of a size appropriate to local cultural practices. In departments with less than 25,000 yearly attendances a single distressed relatives' room is usually sufficient.”

(Christie, 2005)

Emergency Power

Emergency power must be available to all lights and in the Resuscitation and Acute Treatment/Observation areas of the department. Emergency lighting should be available in all other areas. All computer terminals should have access to emergency power. In the event of a total power failure, sufficient space and power points should be available to enable a backup system of lighting to be stored and maintained.

INTERIOR DESIGN OF THE UNIT

The design of an emergency room that allows flexibility and can be adapted to meet changing acuity and care needs of patients has been found in some institutions to contribute to decreased medication errors and falls. The interior design of the Accident and Emergency unit is an important area of providing an efficient care. Many design and construction concept can be applied to achieve a scalable (e.g., the ability to expand or remodel easily) or adaptable (e.g. the ability to adapt to space for different or evolving services) health care facility. “The interior design of the Accident and Emergency unit is an important area of providing an efficient care. A treatment room must be available at all time for the immediate care of the patient who is in an acute health condition. The resuscitation bay should be accessible to the ambulance lobby, wards in the main hospital and adjoining to other important sector of the unit.” (Huddy, J. 2002)  

Modern A&E department should not be designed with at least three bays in the resuscitation room and these must be equipped to enable all forms of resuscitation including pediatrics. Basic equipment in each bay will include: a trolley with head down facility, a trolley mounted monitor/defibrillator, airway and ventilation equipment. Several A&E department have found the provision of an overhead gantry x-ray facility to be extremely valuable for providing high quality x –ray without disrupting the resuscitation process. (Nelson V. 2005).

The emergency room should be located in an area of the hospital where it is easily accessible to all. It should be on the level ground floor and has entrance from within and outside the hospital. Adequate walking access for ambulatory patients is needed as well as sufficient parking space for the ambulance and automobile. Abraham describe the design of Accident and Emergency unit this way, “A treatment room must be available at all time for the immediate care of the patients who is in an acute state, the resuscitation bay should be accessible to the ambulance lobby and wards in the main hospital. It measures about 250sq ft, equipped with sink and elbow operating taps, an x-ray viewing box, patient’s trolley and other equipments. The room should also have pipe oxygen and Nitrous oxide, suction vacuum points as well as controlled drug cabinet”(Christie,2005). The main treatment area should be large and have partitioned      cubicles.

The security room should be very close to the emergency room for the control of the unruly and/ unmanaged patient or acutely disturbed patient to ensure the maintenance of safety and dignity of the patient, staff and other emergency patients.

The reception area in A&E wards is often a flash point for crimes, which range from violence and aggressive incidents, to abuse of patients and staff. Vandalism and theft are also particularly prevalent within A&E. The entrance to A&E should have an access control system fitted for use at nighttime. Experience shows that fights often continue in A&E wards after the initial fight resulted in someone going to hospital. Kelvin, 2003 stated that “When night security staff grants entry, it has proved very effective in promoting further trouble within the hospital”.

A secluded quiet room is necessary to provide privacy to relatives and friends of those who are grieving. It provides an enabling condition for the nurses, doctors or the clergy men to keep the family of the injured patient informed or to console them after the death of their relatives.

Kelvin, (2003) wrote that special rooms are made available for the examination of special cases such as orthorhinolaryngology, obstetrics and Gynecology and dental cases. Anderson summarized the basic physical components of the Emergency Department as follows “well illuminated entrance from the triage point to the resuscitation room, with an expandable structure able to meet the needs of the acutely ill and injured patient.”)

Space determinants revolve around the major functional areas of the department. These may be divided broadly into:

• Ambulance and ambulatory entrances

• Reception/Triage/Waiting area

• Administrative area

• Resuscitation area

• Acute Treatment area (of non-ambulant patients)

• Consultation area/fast track area (for ambulant patients)

• Staff workstations

• Specialty areas example

 Paediatric areas, Distressed relatives/interview room, Procedure room(s), Plaster room, Pharmacy/drug preparation, Ophthalmology/ENT, Mental Health Assessment, Isolation room(s),Decontamination areas, Teaching areas, Tutorial room, Support services, Storage, Clean and dirty utility, Shower/bathroom/toilets, Staff rooms, Linen trolley bay, Mobile equipment bay, Mobile X-Ray equipment bay, Cleaner's room, Lounge/beverage preparation area, Emergency services officer/lounge, Offices and administration area, Diagnostic areas e.g. Medical imaging unit/ laboratory area (optional), Emergency department short stay/observation ward (optional), Circulation space.

IMPACT OF ENVIRONMENT ON THE CARE AND RECOVERY OF PATIENTS

Patient’s physical environment can contribute to their quick recovery and also affect the type of care the nurses’ render to the patient. This is in harmony with Florence Nightingale’ theory, often considered the first nurse theorist; she defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery”. (Erbs, 2008). The importance of being able to see patients is inherent to nursing care, a concept that was recognized early by Florence Nightingale, who advocated the design of open, long hospital wards to see all patients. The design of units and patient rooms should allow caregivers to be in visual proximity to patients; a pod structure can allow close proximity and enable quality care by improving efficiency and effectiveness. Therefore the architectural design of the Emergency department affects the patients’ health.

