Community Medical Center: A Patient-Friendly ED

Contributed by Array Healthcare Facilities Solutions

Overview The new Emergency Department (ED) at Community Medical Center (Community/CMC) in Toms River, NJ, a rural, resort area, is the busiest emergency department in the state, treating more than 95, 000 patients each year. At one time, Community, a Saint Barnabas Healthcare System hospital, lacked the space and facilities needed to handle growing patient volume in the area. This explains why nine years ago, CMC opted to expand their former Emergency Department. Today, thanks to a 23, 000 SF expansion and 28, 000 SF renovation of the existing department designed by Array Healthcare Facilities Solutions (Array), the ED at Community offers more space, privacy, and a wider range of services to their patients, along with decreased waiting for lab and imaging result times.

Community Medical Center is now one of the largest non-teaching EDs on the east coast, and is prepared to handle a wide range of emergencies. Their mission statement, “To provide a continuous commitment to excellence in customer-focused emergent/urgent care,” has become a reality, as after nine long years, the final phase of this lengthy project is complete and to be opened in the latter end of summer 2008.

Before beginning the project, Array and CMC sized the department based on a capacity and population analysis from Health Strategies and Solutions, Inc. and looked into six possible campus locations for the new ED over the course of a year. They finally opted to expand in place; building over and around the existing Emergency Department. Today, the current Emergency Department is double its previous size.

The set-up of the new ED is a mini-hospital within a hospital. Community is a comprehensive self-sufficient unit, with services in diagnostic imaging, cardiac, emergent care, adult and pediatric quick care, point of care lab testing and crisis services, which means patients never need to leave the department to be treated. In order to serve a growing population of retirees, the separate ambulance entrance was designed to feed into a special rapid assessment and cardiac treatment area, as many patients seen are coming in suffering from strokes, cardiac discomfort and other related issues.

The concept of the self-sustaining ED, also with EMT & paramedic support areas, and a patient treatment area dedicated to psychiatric care and crisis unit, allows the Emergency Department at CMC to function on its own without relying on other hospital services. According to a 2007 Press Ganey ED survey, patients who qualify for fast track care (patients with less severe injuries or illnesses who are not likely to be admitted) will leave the Emergency Department more quickly.

InnovationThe makeup of patients at CMC is unique in itself, as their patient volume per year is approximately 95, 000 with a capacity of up to 120, 000, and physicians seeing around 280-300 patients per day. The new ED consists of a total of 78 treatment areas including 7 triage and 14 fast track exam rooms and 40 adult exam rooms. They are separated into four clinical patient treatment “pods” to minimize travel time for staff and maximize efficiency. The pods are specialized as follows: psychiatric screening and crisis intervention, major treatment, cardiac treatment, and emergent patient treatment with a central multi-positions triage suite supporting all pods. Consistency between pods further enhances staff efficiencies; supplies are located in the exact same place in each pod. Collocating physicians and nursing staff in each pod allows for the quick and efficient sharing of patient information and treatment needs. The former ED set-up, a large open setting with many curtained patient positions and a nurses’ station in the middle, no longer met CMC’s needs due to the largely geriatric population whose conditions require privacy and more space per patient. The pods are unique in that each room is private, with walls and doors, rather than cubicle curtains, separating one patient from another. Additionally, staff enters from a central staff area while patients and visitors enter from a public corridor feeding into the pods.

Thanks to this dual hallway system with separate public and clinician circulation, patients don’t see one another or any clinical space, reducing their anxiety level, which is a product of evidence-based design that Array strives to produce as per their mission statement. “The new design has become better for treating 93, 000 patients per year,” said Dr. Laurence DesRochers, Chairman of Emergency Medicine at CMC. “The old ED was built for 45, 000- 50, 000 patients per year so it was cramped. The pod system works for the population and number of patients we are seeing.”

