FACILITY SPACE PLANNING FOR EMERGENCY ......FACILITY SPACE PLANNING FOR EMERGENCY DEPARTMENT USING SIMULATION ANALYSIS Lillian Miller Albert Kahn Associates, Inc. (AKA) is an Architecture

FACILITY SPACE PLANNING FOR EMERGENCY DEPARTMENT

USING SIMULATION ANALYSIS

Lillian Miller

Albert Kahn Associates, Inc. (AKA) is an Architecture/ Engineering firm in Detroit, Michigan. Although the firm has a great deal of history in designing industrial facilities, approximately 32 percent of revenues are generated by the healthcare sector, including 32 Emergency Department projects in recent years. The Health Care Consulting Practice offers a full range of services as evident in Figure 1 – Life Cycle of Facility. Operations Planning was the focus of this study.

Facility

Management

Pre-DesignService

FacilityManagement

Services

Architecture &Engineering

Services

PostConstruction

Services

Real EstateDevelopments

MoveManagement

SiteManagement

Budget &Estimating

Programming& Planning

OperationsPlanning

Interior Design

Program &ConstructionManagement

Commissioning& Start-upOperation &

Maintenance

Asset Management& Financing

OperationsAnalysis

BusinessPlanning

Program

Management

StrategicFacilityPlanning

Facility

Management

Pre-DesignService

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Services

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Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

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Facility

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Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

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Facility

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Pre-DesignService

FacilityManagement

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Services

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Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

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Facility

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Pre-DesignService

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Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

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Facility

Management

Pre-DesignService

FacilityManagement

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Services

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MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Program

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Facility

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Pre-DesignService

FacilityManagement

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Services

PostConstruction

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MoveManagement

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Budget &Estimating


OperationsPlanning

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Figure 1 – Life Cycle of Facility

Foote Hospital is a member of the Foote Health

System in Jackson, Michigan. With 325 beds, the major services include Behavioral Health, Cancer Center, Birthing Center, and Heart and Lung Services. The Foote Hospital Emergency Department is a Level II trauma center for the area. The City of Jackson has another small hospital with an Emergency Department. The surrounding area of Jackson County had a population of about 155 thousand people (based on the U.S. Census Bureau, 1997). The Emergency Department was last renovated in 1983 for a capacity of 34,000. Emergency visits in 2000 were expected to exceed 51,000. Therefore, the space was far under-capacity and had long lengths of stay.

Foote Hospital accepted a proposal by AKA to

perform Operations Planning of the Emergency Department in October 2000. Services included Facility Space Planning, Simulation Analysis, and

Preliminary Design, with the objective of accommodating growth for the next ten years.

Facility Space Planning

Facility Space Planning included the following

tasks: Needs Assessment Operations Analysis Space Needs Layout

Needs Assessment

An administrator led the Project Steering Committee. The Department Task Group included the following members:

Emergency Medical Director Emergency Department Director Nursing Shift Managers Project Operations Analyst, from AKA Project Architectural Planner, from AKA

The task group had additional people conduct

tasks or attend meetings in order to get perspectives from other key roles in the department, such as Emergency Technician, Nurse, and Clerk.

Some members of the task group toured

emergency departments of other facilities and developed a list of features that they liked and disliked. They had a strong desire for the new Emergency design to include certain patient amenities, such as private family waiting and more support space for the staff.

The objective of the Kick-Off Meeting with the

task group was to identify issues with the current layout. The Emergency Department Director announced that an adjacent space to the Emergency Department would be vacated for expansion. However, the group was tasked with determining the space needed for the Emergency Department that would accommodate future growth of visits through ten years, even if it went beyond the allocated expansion area.

The Project Plan and proposed use of simulation analysis was presented to the task group. A simple simulation model of an Emergency Department was shown on a laptop computer (see Figure 2 – Simple Simulation Model), which generated mixed reactions.

Triage ED Bed Phys Sees Pt

Nurse Sees Pt

Order Lab?

Lab Test

Dispo DischargeAdmit

Yes

Order Xray?

Xray

Order Procedure?

Procedure

Order Med?

Medication

No No No No

Yes Yes Yes

Ambulance

Stretcher

Nurse

Doctor

Tech

Wait for

Result

Leave ED

Figure 2 – Simple Simulation Model

A Town Meeting was held with at least one

representative from each position in the department and from each shift. The first half of the meeting was spent identifying problem areas or issues in the current space. A Nominal Group Voting process was used to determine the priority of problem areas.

The second half of the meeting was used to

develop a process flow for the simulation model. Activity times were estimated with an average, minimum, and maximum times by the attending representative of that role.

