Work smarter, not harder

Dr Sue Robinson outlines the theory behind Smart EDs, their benefits and how to introduce them

An Emergency Department (ED) is the only easily accessible ‘open all hours’ point in the NHS, available 24 hours a day, seven days a week, 365 days a year.

The combination of a perceived lack of alternatives, outdated or inefficient processes, increased attendance numbers, more elderly patients with complex needs, more sophisticated and accessible diagnostics, workforce gaps and constraints, a lack of hospital inpatient and social care capacity has resulted in serious and persistent crowding within EDs.

Whether brought by ambulance, referred by community services or self-presenting, the population needs access to an explanation of their problems and treatment options, delivered in facilities designed to provide the delivery of modern emergency medicine, efficient processes and the highest levels of safety; by staff who have the time, space and empathy to focus on their patient’s needs.

These needs are not being met by traditional NHS hospital ED design.

The Care Quality Commission reports that in July 2023, more than half a million patients waited more than four hours to be either admitted, transferred or discharged, and almost 24,000 people waited over 12 hours from the decision to admit to actually being admitted to hospital.¹

All too often, processes and resources focused on elective care compete with those of urgent and emergency cases, which are often seen as an interruption to business as usual and a threat to the effective operation of the hospital and elective care. But the NHS exists to treat both elective and emergency patients and must evolve to improve its performance in both.

One individual leading the charge when it comes to demanding better of our ED estate is Dr Sue Robinson, a Consultant in Emergency Medicine at Cambridge University Hospitals NHS Foundation Trust and Regional Clinical Advisor for Emergency Medicine for NHS England. Sue is also the Royal College of Emergency Medicine (RCEM) advisor on the planning and design of new-build EDs. She campaigns for NHS new builds to be smarter in their design in order to deliver safer care, more efficient processes and an environment that improves both staff and patient experience.

What makes a Smart ED?

So, what exactly do we mean by a Smart ED and why do we need them?

Aside from the statistics referred to earlier, what happens in the ED influences all aspects of the healthcare system, within and outside the hospital, so getting it right matters.

One of the key concepts underpinning the Smart ED is to stop thinking of urgent and emergency care demand as an unexpected interruption to NHS daily business and recognise the need for separation – physically and operationally – of emergency from elective care, accepting the central role of the ED in the effective management of urgent and emergency pathways.

“There needs to be a clear specification of what the service is actually responsible for delivering,” states Sue. “One of the problems we face in planning new departments and indeed developing our services is that there is no national, regional or local service specification for an emergency medicine service. I suspect that’s why everyone thinks they can use the ED however they want.”

A focus on what an ED must deliver has allowed the team behind the Smart ED concept to re-imagine the patient journey from the perspective of patients and families, staff, commissioners and wider society.

Redesign of urgent and emergency care involves more than physical buildings. The Smart ED redesigns processes and structures, physically, operationally and digitally, so that it is truly integrated with the hospital, the wider healthcare system and patients. Many Smart ED principles, processes and technologies could be incorporated into existing EDs and other acute assessment areas within the hospital.

And it’s not unaffordable. It’s estimated that the cost of building a Smart ED is similar to that of a conventional design. However, even under a pessimistic scenario of increased build costs, the Smart ED will yield a positive net benefit to society – in terms of health gain to patients and the financial sustainability of the ED – within three or four years. It will recoup the £3.1 million added costs of reconstruction within eight or nine years. Reduced utility bills due to green energy installations will pay for the entire ED build in just over 30 years.

Professor Ed Wilson, who calculated the figures, commented: “The key drivers of the 30 years claim are the reductions in heating and cooling bills via use of the Aquifer Thermal Energy Storage [ATES] system and reduced electricity bills from the solar panels. Ciaran Raymer, our sustainability expert, was behind these ideas.

“The three-to-four years positive return is based on the value the NHS applies to health gains in terms of Quality Adjusted Life Years [QALYs]. When appraising new drugs, NICE [the National Institute for Health and Care Excellence] is normally willing to pay £20,000 to £30,000 for one QALY.

