The narrative pushed to hospital administrators and strategic and facility planners for years is that site-of-care shifts are causing emergency department (ED) use rates to decrease—and will continue to do so for the foreseeable future.

These projections are based on the idea that as alternative immediate care options such as urgent care centers and retail clinics proliferate, lower-acuity ED visits will shift to the new, lower-cost settings, potentially resulting in a need for less ED space.

Despite the well-documented rise of immediate and urgent care sites, data from the National Ambulatory Medical Care Survey (NHAMCS) and American Hospital Association show that ED use rates are increasing, though year-over-year growth is slowing.

Based on this trend, emergency departments will require either more space, more patient care positions (assigned places where ED patients are seen) and/or more efficient operations to accommodate higher volumes in an equivalent space.

Patient-related demographic variables

Some ED volume may be shifting to alternate locations, but that change is largely being offset due to other variables such as age, insurance coverage, race, facility location, and unmet demand for specialized care, such as behavioral health services. Segmenting the data by demographic segment reveals that some population cohorts are driving higher emergency department use while others are decreasing their ED use.

Age: in the past decade, most age cohorts have shown decreasing ED use rates, with the exception of two groups: patients under age 15 and those ages 45-64.

The largest absolute trend change was in the under-15 cohort, where ED volumes increased at a rate of 6.3 visits per 1,000 children per year. In the 45-64 cohort, ED volumes increased at a rate of 3.4 visits per 1,000 adults per year.

Of note, while the ED use rate for older adults and the elderly (65 years and older) is declining, the rapid population growth in this age group continues to drive high ED utilization, which can be expected to continue.

Insurance type: Emergency department use in the United States is shifting from a mixed population of privately and publicly covered patients to primarily publicly insured patients.

Based on the NHAMCS data, from 2008-2020 the percentage of ED visits paid for by private insurance decreased from 42 percent to 30 percent while the percent paid for by Medicaid/CHIP increased from 24 percent  to 37 percent. (In this same time period, visits paid for by Medicare increased from 18 percent to 22 percent and visits without insurance decreased from 15 percent to 8 percent.)

Race: Segmenting ED use rate by race reveals yet another instance of the inequity present in the U.S. healthcare system. The NHAMCS data reveal that emergency department use by Black Americans is double that of white Americans and quadruple that of other races.

Visits by Black Americans to the emergency department account for a disproportionate share of all ED visits when compared to their share of the population, and their use rate is growing five times faster than that of white Americans.

Geographic area: With most urgent care centers located within metropolitan areas, the growth in use rate in these areas, while still positive, has been controlled over time and is less severe than in areas where other alternatives are less readily available. In non-metropolitan areas, the ED use rate is much more variable from year to year and has generally experienced more rapid growth.

Higher-acuity care demands in EDs

At a high-level, two other factors are shaping the needs and considerations for ED facility planning: acuity and mental health.

Post COVID-19 pandemic, a widely realized trend is that patients who are seeking care at the ED are much sicker than in the past. This could be a result of the low-acuity volume filtering out to alternative sites of care or perhaps it is being driven by choices to delay care during the pandemic.

Either way, the ramifications are being felt in the emergency department and culminate in increased lengths of stay as higher acuity patients require more resources for treatment such as additional tests, imaging services, or procedures.

Finally, while upticks in visits were seen prior to 2020, the pandemic exacerbated the volume of patients arriving to the ED seeking mental health emergency care.

According to Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, unprecedented increases were seen especially within pediatric and adolescent populations—with the proportion of mental health-related visits increasing 24 percent and 31 percent, respectively.

The specific needs of behavioral health patients present opportunities for improved ED planning and design that can stand to benefit both medical and behavioral patient cohorts.

The trends outlined above drive the need to think about emergency department design in new ways, including:

Rightsizing the ED

Often the ED is the largest contiguous space needed on a campus and drives projects when expansion is needed. Therefore, it is crucial that the planning team thoroughly research and use all available data to accurately inform how much space is needed.

Demographic assessments, competitor analyses, and historical volume trends pulled from electronic health records (EHR) are the starting point for forming volume projections.

