Visiting the emergency room at the Hospital of the University of Pennsylvania in West Philadelphia—or really any emergency department in the U.S.—is a long ordeal. Penn’s average wait time was clocked at 80 minutes from the time a patient walked in to when they were first seen by a doctor or nurse to triage their issue. And that’s only the first step. Tests are taken, blood is drawn, labs are conducted, and all the while the patient waits. For those who don’t need to be admitted for a hospital stay, their entire visit to the ER could last more than five hours.
Most of that waiting happens in an exam room, the highly equipped space where life-saving medical treatment takes place. Every exam room filled by a patient waiting for a lab result or a nurse check-in is one less exam room available to treat another, potentially sicker, patient. “With increasing numbers of patients and limited space, that becomes a nonviable strategy,” says Keith Hemmert, MD, an assistant professor of clinical emergency medicine at Penn.
So when plans got underway for the Pavilion, the new $1.6 billion hospital complex that Penn will be opening next month, researchers and clinicians at the medical school saw an opportunity to rethink the way the emergency department functions. With wait times ticking up and valuable exam rooms acting as waiting areas, they realized something needed to change.
In preparation for the new 1.5 million square-foot hospital designed by HDR and Foster + Partners, they dramatically reinvented the ER patient flow process in 2019, prioritizing the initial triage of patients to understand their clinical requirements, and then moving them to spaces within the emergency department that are more appropriate for their medical needs. In the old model, a patient coming in with a non-life-threatening injury would be placed lower on a priority list and would be seen by a doctor only when higher priority cases were cleared. The new process has doctors evaluate each person as they arrive, sending a patient with a twisted ankle to one area to get a splint and a patient with a stab wound to another area to get patched up. Average wait times go down, and patients are placed in different parts of the ED based on their conditions and needs.
“It’s flipped from the traditional model of the triage being done first and then seeing a doctor,” says Robin Wood, a registered nurse and clinical director for emergency and observational nursing at the hospital. “[Instead] the doctor is seeing the patient while the triage is being done, and the patient is directed to the area they need to go.”
Patients see a doctor or nurse at the first possible moment. “In this new process they’re spending half an hour,” says Dr. Hemmert, “so that frees up three-plus hours of time that we can see other patients in that exam room.”
This optimized process has informed the way the new emergency department was designed. The typical ER uses an assembly-line system that moves patients from place to place during their initial evaluation and blood work. The new ER at the Pavilion includes a series of semi-private triage areas where patients do most of their waiting. With reclining chairs, cubicle-like dividers that visually separate patients, and seating for a guest, these spaces offer room for doctors and nurses to evaluate patients, while also reducing the unpleasantness of sitting in an emergency department.
“If you’re in the ED, you’re having a bad day. And so it’s not a great experience to say every five minutes, ‘Move to this chair, move to that chair,'” Dr. Hemmert says.
The new ED also includes 12 exam rooms, which can handle up to 25 patients at a time, helping to serve more patients and bring waiting times down. The revised patient flow process that Penn studied in its old emergency department showed that patients can get in front of a doctor in less than half an hour and, for those not needing admission, out the door in less than four hours. With space designed specifically around this flow process, Dr. Hemmert believes that when the new hospital opens in October, it will be able to make a vast improvement for patients and for the care the emergency department delivers.
“The exam room is no longer a destination where a patient is going to sit for their whole visit. It’s rather a tool that we’ll use to treat the patient as needed,” Dr. Hemmert says. “This has been recognized as the way most emergency care is going. The new building was designed with this in mind.”