“We estimated the number of QALYs the Smart ED would generate over and above a conventional ED design; this is basically a measure of the added benefit to patients through increased throughput and quality of care resulting from the design. I then converted this into monetary terms using NICE’s threshold. On this basis, there is a positive net benefit to the health economy (i.e. the NHS’s balance sheet and patients’ health gains added together) after three-to-four years, versus the NHS’s balance sheet alone (which is the 30 year figure).”

At a glance

The Smart ED:

Takes advantage of national enabling developments in urgent and emergency care.
Incorporates elements within the spatial design that enhance the patient and staff experience, improve efficiency and maximise safety.
Is designed to facilitate the delivery of the most efficient processes, which must be in place before design takes place.
Includes elements of technological and digital design that embraces innovation and connects patients to their data and medical records.
Provides a consistent experience for patients and their families which is convenient, efficient, and intuitive, where staff can fulfil their full care potential.
Can expand and contract to accommodate the daily ebb and flow of attendances.
Incorporates and embraces sustainability principles.
Uses well-researched and clinically tested concepts to treat patients safely and effectively.
Does not cost more than a conventional ED build.

How does a Smart ED work?

The ‘mantra’ of the Smart ED is: Design for safety. Design for flow. Design for the team. Design for the patient.

EDs are considered unpredictable because patients can arrive at any time without an appointment, but data shows that patient arrival patterns are in fact highly predictable. The total volume of patients may vary, but this changes the amplitude, not the frequency distribution. Therefore, the ED must be able to ‘breathe’, going from small to large and back to small again every 24 hours.

The Smart ED has a linear design which comprises a central staff work core surrounded by patient spaces. The whole layout is simplified, easy to understand, supervise and modify. Every room can be used to treat every patient and the whole ED can expand and contract to meet demand.

The principles used in designing the Smart ED include:

Late binding. Important decisions should be committed to as late in the construction process as possible. Spaces, furniture and infrastructure should be modular, movable and flexible up to the last minute.
The nine-second rule. One must be able to determine how the ED will work within nine seconds of looking at the floorplan.
Signage is not wayfinding. The building should be designed to naturally guide the occupants as opposed to having to rely on signs. Making corridors higher and brighter towards the entrance and lower and less bright towards the inner parts of the ED naturally orients the patient. Use colours and lights to focus patients’ attention on important destinations. Doors for staff only should be painted the same colour as the wall, whereas patient access doors should be painted in contrasting colours with additional lights to highlight them.
Equalise staff workload. Clinical spaces must be designed to allow staff to treat patients of all acuities rather than segregating some staff to treat more difficult patients, which results in inefficiencies.
Same handed, same places. All treatment spaces should be laid out the same to avoid ‘hunting’ for supplies.
Separate patient and staff flow. Staff require quiet, uncrowded areas in which to think and work.
Build in infection prevention and control. Single patient rooms and the ability to segment the ED are critical to infection control.
Extension of daily activities during surge events. All contingencies should be accommodated as an extension of normal daily staff activities rather than relying on external devices such as tents.
Horizontal (corridors) and vertical (elevators) circulation is the only permanent element of the ED. Everything else should be designed to allow for change and growth, leaving major circulation open-ended and structurally independent.

The design of the Smart ED aims to maximise the patient experience and limit the stress often associated with visiting the ED. The plan to include a rapid assessment area, the use of a linear topology and integration of features that enhance efficiency – such as UV room decontamination and decentralised supplies – ensure the design supports a journey with minimal delay.

“We have an arrival system where you’re seen very quickly and either redirected away, streamed to another service or transferred into the main ED. Key to managing the workload is right sizing in terms of both rooms and staffing resource; reducing available rooms to cut costs must be resisted,” explains Sue.

The Smart ED patient flow is as follows:

PRE-HOSPITAL

Patients contact the ED via an app or call 111 or 999 so the ED is aware of their arrival. The ED staff organise an appropriately stocked space ready for the patient’s arrival, evaluation and treatment. A robot delivers supplies specific to the patient’s complaint to their room.

