EVALUATION, ANALYSIS AND BENCHMARKING OF THE … · EVALUATION, ANALYSIS AND BENCHMARKING OF THE...
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www.haciric.org EVALUATION, ANALYSIS AND BENCHMARKING OF THE DESIGN OF EMERGENCY DEPARTMENTS IN ITALY Transforming Healthcare Infrastructure and Services in an Age of Austerity HaCIRIC International Conference, 19-21 September 2012, Cardiff Dr Federica Pascale, HaCIRIC, Loughborough University
Transcript of EVALUATION, ANALYSIS AND BENCHMARKING OF THE … · EVALUATION, ANALYSIS AND BENCHMARKING OF THE...
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EVALUATION, ANALYSIS AND BENCHMARKING OF THE DESIGN OF
EMERGENCY DEPARTMENTS IN ITALY
Transforming Healthcare Infrastructure and Services in an Age of Austerity HaCIRIC International Conference,
19-21 September 2012, Cardiff
Dr Federica Pascale, HaCIRIC, Loughborough University
www.haciric.org
PRESENTATION FORMAT
• Background
• Aim & Objectives
• Research questions
• Methodology
• Performance Requirements
• EDs Design Criteria
• Design State of EDs in Italy
• Conclusion
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EDs attendance
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Num
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Attendances at accident and emergency departments, England, 1987-88 to 2008-09
First Attendance Follow Up Attendance
In recent years there has been an increase in using urgency and emergency facilities in all industrialized countries, which are
found to deal with enormous problems of overcrowding.
Annual average of emergency department visits:
• Italy: 30 million (60.6 million inhabitants)
• England: 20 million (51 million inhabitants)
• United States: 100 million (313 million
inhabitants)
• Canada: 10 million (34 million inhabitants)
54%
23%
Source : http://www.ic.nhs.uk
Source : http://www.cdc.gov
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Italy is seventh in list of the ten industrial countries most
affected by natural hazards in the last decade
Country No. disaster No. Killed No. Affected Damages (billion US$)
United States 228 4,514 20,792,250 386.2
Australia 65 615 314,418 18.6
Japan 62 20,046 1,570,365 382.0
France 42 21,082 559,596 17.9
Canada 34 31 18,403 2.1
Germany 33 9,505 332,324 29.9
Italy 32 20,508 83,248 13.4 Korea Rep 26 580 558,195 12.5
United Kingdom 26 370 387,126 12.1
Greece 26 108 17,003 2.9
Natural disasters reported 1900-2010
Num
ber o
f dis
aste
rs re
port
ed
Source: www.emdat.be
With the ever increasing number of hazards in the world, EDs are increasingly faced with the challenge of ensuring care during periods when demand exceeds available resources.
Increasing hazards
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ACHIEVEMENTS …TO BE ADDRESSED
• Improve physical infrastructures to support the “Hub and Spoke” network.
• Recognition of the Postgraduate School in Emergency and Urgency Medicine
• The change in the university education of Italian nurses
Emergency system" based on the "Hub and Spoke" model
Source: Ferrari, A. M., 2009
Italian EDs: Daily Operation
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ACHIEVEMENTS …TO BE ADDRESSED After the L’Aquila earthquake (6 April 2009), the performance of the emergency system was very high. After 48 hours from the earthquake: • 28 thousand people were rescued; • 10927 emergency rescuers from different
agencies; • 30 reception camp; • 2962 tends; and • field health posts were built
Source : www.republica.it
Source : Civil Protection
L’Aquila earthquake caused major damages to San Salvatore Hospital, built in 2000 to withstand a magnitude 6.3 earthquake with minimal damage.
Emilia-Romagna earthquake (May 2012) caused the complete evacuation of 4 hospitals in the Emilia-Romagna region Source : www.republica.it
Italian EDs: Special circumstances
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Italian ED design guidelines
National Guidance: • DPR 14 January 1997
• Structural, technological, organizational and staff standard for
Emergency Departments. (SIMEU, 2005)
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More work is needed in Italy to improve the design approach of EDs as many have been designed according to guidelines that do not necessarily meet with the
flexibility, efficiency, and effectiveness needs.
“A thorough understanding of quality-improvement principles and benchmarking now is necessary for emergency department (ED) leaders to be successful in providing patient-centered care, improving customer satisfaction, and evaluating service initiatives” (Welch et al., 2006).