Dual hallways allow for less congestion, a quieter experience and allow patients to go directly to their room without seeing other patients being treated. This attention to the patient experience is part of the model around which the new Emergency Department was designed. The organization of the facility, as well as the patient environment, were designed to create a soothing, healing environment to make every patient’s experience as pleasant and calming as possible by way of colors, textures and materials that promote quality and comfort. The rooms at Community Medical Center exemplify Planetree ideals as they are focused on the patient’s comfort and well being. “The new Emergency Department allows CMC to handle growing volume and incorporates patient privacy in the pod rooms,” said Frank Gelormini, Vice President, Administration, of Community Medical Center. “Our treat and release times have been reduced and overall department efficiency has been improved. Anytime we can have increased throughput, we know it’s a great design.”

Not surprisingly, one of the chief complaints and issues that hospitals face regarding Emergency Departments is the lengthy time patients spend in hospital waiting rooms when they need to be treated. This is due to the national crisis of lack of hospital beds both in the ED and for admissions. Community Medical Center was designed with patient comfort and satisfaction in mind as another unique aspect to the design at CMC is the spacious lobby and waiting areas. “Our philosophy was that the waiting area should be for families and visitors, not patients,” said Array HFS Co-Founder & CEO Doug Lindsay. Vending machines, bathrooms and other positive distractions are all right there for the comfort of all individuals involved in the hospital-visit experience. Additionally, the waiting area is broken into smaller clusters so that families and loved ones are not on top of one another, allowing for more private spaces during what could potentially be a difficult time. According to Press Ganey’s 2007 Emergency Department survey for patients, improvements to Emergency Department’s waiting areas can help improve patient satisfaction during an ED wait.

While the concept of the “no-wait ED” has not yet become a reality because it hinges on throughput and the number of beds physically available (if there aren’t open beds at the moment, there is no choice but to have a wait), the CMC Emergency Department was designed with wireless technology so that when patients come in after triage, they are able to be registered bedside. Although bedside registration is used at Community today, there are limitations due to the speed of the wireless system. It is anticipated that this will be corrected in the future with infrastructure upgrades. However, bedside registration in itself is a huge step, greatly adding to patient satisfaction and the reduced time spent in the ED, which is currently down to approximately 120 minutes per patient from the time of entry to being discharged or admitted to a nursing unit room. According to a 2007 Press Ganey ED Survey, the average wait time in EDs was 4 hours and 5 minutes. Bringing it closer to home, New Jersey’s average wait time was 248 minutes in 2007, with an average of 108, 443 patients per year, and the 3rd highest in all 50 states. As evidenced by this data, time spent in Community’s ED is considerably less than the average wait time both nationally and locally. Another patient-friendly amenity, a new parking garage dedicated to ED patients and visitors, was designed by Array in pre-planning due to the lack of surface parking. Now with ample parking, the adjacent garage allows patients to walk under a clear skylight canopy directly to the ED, protecting them in cold and inclement weather. If arriving at CMC by ambulance, the ED ambulance entrance leads directly to a rapid assessment and cardiac treatment area for assessment prior to placement in a pod. The multi-bay ambulance entrance is located near the major treatment pod

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to allow for quick reaction to critical patients. In addition, Array designed a 15-bay geriatric and secure holding facility for the hospital to accommodate the largely geriatric population in the Toms River area.

The time taken to complete this project can be attributed to the lengthy planning, documentation and multiphase process that lasted for nearly four years as a result of the decision to expand in place. The great success of the finished project can also be attributed to the extensive planning and design process. The project was finished both on-time and slightly below the GMP. Principal, Phillip Moffson of Array believes that the smooth construction process was due to “open and ongoing communication and coordination between the hospital, Array and the Construction Manager, the thorough planning process due to complex phasing, and the benefits of a significant mock-up for ED staff to stimulate Emergency Department activity in a nearby off-site warehouse.”

The mock-up consisted of five exam rooms, a nurses’ station and two dictation rooms before construction of the project even began. This was the largest scale mock-up Array had ever produced, which allowed all involved to see and understand what the ED would look like and discuss what worked, what did not and what needed to be changed. This served to greatly reduce changes during construction. ”The ED mock-up undoubtedly saved Community in change orders. Having the physicians and staff see a full size treatment room prior to construction went a long way in their support of the Unit,” said Vince DellaDonna, former Director of Planning & Design for Saint Barnabas Healthcare System.