An automated car park is located directly across from the ED entrance; the patient or relative arriving has their car robotically stored in the automated car park while the patient makes the short journey to the ED entrance. If assistance is needed, a staff member waits at the curb with the necessary equipment.

ON ARRIVAL

Patients are assessed for infectious disease at entry. If positive, they are directed to the appropriate space for registration and further assessment.

All walk-in patients are seen in the lobby by a trained nurse. If the patient requires immediate treatment, they are sent directly into the main ED where registration and initial assessment will take place.

A variety of options will be available for triage; digital triage kiosks or face-to-face assessment by a trained nurse. If appropriate, the nurse will stream the patient to another venue for treatment and an assistant will make appointment arrangements while the nurse moves onto the next incoming patient. The nurse will visually scan the patient to determine if it is likely the patient will be admitted and can they be streamed to another admission area.

If the patient does not require immediate intervention, they are directed to an exam room immediately behind the nurse for further assessment by a senior clinician.

WITHIN THE MAIN ED

A senior clinician will perform the first evaluation and order required tests and treatments. The clinical team will explain the likely steps the patient will follow using the screen in the patient’s room, iPad in a pod or via their phone app. Tests are performed within 60 minutes and results made available to the clinical team, who return to the patient room to discuss the results and prognosis with the patient. A summary of the visit, aftercare instructions and a digital script for any medications will be sent to the patient’s mobile device. The script can be used at a medication vending machine in the lobby. The patient’s car will be retrieved from the automatic car park by the staff in the ED so the patient can leave.

If the patient is directed to an exam room, a consultant-led team will examine them and either treat the patient and discharge directly from that room or order tests and move on to the next incoming patient. If no further investigation is required within the ED, the patient will have an appointment made at another venue or will be discharged home. Patients that require further investigation will sit in the waiting room until test results are complete.

How to build a Smart ED

Having looked at the theory, what about the practicalities? Sue has some advice.

ENSURE YOUR PROCESSES ARE AS EFFICIENT AS THEY CAN BE

“If you take poor processes and inadequate staffing into a new build, it will not deliver. The space needs to be designed to facilitate the delivery of the most effective processes and, while the build might afford you some efficiencies for staff, it will not completely negate the requirement for resources to match workload and for everyday processes to be highly efficient.

“In my experience, teams rarely get enough warning that their ED is about to be refurbished or rebuilt, so they must always be reviewing processes and pathways to enhance efficiency and effectiveness, so they are ready when the time comes.”

IDENTIFY OBJECTIVES

“Understand what you’re expected to deliver and articulate what your key deliverables are in terms of service, such as staff and patient experience, and patient safety.”

Sue has written example criteria, which encompass ‘hard’ criteria that can be measured through surveys and statistics (e.g. an improvement in key metrics, reported staff and patient experience, and an improvement in staff retention) and ‘soft’ criteria to be reported anecdotally, such as:

Does the design provide efficient patient flow?
Are staff work areas, supplies and medications located to minimise staff travel?
Are work areas designed to maximise staff interaction and visual connectivity?
Can the ED functionally respond to potential high-risk events and infectious patients?
Is the design flexible and able to accommodate future growth through internal adaptation or expansion?

“For me, a key deliverable is to ensure that the patient has all conversations about themselves in a private environment. We should not be asking patients to give personal details in the middle of a waiting room or in a corridor or cubicle where everyone can hear.

“Then there’s future planning. You need an ED that’s the right size. You need to plan for the busiest day, rather than the average day, but you also need to plan for future changes – such as local demographics and population growth – so you need to know how long the build needs to work. Beyond 20-25 years, you cannot predict, even though most NHS builds are expected to live well beyond that. Will the way urgent and emergency care is delivered change in the future? How will that impact on us getting the figures right? There’s a degree of fact, but there’s also a degree of future-gazing.”