A review of the current layout for code and

regulation violations was also conducted by AKA. Any violations were to be corrected in the renovation.

Operations Analysis

The volume of emergency visits was collected for several years. Figure 3 shows the Daily Average Emergency Visits. Although a couple years showed a decline, an overall trend of two percent growth emerged. This growth rate was consistent with national trends through 1999. The task group agreed to review future growth through ten years at a growth rate of two percent. However, the Medical Director was concerned about a drastic increase if all patients in Jackson County started going to Foote Hospital Emergency Department, which could happen if the other Jackson hospital downgraded or closed their emergency department.

Daily Average ED Visits

130.0

169.5

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

# Pt

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Daily Avg Lo Month Daily Hi Month Daily Figure 3 – Daily Average Emergency Visits

The following alternative processes of patient

flow were discussed. Low acuity patients assigned to physician

assistant or nurse practitioner in a fast track module during day and evening shift

Patients held for 23-hour observation or patients admitted and unable to get an inpatient bed in a timely manner would go to a Clinical Decision Unit (CDU)

Move an Outpatient Clinic adjacent to the Emergency Department as an alternative place of treatment for non-emergent patients which would result in fewer visits to the Emergency Department

Emergency patients placed in modules based on acuity level: low, medium and high

Faster response of results from Radiology and Laboratory

Increase resources as necessary to prevent bottlenecks, such as number of emergency beds or physicians

Simulation analysis was used to determine the

effects of these alternative processes.

Space Needs Various methods are available to calculate beds

and space needed without simulation analysis. Space benchmarks have been used to determine

bed needs for many years. The article “Data Benchmarks – How Does your Emergency Department Measure Up to These Benchmarks” was in the Cost Reengineering Report in December 1997. The report indicated about 1,100 visits per emergency bed and also suggested total departmental gross square feet to be 550 to 600 per bed.

AKA’s experience with 32 Emergency

Department projects has led to the development of their own benchmarks. Their industry statistics

indicated an average of 2,000 visits per emergency bed for a community hospital and 1,600 visits per bed for a trauma center. AKA also suggested a range of 600 to 900 square feet per emergency bed for departmental gross space estimates. The larger space ratio would allow private rooms for patients and more support space.

An operational assessment was performed to

determine the optimal number of beds for the facility space planning. The calculations require input data of patient visits by type on a peak day, length of stay by type, and bed utilization factor. This calculation is available in “Space Planner Toolkit, Hospital Edition”, by Frank Zilm, AIA and Kent Spreckelmeyer, AIA, 1995, American Society for Healthcare Engineering of the American Hospital Association.

Current peak daily visits were obtained from the

nursing manager. Emergency visits were projected for future years based on established growth rate. Daily peak volumes in the future were based on current proportions. The average length of stay for discharge patients with routine treatment was 2.5 hours and admitted patients with extra holding time was 5.5 hours. The admission rate was 12 percent. The projected number of emergency beds and observation holding beds were then calculated. Table 1 shows the Average and Peak Daily Visits with Calculated Beds.

Table 1 – Average and Peak Daily Visits

With Calculated Beds Scenario Year 1 Year 5 Year 10 Future Daily # 142 156 172 184 Peak # 170 187 206 221 Beds 34 36 39 42

AKA’s architectural planner created a Gaming

Board with colored squares of various sizes that corresponded with the size of rooms, such as 130 square feet for treatment room and 55 square feet for toilet. The task group tried to fit as many room pieces into the department space boundaries as possible based on functional adjacency and allowing for corridors and building fixtures.

Based on this exercise, it was established that the

department space could accommodate the additional beds needed through the next five years. However, the desired support space would not fit in the current department space boundaries. Therefore, space needs were greater than the space allocation. The task group wanted to verify this conclusion and they anticipated that activity time improvements or alternative process

flows would allow for greater patient volume through the space. Simulation analysis was used to support this case.

Simulation

Simulation Analysis was performed to evaluate

how alternative processes would affect bed needs. Simulation included the following tasks:

Data Collection Model Development Outcomes Analysis Bed Needs

Data Collection

A large variety of data was required for a simulation analysis, which was analyzed and reviewed by the task group. The task group assigned additional data collection where necessary.

Arrival rates were obtained from patient Log In

Sheets. Figure 4 shows the Patient Arrival by Hour of Day. The trend of increasing arrival rates started at 8 AM.

Projection of Patient Arrival by Hour & Year

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Figure 4 – Patient Arrival by Hour of Day

These patients tended to be low acuity. This

trend is earlier compared to national trends where arrival rates start to increase at 10 AM or 11 AM. Upon investigation, the majority of these patients did not have a primary physician and were going to the Emergency Department as a clinic.