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AIM, OBJECTIVES, RESEARCH QUESTIONS AND METHODOLOGY
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Aim To improve the benchmark of EDs design in Italy.
Objectives • Identify the most relevant design requirements affecting the performance
of EDs in Italy; • identify international best practice; and • evaluate the design of existing EDs in Italy.
Research questions 1. What are the most functional requirements affecting the response
of EDs? 2. What lessons can be learnt from, and passed to international
practice? 3. What is the design state of EDs in Italy? 4. How to improve the benchmark of EDs design in Italy?
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Methodology
• A literature review was made to identify performance requirements, related to the intended use of the building and the international design criteria, developed to meet this demand.
• Guidelines • Reports • Scientific papers…
• Current gaps in the Italian EDs’ design approach were
identified by comparing the international design strategies with the design of 19 case studies of major facilities.
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Sources: Spekkink D., 2005
• Benchmarking was used to analyse the most relevant performance requirements affecting the response of EDs.
• The language followed in this study is based on the performance-based design concept.
Performance concept
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Performance requirements Functional
requirements classes
Functional requirements in literature
Guidelines Research Reports Journal Papers
(DH, 2005) (Huddy, 2002) (ACEM, 2007) (NHS Estates,
2003) (Smith et al., 2003) (Zilm, 2003)
(Olsen et al., 2008)
(Greene, 2002)
Safety and security
Security of the staff Visibility and
communication Fire safety Access control
Visibility Visibility
Prevention of crime and abuse
Psychiatric module safety Psychiatric module
safety Surveillance Accessibility
Safety for staff and public
Protection of the building fabric
Decontamination Decontamination Security of the staff Decontamination Adaptability
Fire safety Infection control
Infection control
Decontamination
Capacity to receive large number of people
Comfort
Privacy and confidentiality Privacy and dignity Privacy and dignity Privacy and dignity Privacy and dignity Privacy Privacy and dignity
Well-being of patient and staff
Daylight Lighting Well-being of patient and
staff Confidentiality Welcoming setting
Sound control Support staff interaction
Functionality
Wayfinding Space provision Accessibility Wayfinding Scalability Scalability Adaptability
Accessibility Wayfinding Space provision Flexibility Prioritisation of the clinical
area
Adaptability Visibility and
communication Accessibility Adaptability Floor plan intuitively clear
Accessibility Modularity
Modules contiguity Space provision
Standardisation Ubiquitous Access to
Information
Image Healing and caring
environment Healing and caring
environment Healing and caring
environment Supportive work
environment
Management Flexibility Flexibility Minimal Maintenance Flexibility Universal Space
Modularity Modularity Flexibility
Integration Other hospital facilities Ancillary support area Ancillary support area
Environment Energy conservation
Sustainability
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Accessibility
• Airports model with multi-lane access ramps and with several access points within the structure
• Drop-off area covered with a canopy high enough to allow access to various emergency vehicles such as buses
Public entrance Ambulance entrance
• Entrances aligned on non-adjoining façades of the building
Sources: NHS Estates, 2003
• Pedestrian entrance connected to the waiting room and the assessment area and the ambulance entrance connected directly to the resuscitation room and the major treatment area
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Flexibility
• Universal treatment room
• Dual-use of non-clinical space to use it as treatment space in contingency situation
• Module approach not designed for a specific type of specialty and type of patients
Sources: Huddy, 2002
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Security
Sources: NHS Estates, 2003
• Reception’s position should allow the staff to supervise the access and the waiting area
Locations that can be over seen from the reception
• The multi-mode decontamination concept
• EDs’ portals should be able to detect different types of threats and they should be implemented as real filters with automatic sliding.
• Treatment rooms with glass-front sliding doors
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Privacy
• The patients and visitors’ routes should limit the number of changes in direction and distance between the main entrance and the treatment area,
• Full auditory and visual privacy for people in assessment rooms. Triage and patients’ assessment space arranged in apposite rooms,
• EDs designed with all private care space and all treatment rooms should have full-height walls and doors.
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Case studies
To assess the design performance of Italian EDs, a sample of 19 case studies was used. These case studies were carefully selected to: • cover all national territory; and • different design periods.
They are located in hospitals built from the 1950s to the last ten years; but two of them take place in hospitals built before 1900.