DOCUMENT YOUR DECISIONS

“If you’re going to learn from something, you must be able to go back and look at the decisions to determine which were right and which were wrong. This is something the NHS does very badly – we don’t learn from each build. Everyone is expected to start from scratch and make their own mistakes, but if you looked around the whole country, someone else would have made a mistake you could avoid. The NHS should have dedicated resources to ensure this is done for each build and the learning shared.”

ENGAGE WITH STAFF

“Nothing should be drawn until you’ve had your clinical brief, which should include the service specification, the size of the service and the key objectives required of the new build.

“All too often, the view taken is ‘What can we squeeze into this space?’ rather than ‘What actually needs to be built for what we have to deliver?’ and, by the time the clinical team are asked to be involved, an architectural team has been employed to design without any clinical brief. This is a missed opportunity to get the most from the build.

“It’s not easy, because often people want to know the percentage increase in key deliverables and that’s not just in the gift of the design – it’s a whole system thing. But there should be some key deliverables that are within the control of the design, such as privacy and dignity, and an improved staff experience in terms of natural light, sufficient space for restrooms and changing facilities.

“The other challenge is encouraging design teams to stop thinking in old-fashioned ways or just coming up with the same old design because it’s always been like that. We have to be prepared to challenge that sort of behaviour and culture, and design to improve.”

CONSIDER THE LONG-TERM ECONOMICS

“Design teams need to resist reducing the size or quality automatically because of the budget, because they won’t get what they want and the build will not deliver expectations. Starting the process with the question: ‘What level of quality do we want to deliver?’ often helps these conversations. Any discussion around reducing or cutting back needs to consider the impact on quality or stated objectives and the outcome clearly minuted.

“Constantly consider the health economics during the process of design. Undertake a proper economic evaluation rather than just looking at the cost now. The temptation is to say, ‘It’ll cost this much so we can’t afford it’, but think ‘We’ve introduced linear design, which releases several nurses; we’ve reduced 24-hour stocking; we’re going to use robots, which will release time equivalent to three whole time equivalent (WTE) nurses a day; we’ve put in the UV light system and automatic light systems, which will release the room two hours earlier.’ Build in sustainability. You’ll pay back the build within 30 years if you put in stuff that pays back and consider the wider economics.”

“A lot of people think that economics is just about cost,” says Ed. “It isn’t. It’s about balancing inputs (cost) with outputs (health gain to patients). Cost is important because it represents a quantity of resources transferred from some other use. But the reason the NHS exists is to improve the health of the population, so both need to be considered in any decision process.

“It all comes down to the fundamental concept of opportunity cost. Resources are finite, so a decision to dedicate resources to one use means we are foregoing the benefits from some alternative use. That foregone benefit is what we call the opportunity cost. Within the NHS, that means other patients’ lives. This is true whether the decision is to buy the latest cancer drug, employ the next orthopaedic surgeon, and of course, whether and how to expand our hospital facilities or build new ones. When we make capital investments, we need to know that the added benefit to NHS patients from the one we choose exceeds the foregone benefit from alternative uses of those same funds, whether that be an alternative capital investment or expenditure on direct patient care.”

Andrew Angwin, Head of Same Day Emergency Care and Acute Medicine, NHS England

There’s plenty here for teams to consider when redesigning EDs. The classic case is fitting the ED into the space available rather than asking: what do we need? The other big thing is cost control. Inevitably, with older hospitals, the estimates for all the background stuff – mechanical, electrical and ventilation – always seem inadequate, so you end up spending more than planned and cutting elsewhere.

For me, the biggest challenge is ensuring SDEC units remain focused on admission avoidance. That means committing to not bedding it. If you do bed it, it gives an immediate boost to the ED, but the next day you can’t use your SDEC for its purpose, which means patients that you might have been able to send home are getting admitted.

Another challenge is ensuring the SDEC doesn’t have a lot of activity that isn’t same day or emergency filling up capacity. Quite often, Trusts have set up units from ambulatory care or medical day units, therefore the SDEC continues to host those services – things like planned infusions.

