by Russell Boniface
Associate Editor

Summary: You won’t be asked to have a seat at the new University of Iowa Hospitals & Clinics Emergency Treatment Center (ETC), a 70,000-square-foot trauma center employing a four-quadrant design for 24-hour staffing and no patient waiting. The Chicago office of RTKL Associates used computer simulations based on real-time patient data to develop staffed quadrants that will open as patients are expected to arrive, ensuring immediate patient attention in private rooms. The $25 million renovation and expansion in Iowa City began its 14-phase construction in September and will open in 2009 to accommodate 45,000 patients annually.

Factoring time data
“One of the biggest complaints nationally in emergency departments is the wait time,” says Alan Wilson, AIA, RTKL vice president and principal-in-charge on the Iowa ETC project. Wilson consulted with Frank Zilm, FAIA, of Kansas City-based Frank Zilm & Associates, and consultant Jim Lennon, AIA, of California-based Jim Lennon Associates. Zilm’s patient volume data helped Wilson design enough rooms of proper size to, as Wilson describes, “effectively put every patient in a bed.” Lennon’s operation analysis of real-time data, based on a typical daylong caseload, told Wilson the times of day when patients are most likely to arrive and for how long they will need care, creating the idea of a quadrant design.

We used real-time data in the plan

“Every emergency department tracks the time a patient arrives, sits in the waiting room, and gets seen by a physician,” explains Wilson. “I think we are unique in that we used real-time data in the plan. We saw how the hospital’s ETC, starting at 6 a.m., goes through a life cycle during the course of a day.”

Four quadrants, zero waiting
Computer simulations used the data to visualize the number of expected patients, when they would arrive, where they would go, and how long they would stay before discharge. Wilson then designed the ETC into four quadrants. “During the course of the day, the ETC will staff up by quadrant according to predicted patient volume. At 6 a.m. patient volume is light, so the ETC will staff one quadrant with nurses, physicians, and technicians. Then, at 10 or 11 a.m., the time when enough patients come in, the second team will arrive to staff the next quadrant. The intent is to have no patient wait time. In mid- to late evening the volume will reduce, so staff will be reduced to the initial quadrant.”

Wilson adds that the ETC has the option to take minor cases to one quadrant and open up any or all of the quadrants for serious cases. “Up to 35 patients can be treated if all four quadrants are running. But one quadrant will be always be staffed 24/7,” he says.

One quadrant will be always be staffed 24/7

Iowa Hospitals appreciated how the simulation revealed the amount of hospital staff needed at given times. Says Wilson, “This helped the client calculate operational costs based on how many doctors, nurses, and technicians would have to be on.”

Unlike traditional emergency rooms, where beds are sectioned by curtains, Iowa’s ETC has 35 private rooms, each 140 square feet with chairs so family members don’t have to sit in the waiting room. Oak doors complete the privacy. The rooms are large enough that they could be fitted with a second bed. Two trauma rooms and two cardiac rooms complete the no-wait design. The cardiac rooms even allow for emergency surgery.

Findability
Wilson explains that “findability” is a major criterion for designing an emergency room. “We placed the Iowa ETC near the front of the hospital. The patient will drive up and find it easily.” But there was another reason: “The ER is the 24/7 entrance to most hospitals; it’s a major thoroughfare. Fifty percent of hospital admissions go through it. For many patients, their hospital perspective is the emergency department.”

Fifty percent of hospital admissions go through the ER

To be clearly visible, the Iowa ETC drive-up entrance is separate from the ambulance entrance. “We separated the ‘walking wounded’ entrance from the ambulance traffic,” notes Wilson. “Those two patient populations never see each other, and both are easy to get to.”

Building in phases
The Iowa ETC is tan-gray concrete with a glass canopy at the entrance. Features include:

• A spacious vaulted lobby to improve visibility and allow daylight
• Private corridors to shield trauma arrivals from public view
• Wide hallways
• An anti-contamination system in the garage in the event of a disaster.

Wilson says it’s a challenge to renovate and expand the ETC in phases around the existing emergency department and at the base of a patient tower. “You’re trying to keep them in business while building it all new right around them.”