Resource schedules were obtained from

Assignment Sheets by day of week. The schedule tried to ramp up staff as patient census in beds was increasing and ramp down as census decreased after Midnight. The simulation module was not designed to designate all staff activity. Therefore, a certain percentage of busy time was randomly allocated to staff to make them unavailable. Physicians wanted

the schedule to reflect the last hour of their shift as busy on charting duties.

The development of the process flow began at the

Town Meeting. The task group verified the finer details in the process for collection of activity times and decision points.

Emergency Department staff collected data for

activity times from chart review, observation and self-recording. Activity times were needed for the following tasks:

Triage by Nurse Registration by Clerk Patient Taken to Bed by Tech or Nurse Assessment by Nurse and Physician Order Written by Physician Order Entered by Clerk Specimen Collection by Tech Patient Taken to Radiology by Tech Other Procedure by Tech or Nurse Medication Administration by Nurse Wait Time for Results from Laboratory,

Radiology, and Other Procedures Results Compiled in Chart by Clerk Disposition Decision by Physician Consulting Physician on Phone by Clerk Consult with ED Physician Discharge Tasks by Nurse and Physician Admission Tasks by Nurse, Physician and

Clerk Transfer Tasks by Nurse, Physician and

Clerk The process flow identified a number of decision

points at which patients were directed to various treatment options based on condition. Key data collected included the volume of patients (specific percentages of the total number of patients tracking through the Emergency Department) for each of the options listed below:

Trauma or Triage Acuity Level Fast Track or Routine Treatment Lab Test Radiology Exam Other Procedure Medication Consultation Call Disposition Decision of Discharge,

Admission or Transfer to Other Facility The patient’s attribute of acuity level affected the

route through the process flow and decision points.

Low acuity patient could be assigned to the Fast Track, received fewest orders, and were all discharged.

Moderate acuity patients went to treatment beds, had more orders, and had mostly discharge patients but some admissions.

High acuity patients had some patients bypass Triage and go straight to Trauma while others went to Triage and Treatment beds. High acuity patients also had the highest rate of orders and admission. Some high acuity patients were transferred out to another facility.

Model Development

The simulation model was made using a flowchart based simulation language, Process Model . The initial model was developed using current existing conditions. Not all conditions were inserted in the model, because real-life has too many variations.

The outcomes of the initial model gave patient

length of stay values that were consistent with actual cases. Based on this verification, alternative models were designed to determine their effect on the following scenarios:

Increase patient volume for anticipated growth rate and the elimination of a second local emergency department

Faster process times from Radiology, Laboratory, and going to an inpatient bed

Patient flow with alternative treatment areas: Emergency, Outpatient Clinic and Clinical Decision Unit

Models were run with a higher number of beds

for increasing patient volumes. If the beds were not sufficient, some patients would encounter a bottleneck and not enter a bed within two hours of arrival. In real-life, patients would walk out if they did not get a bed within this period of time. Therefore, time into bed and overall length of stay were the primary measured outcomes for each scenario.

Outcome Statistics

Outcomes statistics were designed to provide measures for the task group to compare with real-life conditions, such as:

Beds Filled by Hour of Day Patient Census by Hour of Day Overall Length of Stay by Acuity Level Times between strategic points of interest:

Arrival, In ED bed, See physician, Enter orders, Disposition decision, and Leave ED

The outcome analysis for the different yearly volume and scenarios were based on the 90th percentile of beds filled, instead of the maximum or worst case of beds filled. This is a more economical approach for the design. Management intervention usually presents worst-case conditions that the model cannot replicate.

Bed Needs

The number of beds filled in the 90th percentile by year and scenario are presented as Emergency Beds Needed in Table 2. The bed needs are smaller than the original projections from the length of stay calculations.

The Fast Results scenario projects fewer beds

needed than the No Change because length of stay is shorter. The scenario with three treatment areas (ED, CDU and Clinic) has slight improvement in Year 5. These results could be improved by encouraging a greater volume of low acuity patients to use the Clinic instead of Fast Track in the ED. Fast results in the ED with CDU and Clinic have similar bed needs as just the ED alone with Fast Results.

Table 2 – Emergency Beds Needed

Scenario Year 1 Year 5 Year 10 Future No Change 29 32 35 39 Fast Results 27 28 32 35 ED, CDU & Clinic 29 31 35 40

Fast Results in ED, CDU & Clinic

27 30 32 35

Other Outcomes

Although the simulation was not a full staffing study, it provided outcomes that were beneficial to staffing and scheduling.