There have been five other significant reviews of the literature relating to the physical environment and patient outcomes. Nelson and colleagues identified the need to reduce noise pollution and enhance factors that can shorten a patient’s length of stay (e.g., natural lighting, care in new/remodeled units, and access to music and views of nature); according to their study, patients can benefit from the skillful utilization of music and artwork. (Huddy,2002). Ulrich and colleagues found research that demonstrated that the design of a hospital can significantly improve patient safety by decreasing health care associated infections and medical errors. They also found that “facility design” can have a direct impact on patient and staff satisfaction, a patient’s stress experience, and organization performance metrics. “Hospital design, particularly when well planned, can enhance patient safety and create environments that are healthier for patients, families, and staff by preventing injury from falls, infections, and medical errors; minimizing environmental stressors associated with noise and inefficient room and unit layout”(Nelson, 2005).Among the design features that will contribute to the reduction of operative/postoperative complications and infection control are spacious cubicles, a sink at the entrance to the emergency rooms, which you must pass in either ( to encourage hand washing); internal window blinds(to reduce accumulation of dust); a house wide air filtration system that includes central HEPA filters; ultraviolet lights in the clinical areas; airflow systems in which clean air passes the patient and is recycled and filtered again; and a radiant heat panel above or below every patient window to eliminate condensation. These are all features that minimize infection. Air supply and return grates that need cleaning have been upgraded to stainless steel so cleaning is more effective. However the most important point about design is the location of the sink, since the hand washing is the number one preventive measure for hospital- acquired infections. Therefore not only does a well planned A&E unit benefit the patient but it also affects the medical staff as well.

THE ROLE OF NURSES IN THE DESIGN OF THE UNIT

Nurses are involved in the design and construction of the accident and emergency unit which will meet the needs of the patient. In a 2004 report commissioned by the Agency for Healthcare Research and Quality, The Hospital Built Environment: What Role Might Funders of Health Services Research Play, (Lincon2003) the following gaps in the literature were identified: What are the effects of the built environment on the quality of communication and information sharing between clinicians, patients, and families? What is the relationship between environmental factors and the working conditions for clinicians? What are the best mechanisms and designs for facilitating effective hand washing? What is the effect of elements in the building environment that reduce staff fatigue, distractions, and stress? And what is the role of built environment in decreasing infection rates across patient types? Nurses can have a critical role in addressing these and other research gaps. In this relatively new and exciting area of research in health care, nurses need to and should be actively involved throughout the research and quality improvement processes involving the design of the work environment space.

Nurses need to be involved and have an active role in evaluating, planning, and testing the layout of patient units and patient rooms to ensure a healing and comfortable environment for both patients and clinicians. Lessons learned should be shared with others to enable improvements across the country, not just on one facility. Current laws and regulations will need to be modified to support new hospital standards and building codes. Nurses will need to be involved in planning for transitions and assessing environmental and structural features that improve the quality of care afforded patient. The importance of nursing leadership in the whole process of the architectural design cannot be overstated. Without the commitment, knowledge and perseverance of the nursing leadership in the design of the accident and emergency unit, the unit may end up not meeting the needs of the patients. Denis(2004) opined that the hospital management needs to involve nurses in the facility design process because of nursing’s essential role in caring for patients, and because nurses interface with all the systems of a hospital at the “sharp end,” including equipment, technology, facilities, and patients—more so than any other care provider in a hospital. Not discounting the role of physicians, other clinicians, and health care staff, nurses provide care 24 hours a day, 7 days a week. And such, nurses providing care are most aware of the best way to design a patient room. For example to design room to minimize the potential for human error and harm to patients.

EFFECT OF AN ADEQUATE A&E DESIGN ON         PATIENT.

According to David (2006), the physical design and floor of the Accident and emergency unit must be such that it promotes and facilitates the smooth running of the unit. “The emergency unit should ensure adequate circulation and space for the patient, staff and equipment, promote orderliness and discourage purposeless movement” (David, 2006). There are several examples of the impact of evidence-based design in acute care settings. Research in the early 1970s found that unit efficiency was determined by the design of the unit, not room size or occupancy. Several researches conducted since then have continued to emphasize the importance of designs. One study began with a systematic evaluation of best practices in 19 Accident and Emergency units (A&E), built between 1993 and 2003, that received a design award from the Society of Critical Care Medicine, the American Association of Critical Care Nurses, and the American Institute of Architects. The reviewer found positive characteristics of the A&E to include cubicles for improved patient care, safety, privacy, and comfort; bed locations that provided easy access for clinicians; hand-washing sinks and waste disposal in the patient bed side and use of natural lighting.

The emergency unit should also ensure safety at work for all, promote and reinforce learning for the nursing and medical students. The ambulance receiving area must be large enough to allow for the entry and exit of ambulance and ambulant patients without delay. An overhead protection is advisable to shield the patient from all types of weather conditions. “High rates of postoperative infections, especially related to wounds among patients ages 65 to 70, have been found to be associated with facilities that were overcrowded, had no isolation facilities, and had deficient ventilation systems”(John,2005). Without effective ventilation systems, efforts to avoid ventilator-associated pneumonia—such as patient positioning and airway management have a greater potential of not being as beneficial as it should be.

                                                                         

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 Reference

Andrew Swain, etal (2009) Cambridge textbook of accident and emergency medicine. Press syndicate of the university of Cambridge United Kingdom

Christie, C. (2005). Waiting for Health – Strategies and Evidence for Emergency Department                  waiting Areas, Lippincott and Wilkins Philadelphia.

David T.K (2006) Health by design – designing a health promoting emergency department,5^th     ed. Churchill Livingstone New York.

Denis H. (2004) Secured by Design - Hospitals, A Perfect Guild. Bailliere Tindall, New York.

Edwards & werneke (2002), The built environment as a component of quality care:

 understanding and including the patient’s perspective. , Lippincott and Wilkins Philadelphia

Huddy, J. (2002) Emergency Department Design - A Practical Guide to Planning for the Future,         Churchill Livingstone New York.