Another key factor to the success of this Emergency Department project was the CMC staff involvement. Participants included 15-20 staff including doctors, nurses and hospital representatives who were present at every meeting for over two and a half years. The hospital also hired a head nurse to oversee the project and work alongside Array and the Construction Manager as the main liaison during planning, design and construction.

Challenges & Complexities The most significant challenge to the project was to keep all major services running without disrupting operations while construction was going on around the existing ED.

Since the existing facility was expanded in place, the department had to remain fully operational at all times. This required a complex phasing plan that included detailed phase-by-phase information for the Construction Manager on the job, Barr & Barr Inc., as well as hospital administration and staff. Keeping operations, as well as communication, ongoing while construction went on was difficult; the ED had to remain open 24/7 with patients constantly arriving and being treated in the facility. Array, Barr & Barr and CMC all treated this situation with necessary sensitivity, literally working around existing departmental operations.

While there were many complexities surrounding this project, the most challenging aspect was moving the mechanical/electrical room from the first to the third floor without disrupting operations. This work took nine months to complete. The electrical room controls all major services for portions of the Emergency Department, Operating Rooms and other areas of the building, so conducting the move while remaining operational was an especially intricate maneuver. Fortunately, this move went extremely well due to the advanced planning and timing preparation prior to the actual move.

Other challenges included creating multiple temporary access routes for ambulances throughout the duration of construction and maintaining adequate treatment capacity during construction. Due to the significant patient volume, CMC mandated that they have available pre-construction patient treatment capacity during all phases. As such, it was compulsory to prepare new spaces prior to closing and vacating the existing ones.

Despite all the challenges to this project, the outcome was positive and people at Community and in the Toms River community are pleased with the finished product. “We achieved the project within the time frame and within budget,

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meeting the needs of the users, the design intent of the architects and maintaining hospital operations, and we did it all safely,” said Keith Stanisce, Executive Vice President/Director of Operations of Barr & Barr Inc. Builders. “That is an accomplishment in itself, with the final outcome being successful, mainly due to the communication in phasing and solid working relationship of all involved.”

ConclusionIn today’s day and age, 40% of admitted hospital patients come through the Emergency Department. The ED acts as a front door to the hospital, and patients deserve to have a positive experience there. With private treatment rooms for privacy, bedside registration for improved flow, point of care lab testing and dedicated imaging within the department, throughput is accelerated to allow patients to cycle through quickly. The new ED at Community Medical Center makes patients, family members and the community feel confident of their care and the environment in which it was received; meeting CMC’s initial goal of making throughput both better and faster for patients. In addition, the staff and physicians find the new department to be running smoothly and efficiently, which was a key goal of the renovation and addition.

A display in the front lobby of CMC boasts “Our Community is Growing and So Are We.” With 78 treatment rooms for rapid response and quick treatment, quick care for adults, pediatric care treatment of minor injuries or illnesses, expanded radiology services dedicated to ED patients, expanded cardiac trauma treatment areas and expanded EMT and paramedic support areas, CMC is doing everything in their power to provide the best possible care to its large patient population and rapidly growing community.

When this project began nine years ago, a bet was made at a bi-monthly meeting that would become a typical part of life for Array HFS architects, Barr & Barr Inc. Builders and Community Medical Center representatives. The bet entailed how many project meetings would be conducted prior to the completion of the new ED. As the number nears 140 meetings in nine years, everyone seems melancholy to see the end in sight. Friendships have been forged among all parties involved in this long, but successful project.

The culmination of Community Medical Center’s Emergency Department is nine years in the making, and has ended in a success story for all involved. The innovative pod structure, dual hallway system, detail to patient and visitor needs as well as patient processing techniques make this a model to look to for years to come. It is truly a patient-friendly Emergency Department ahead of its time.

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Emergency Department Floor Plan

Pod Staff Area

ED Canopy to/from Parking Garage

Typical Pod Exam Room

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