Staffing schedule of Emergency physicians was a bottleneck in patient throughput

Utilization of physician assistants or nurse practitioner for ED Fast Track was too low for cost effectiveness at certain times of day

Design

Preliminary Design included the following tasks: Space Program Cost Estimate Alternative Designs Schedule

Space Program A space program is a listing of all rooms by

quantity and space allocation. The sum of space allocations is the net department gross square footage. A factor is added for building contingencies, such as walls, stairs, and hallways. The result is the total departmental gross square feet.

Space programs were developed for alternative

designs.

Alternative Designs Alternative designs were made of the Emergency

Department. Scenario A was a Do Nothing alternative. Scenario B has more beds but not any

additional support space. The renovation design is kept within the existing space boundaries of the Emergency Department and adjoining space for expansion.

Scenario C has more beds and some of the additional support space. The design requires renovation of existing space and new construction beyond the boundaries.

Scenario D has more beds and all of the desired additional support space. The design requires renovation of existing space and more new construction beyond the boundaries.

Scenario E has more beds and all of the desired additional support space. The design requires renovation of existing space and new construction beyond the boundaries. The design also has some support space placed on the second level, above Emergency.

Cost Estimate

The cost estimate was based on a standard cost per square foot for renovation or construction. Contingency, Permits, Architectural/ Engineering Fees and Furniture/ Furnishings/ Equipment allocations were initially given as a percentage of renovation and construction cost. More accurate costs were collected as the project progressed and specific decisions were made.

Schedule

A time schedule was made with major decision points and tasks, which included:

Approvals Pre-Design Schematic Drawing Design Development Construction Documents Bid and Award Construction

The project had two phases: renovation of

existing space and new construction. The schedule was regularly reviewed to ascertain if the project was on time.

Conclusion

Phase One Emergency renovation is currently

under construction, which increases beds to existing boundaries. The Foote Hospital Board has approved Phase Two Emergency renovation, which allows expansion of the building on first and second floors. Due to the closure of the other local hospital, management is closely monitoring emergency visit volume to determine how quickly additional beds will be needed.

The next step could be to perform another

simulation analysis that focuses on staffing and scheduling. Outcomes analysis could evaluate staff utilization as it relates to the new design, patient volume, staff schedule and assignment by nursing station.

Biographical Sketch

Lillian Miller is a consultant at Albert Kahn

Associates, Inc., in Detroit, Michigan. She has a bachelor of science in industrial engineering from Wayne State University, in Detroit and a master of science in industrial and systems engineering from The University of Michigan-Dearborn. She presently performs master facility space planning, simulation analysis and operations analysis for the Health Care Consulting Practice group. Prior to joining AKA four years ago, she worked for 18 years at various hospitals in metropolitan Detroit as a senior management engineer and operations analyst. She is a member of SHS/IIE, and Michigan Simulation Users Group. She has previously presented and published at HIMSS and at a simulation vendor users’ group.


For Emergency Department

Using Simulation Analysis

SHS ConferenceFebruary 2004

Lillian Miller

Agenda

• Foote Hospital• Emergency Department• Facility Space Planning• Simulation• Design

Albert Kahn Associates, Inc.

• Architecture and Engineering firm

• 100+ Years Experience• Quality Commitment• Strategic Facility

Planning

Albert Kahn Associates, Inc. Life Cycle of Facility

Faci

lity

Man

agem

ent

Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

Services


MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

am

Manag

emen

t


Faci

lity

Man

agem

ent

Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

Services


MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

am

Manag

emen

t


Faci

lity

Man

agem

ent

Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

Services


MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

am

Manag

emen

t


Faci

lity

Man

agem

ent

Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

Services


MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

am

Manag

emen

t

Faci

lity

Man

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Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

Services


MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

am

Manag

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Faci

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Man

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Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

Services


MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

am

Manag

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Faci

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Man

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Pre-DesignService

FacilityManagement

Services


Services

PostConstruction

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MoveManagement

SiteManagement

Budget &Estimating


OperationsPlanning

Interior Design



Maintenance


OperationsAnalysis

BusinessPlanning

Progr

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Foote Hospital

• Health System• Jackson, Michigan• 325 beds• Major Services:

– Behavioral Health– Cancer Center– Birthing Center– Heart and Lung Services

Emergency Department

• Two EDs in Area• Level II Trauma• Built in 1983• 20 ED Beds• 34,000 Visits

Capacity• 50,388 Visits in

2000


• Needs Assessment

• Operations Analysis

• Space Needs• Layout

Simulation

• Data Collection• Model

Development• Outcomes

Analysis• Bed Needs

Triage ED Bed Phys Sees Pt

Nurse Sees Pt

Order Lab?