The Smart ED is a great concept; starting with a clinical brief before you start drawing spaces is really positive. Most patients who go through SDEC can be treated in a chair, so you can design out the risk of it being bedded by deliberately making it an ambulatory area. And anticipating demand is important: look at when people arrive, rather than when the ED becomes full. EDs generally topple over during the night, but that’s [a result of] not keeping up with demand during the afternoon.

There are two things I would add. The first is access: ideally, EDs should know patients are coming ahead of time and have the ability to redirect patients to the most appropriate place. One thing we’re pushing is getting suitable patients directly to SDEC if they’ve already been assessed by a senior GP, ambulance crew or 111. This supports admission avoidance because it gives units more time to do what they need to and send people home on the same day. It also allows ED to focus on patients who have not spoken to a clinician before attending.

The second thing is to use a simulation model as part of the design process. There are models being developed which allow you to replicate your current system and then build scenarios and adaptations to see how patient flow is affected. It’d be amazing if, before you committed any money, you could test the impact of different designs and flows.

Dr Gary Davies, Consultant Respiratory and Acute Medicine Physician and Hospital Medical Director at Chelsea and Westminster Healthcare NHS Foundation Trust, Lon-don Regional Clinical Advisor (Acute Medicine) and London Clinical Director SDEC

Non-elective capacity coming through the front door is probably ‘the new Covid-19’ in terms of its effect on the health service. Traditionally, we had one hospital front door for non-elective patients, which was the ED. We now have two – the ED and the UTC – but there should be three: the ED takes the most severe patients, then SDEC in terms of acuity, then the UTC. The work of Andrew [Angwin]and I is about getting the patient signposted to the correct place for the care they need as quickly as possible – either their pharmacist or GP, or the correct area if they come to the hospital.

Our thinking is anybody walking into an ED is a failure of the system because the skillsets of emergency physicians are for critically unwell people who should mostly be arriving by ambulance or referral from a clinician. Getting those different routes communicated to the public is quite difficult. It is about rewriting behaviours – visit your local ED when you can’t access anyone else—that have been ingrained in the public. We’ve done a lot of work with national broadcasters and social media to communicate this, but we still have more to do.

It’s also important to think about the flow of patients. Often, the most junior member of staff sees them first, then somebody more senior, before eventually the senior decision-maker, by which time the patient’s been here for several hours. Evidence shows that a senior decision-maker at the front door making that initial decision is more likely to direct patients onto the right pathway. This was demonstrated during the junior doctor strikes, when the performance of Trusts improved; however, this wasn’t sustainable, and we need to get a balance with junior doctor training, as otherwise we do not train the consultants of the future.

The other key thing is asking, ‘What are we going to do [for this patient] that they couldn’t have done from or at home?’ Patients often think hospitals are safe, but they come with a lot of risks. Evidence shows that elderly patients who spend several days in hospital beds become weaker and are less likely to function at the level they could when they come in.

Nationally, we potentially don’t have enough inpatient beds if we work in our traditional ways, equating to around 10 hospitals. It would take years to physically build that many, so the only way we’re going to achieve appropriate care is by working in innovative ways and keeping them out of hospital but still providing the treatment they need.

Key takeaways

By designing a right sized Smart ED that incorporates proven strategies that provide dignity and privacy, optimise treatment, reduce crowding, control infection risks and enable staff to work efficiently, we can better manage workload and the flow to acute hospital beds for those who need them.

To meet current and future demands our EDs must evolve and improve. They must become smarter.

FOOTNOTES

¹ https://www.cqc.org.uk/publications/major-report/state-care/2022-2023/access-to-care#:~:text=Data%20from%20NHS%20England%20shows,reported%20poorer%20than%20average%20experiences.]

This article was taken from the January 2024 edition of FORTIS magazine.

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This article was written for the January 2024 edition of FORTIS magazine; a forum for the NHS to share ideas, innovations and case studies. To read the publication in full and access digital copies, visit FORTIS magazine. FORTIS magazine is free for NHS change-makers and leaders and is available as a print or digital copy. FORTIS magazine is managed and owned by Health Spaces Ltd.

Work smarter, not harder