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WARM ROOM
Design state of EDs in Italy: Accessibility
The Presidential Decree of 14 January 1997 imposes a requirement to have a covered and heated drop-off area, normally called “WARM ROOM”.
Ambulance Pedestrian/Cars
• 99% of case studies have only one way of access for pedestrians, cars and the ambulances.
• 61% of the case studies have two separate access doors. In most of the cases they were aligned, close and interconnected.
• In most of the cases there is a linear connection between the entrance and the resuscitation room and the route is not dedicated and crosses public areas.
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Infermieri
SALA MEDICIStanza
21080
80
210
Spogl.
riunioni
Stanza
Stanza
Radiol. d'urgenza
C.P.S.
Ecografia
-0.10Entrata
-0.10Uscita
Camera caldaUscita
Tunnel collegamento
at tesa parent i
12
0
12
0-0 .14
Uscita
15
0
15
0
emergenza
Filt rowc
t ritap.
MUPS
CODICI BIANCHI
IN ATTESA p.l.
PAZIENTI D.IN ATTESA p.l.
LETTI TECNICICODICI VERDI
VISITACODICI VERDI
STANZA CPS
IN ATTESATRASFERIMENTO
CODICI ROSSI
SalaEmergenze 1
passaggio pedonale
SALAGESSI
CODICI GIALLI
Visita
PAZIENTI TRIAGIATIIN ATTESA
ISOLAMENTO
DEPOSITO
WC
INFERMIERI
GuardiaM.U.P.S.
M.U.P.S.
PRO
NTO
SO
CCO
RSO
Sala let tura
Controllo
Medicheria
Dep. pulito
Medico
RELAX
montacarichi
Fax
sporco
Arrivo
SALA MEDICIStanza
21080
P.L. 13 -16
80
210
riunioniM.U.P.S.
Uscita
-0.05
0.00
Camera calda
W.C.
disimpegno
Sala emergenza 2
PRO
NTO
SO
CCO
RSO
mq
1600
W.C.
Radiologia
Contr.
vuota W.C.
T.A.C.
Sala let tura
Controllo
Tecnici
Infermieri
SALA MEDICIStanza
21080
BANCA
Spogl.
Spogliatoio
Spogliatoio
PAZIENTI U. Stanza
DEPOSITO
di guardiaMUPS
Sezione
d'urgenza
Degenza
Filt ro
riunioni
Stanza
Stanza
Radiol. d'urgenza
Vigilanza
Triage
Refert .CPS
Dep.
vuota
Bonifica
W.C.
Ecografia
Isolamento
Triage
polivalentesala
CODICI ROSSI
TecniciLet t i
parent iat tesa
Box
di guardiaMedico
ant i - wc
wc
DEPOS.
0.00
SALA
DIRETTORE
MEDICHERIA
W.C.
W.C.
Tecnici
infermieri
Atrio
Degenza
0.00
-4.65Dep.
O.B.I.
AMBULATORIO
Triage Area
Red Area
Green Area
Yellow Area
White Area
Most of the EDs presented separate care areas based on the medical specialities. The layout of 55% of case studies had separate units based on acuity level, related to the Triage categories of priority (non-urgent, urgent, emergent, trauma).
“This segregation eliminated the flexibility for overflow into other
patient care spaces, increased the amount of materials and equipment
duplicated in each area, and increase staff needs to cover
different component” (Huddy 2002).
Design state of EDs in Italy: Flexibility
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Only 22% of case studies is equipped with single decontamination room. But these are designed with a single decontamination room, solution not able to meet potential mass demand of decontamination due to a NBCR event.
RAMP FOR NBC EVENT Decontamination Unit
Warm Room For NBC Event
Design state of EDs in Italy: Security
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• In 37% of the cases, reception/triage area is organised in a specific room with one or more glass wall. This solution, limits staff ability to see different areas from the other side, it improves the patients’ privacy.
• In the majority of the cases this area is organised as triage/reception desk, equipped with security glass. This solution improves surveillance but drastically reduces patient privacy.
Triage Area
Design state of EDs in Italy: Security and privacy
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• None of the case studies have a central workstation in the treatment area, thus limiting the ability to see patients in any treatment rooms.
• Treatment room design: 48% have single treatment
room with full-height walls and doors;
26% have the different treatment areas organised in open spaces with curtained and cubicle space; and
26% have a mix configuration.