Lab Test

Dispo DischargeAdmit

Yes

Order Xray?

Xray

Order Procedure?

Procedure

Order Med?

Medication

No No No No

Yes Yes Yes

Ambulance

Stretcher

Nurse

Doctor

Tech

Wait for

Result

Leave ED

Design

• Space Program• Cost Estimate• Alternative Designs• Future Design• Schedule

Facility Space PlanningNeeds Assessment

• Team Development• ED Tours• Available Space• Town Meeting• Codes and Regulations

Facility Space PlanningOperations Analysis

Obtainmarket study

Gather data

Tour facilityAssessment

Determinecurrentcapacity

Determinespace needs

Facility Planning

Interview keypersonnel

130.0

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Facility Space PlanningSpace Needs

• Average and Peak Volume

• Key Rooms and Dept Space

• Trends and Benchmark

• Alternative Processes

Facility Space PlanningLayout

• Gaming Board• Initial Layouts• Beds• Support Space

SimulationAnalysis

ProblemIdentification

ModelDevelopment

Data Collection& Analysis

ModelValidation &Verification

ScenarioDevelopment

ResultsAnalysis

Presentation

ProcessDefinition

SimulationData Collection

• Arrival Rates• Resource

Schedule• Patient Types• Activity Times• Decision

Points

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SimulationModel Development

RN Triage & Quick Reg

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RN EvaluateMD DO

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Clk Enter Orders

Clk Pull Records

Clk Call Ancillary Tech Lab Tech X-ray RN/Tech

ProcedureRN GiveMed IV

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Clk Call Consult

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Clk Call for Transfer RN TransferMD DO

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Admit RN AdmitMD DO Admit

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ImmedBed

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Terminal

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NP PA Chart

MD2 chart1

MD2 chart2

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SimulationOutcomes Analysis

• Patients in ED• Beds Filled• Length of Stay• Interim Times• Bottlenecks• Desired

SimulationBed Needs

40353129ED withCDU & Clinic

35322827Faster Process

39353229Routine Process

Far FutureYear 10Year 5Year 1Scenario

• By Visit Growth• By Process Scenario

DesignSpace Program

• Room Types• Room Quantity• Room Area• Listing• Net Sq Ft• Building Factor• Dept Gross Sq Ft

Room or Space

Category 1 (High Acuity Level)Exam/Treatment RoomTrauma RoomIsolation/Treatment RoomIsolation Ante RoomCardiac RoomNurse Station Pyxis Machine AlcovePatient ToiletStaff ToiletPneumatic Tube Station AlcoveStretcher AlcoveEquipment AlcoveCrash Cart Alcove

Subtotal:

Qty. Area Total Net Sq. Ft.

4 230 9204 250 1,0002 230 4600 60 01 250 2501 400 4003 25 752 55 1101 55 551 15 152 25 502 115 2301 15 15

3,580

Proposed

DesignCost Estimate

• Renovation• New Construction• Permits and Lab Testing Fees• Furniture, Furnishings, and Equipment• Architectural/Engineering Fees• Contingencies• Escalation

DesignAlternative Designs

A. Do NothingB. Minimal RenovationC. Expand HorizontalD. Further Expand HorizontalE. Expand Horizontal and Vertical

OPTION C OPTION D & EOPTION A & B

EXISTING HOSPITAL

WALK - IN

ENTRY

MAI N LOBBY

SECURE P ATIENT ENTRY

EMS ENTRY

M AIN LOBBY

EMS ENTRY

WALK - IN

ENTRY

EXIST ING CANOPY

EXISTING HOSPITAL

M AIN LOBBY

EXIST ING CANOPY

EXISTING HOSPITAL

WALK - IN

ENTRY

M AIN LOBBY

SECURE P ATI ENT ENTRY

EMS ENTRY

OPTION C OPTION D & EOPTION A & B

EXISTING HOSPITAL

WALK - IN

ENTRY

MAI N LOBBY

SECURE P ATIENT ENTRY

EMS ENTRY

M AIN LOBBY

EMS ENTRY

WALK - IN

ENTRY

EXIST ING CANOPY

EXISTING HOSPITAL

M AIN LOBBY

EXIST ING CANOPY

EXISTING HOSPITAL

WALK - IN

ENTRY

M AIN LOBBY

SECURE P ATI ENT ENTRY

EMS ENTRY

DesignFuture Design

DesignSchedule

• Phases I and II• Approvals• Pre-design• Schematic Drawing• Design Development• Construction Documents• Bid & Award• Construction

Project Statusand

Questions