However, arriving at the right number of future care positions also requires a critical look at current-state operational performance—namely the average length of stay—gleaned through EHR data.

The planning team should not rely on the status quo if it is not meeting benchmarks. Alongside emergency department leadership, current operations should be critically analyzed to determine areas where adjustments can be made that can improve length of stay.

These targets can be combined with future-state volume projections to inform the total number of positions, and therefore square footage, needed to accommodate the planned scenario.

Alternative triage layouts

The conventional triage model looks like this: after a patient arrives to the ED and checks into the waiting room, the patient is triaged by a nurse and then returned to the waiting area. Once called, the patient is placed in either a large or small room/bay and remains there for the duration of their stay.

While this model has served healthcare well for many years, it may no longer be the best model for the increased volume of higher-acuity patients as it can be error-prone in busy settings

Several health systems are implementing other ED triage options such as basic split flow (patient moves from check-in to horizontal or vertical care areas), split flow with hybrid triage, rapid assessment zone (large room with recliner bays), and pull to infinity (patients receive initial vitals and move to a triage recliner zone for assessment and treatment or care trajectory assignment).

These models are employed to achieve faster decision-making, more efficient sorting of patients and distribution of resources to the most acute cases, and more rapid initiation of the treatment process, especially in high-volume emergency departments.

Several of these approaches use nontraditional, and often smaller, key planning units to better leverage scarce space resources. Designing the operations and the physical space in tandem can allow for more patient care positions in the same square footage.

Structuring EDs for flexibility

Related to the triage process and the mix of patient acuity within the ED, flexibility can be built into the space by incorporating both vertical and horizontal positions.

While the right balance needs to be determined by understanding a facility’s specific acuity mix, vertical positions offer multiple benefits. For example, by conducting triage in recliners, care advancement can begin immediately.

These positions also allow a more seamless flow for low-acuity patients who may not need to be in a horizontal position during their stay. Finally, because these positions take up less space than beds (requiring about one-third less space), they can increase capacity when expanding the physical footprint of the ED isn’t an option.

It is essential that these positions are planned for in advance, with proper space—around 80 net square feet per recliner allocated—so that they don’t interrupt flow through the department and hinder care processes.

Additionally, flexibility needs to be built in to overcome staffing challenges, especially in departments that experience wide variation in volume. A pod design can allow staff to oversee all patient positions from a central nurses’ station.

However, if the pods are physically separated, it can limit the ability to expand and contract open positions because staff cannot see from one area into another. Instead of creating physical barriers, designing along a central, unified chassis and then operationalizing that into “zones” gives flexibility to open new positions without waiting for an entire pod to be sufficiently staffed.

Dignified models of care

Nearly 15 percent of all ED visits are behavioral health related, according to Virtuity, a physician-owned healthcare organization, but traditional emergency department design is not as conducive to treating these types of patients.

While these patients wait for care in the general emergency department, treatment is often not initiated until placement in an inpatient bed/facility is possible.

The inherent risks and stressors of the ED, such as potential access to objects that can be used for self-harm and the cacophony of alarms and other patients/providers can exacerbate their conditions.

Psychiatric patients can occupy emergency department beds for a considerable amount of time since they are often subject to psychiatric holds and because there is a deficit of appropriate inpatient options to transfer these patients to for care. As a result, mixing medical and behavioral populations often results in increased lengths of stay for both patient types.

The creation of dedicated spaces—such as crisis units in an adjacent or dedicated section of the ED or an EmPATH (Emergency Psychiatry Assessment, Treatment, and Healing) unit, which delivers acute interventions for emergency behavioral health patients in a therapeutic setting—can help to better serve these patients while reducing the burden on the entire department.

Investing in ED planning

The ED often serves as the front door to the hospital, making the design of these spaces one of the most crucial elements to get right on a facility project.

A planning process that incorporates knowledge of the most up-to-date trends, empirical data, and departmental leadership and perspectives can help to ensure that the resulting facility provides all patients with the best healing environment.

Jill Barbaro, MHA, is a strategic planner at Array Advisors (Conshohocken, Pa.) and can be reached at [email protected].