Green Area
Red Area
Design state of EDs in Italy: Security and privacy
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Infermieri
SALA MEDICIStanza
21080
80
210
Spogl.
riunioni
Stanza
Stanza
Radiol. d'urgenza
C.P.S.
Ecografia
-0.10Entrata
-0.10Uscita
Camera caldaUscita
Tunnel collegamento
at tesa parent i
12
0
12
0-0 .14
Uscita
15
0
15
0
emergenza
Filt rowc
t ritap.
MUPS
CODICI BIANCHI
IN ATTESA p.l.
PAZIENTI D.IN ATTESA p.l.
LETTI TECNICICODICI VERDI
VISITACODICI VERDI
STANZA CPS
IN ATTESATRASFERIMENTO
CODICI ROSSI
SalaEmergenze 1
passaggio pedonale
SALAGESSI
CODICI GIALLI
Visita
PAZIENTI TRIAGIATIIN ATTESA
ISOLAMENTO
DEPOSITO
WC
INFERMIERI
GuardiaM.U.P.S.
M.U.P.S.
PRO
NTO
SO
CCO
RSO
Sala let tura
Controllo
Medicheria
Dep. pulito
Medico
RELAX
montacarichi
Fax
sporco
Arrivo
SALA MEDICIStanza
21080
P.L. 13 -16
80
210
riunioniM.U.P.S.
Uscita
-0.05
0.00
Camera calda
W.C.
disimpegno
Sala emergenza 2
PRO
NTO
SO
CCO
RSO
mq
1600
W.C.
Radiologia
Contr.
vuota W.C.
T.A.C.
Sala let tura
Controllo
Tecnici
Infermieri
SALA MEDICIStanza
21080
BANCA
Spogl.
Spogliatoio
Spogliatoio
PAZIENTI U. Stanza
DEPOSITO
di guardiaMUPS
Sezione
d'urgenza
Degenza
Filt ro
riunioni
Stanza
Stanza
Radiol. d'urgenza
Vigilanza
Triage
Refert .CPS
Dep.
vuota
Bonifica
W.C.
Ecografia
Isolamento
Triage
polivalentesala
CODICI ROSSI
TecniciLet t i
parent iat tesa
Box
di guardiaMedico
ant i - wc
wc
DEPOS.
0.00
SALA
DIRETTORE
MEDICHERIA
W.C.
W.C.
Tecnici
infermieri
Atrio
Degenza
0.00
-4.65Dep.
O.B.I.
AMBULATORIO
Evaluation of Case study 19
P=57%
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• The most influential physical performance requirements affecting EDs’ response are:
• Accessibility; • Flexibility; • Security; and • Privacy.
• Important lessons about how to address these requirements can be learnt from international experience; however, Italian design approach for EDs presents considerable differences with the international best-practices.
Conclusions (1/3)
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Conclusions (2/3)
• The implemented Italian design strategies to meet requirements of accessibility are very far from international design criteria. Italian EDs present generally one way of access for pedestrian, car and the ambulance and the use of the "warm room" reduces the accessibility, especially in case of MCE.
• The model of EDs emerged by case studies is heavily affected by the medical specialities, with EDs layout fragmentised in functional areas dived by specific level of care, related to the Triage categories. This solution limits EDs’ flexibility in terms of space, resources and staff.
• The design approach with reception/triage room, the extreme fragmentation of the treatment area and the absence of central workstation reduce the visibility in the public space and in the treatment rooms.
• The case studies present two opposite solutions: single treatment room with full-height walls and doors that maximizes patients’ privacy; and treatment areas organised in open spaces with curtained cubicle space that drastically reduced patient privacy.
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• The most relevant constrains that prevent from adopting the international design criteria are: the age of buildings where EDs are located. In the cases, it is very difficult to modify the space to meet international best practise, because of constrains related to building’s framework. For these cases, the most effective solution is relocated the EDs in new buildings.
and the influence of the medical specialities on the design approach. EDs layout results fragmentised in functional areas dived by specific level of care, related to the Triage categories. This solution creates an excessive fragmentation and limits EDs’ flexibility in terms of space, resources and staff; especially in relation with the unpredictability of the future access volume of different types of patients and of a sudden influx of injuries owing to a MCE.
Conclusions (3/3)
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Thank you for your kind attention!
Any comments/questions?
