KAISER SAN RAFAEL MEDICAL CENTER: Creating a New, State-of-the-Art ED

Thomas Meyer, MD

Kaiser Permanente physicians first opened medical offices in San Rafael in 1958 on the 4th Street “Miracle Mile.” In the early 1960s we bought the wooden A-frame structure at 99 Montecillo Road in Terra Linda. When our existing hospital at that site opened in January 1976, the Emergency Department was state-of-the-art. But the practice of medicine is ever-evolving, so when I came to San Rafael straight out of residency in 1992, the ED was already showing its age. This was especially evident as I’d had the good fortune to move into a brand-new, 60-bed ED in the second year of my residency in Cincinnati.

Plans to remodel or replace the ED had been on the books at least five years before I arrived. New versions were drawn, then scrapped at least four times over more than 20 years. And while I am very proud of the great care we’ve always given our patients, for much of my career it seemed we did so despite our physical layout. So when we finally received the green light in 2009, we were very excited to begin, from scratch, on plans for an all-new ED.   Dr. Meyer is chief of the Department of Emergency Medicine at Kaiser San Rafael Medical Center.

From the outset we felt extensive user input would be crucial for success. To their credit, the architects were more than willing to collaborate. Thus, my managers and I were given near total control over all aspects of the design, as long as we stayed within the approved size and scope of the project. Throughout the process we had guidance from our outstanding in-house development team headed by Willa Jefferson-Stokes.

The most obvious thing we needed was more space (the old department was 7,000 sq. ft.; the new one is 17,000 sq. ft.). Simply following modern hospital building codes delivers more space. The key, however, is to make sure it’s organized in a way that allows you to deliver optimal care. There were many issues to address.

Standardize room design
In the old ED, each room was unique. While this might add charm to a bed-andbreakfast, it’s a real pain in an ED, and as health care professionals, we always look to minimize pain. Some rooms had two beds, some had one. Some had a monitor and medical gases, some did not. A few had overhead procedure lights but most did not. Equipment in one room was not likely to be in the same place in any other room. Whatever was needed, you always had to think twice to find it. This wasted precious time and energy many times on every shift.

In the new ED, every room is private. Except for minor variations made necessary by columns and bracing, nearly all rooms have an identical layout and equipment. Even special-purpose rooms such as trauma, GYN, negative pressure and ENT/eye rooms hew closely to the layout principles of the standard rooms. Thus, physicians and staff don’t have to reorient each time they enter a room. This greatly facilitates patient care as well as the stocking of rooms.  

Organize rooms for optimal patient care
Removing barriers to optimal patient care produces better care. And what is more important for safe patient care than effective hand hygiene? Left to their professional instincts, architects like to save on plumbing by having sinks share a wall between rooms. Yet because physicians are trained to always examine from the patient’s right side (to do otherwise is like trying to play a guitar backwards), if the sinks were placed according to the architects’ training, half the time doctors would have to cross the room to wash their hands before and after an exam. Less hand washing could result. If hands are always washed as they should be, precious time and energy would be wasted. In the new ED, the sink is on the right side of the gurney, just inside the entry to every room. No time wasted. Clean hands always.

Patients are more comfortable when a physician is sitting at the bedside rather than towering over them. Studies have also shown that patients perceive that a physician who sits spends more time with them than a physician who does not, even when they are in the room for exactly the same amount of time.

In the old ED, rooms were cramped, cluttered and outdated, so sitting at bedside was often not possible. The new ED provides dedicated space for physicians and nurses to sit at the patient’s right Marin Medicine side. This space has an adjustable-height exam stool and is clear of any potential obstructing objects such as IV poles, monitors, computers, patient warmers and storage bins, all of which are mounted on the walls. Family has dedicated seating on the opposite side of the gurney to avoid the awkwardness of a seated person being displaced.

Computers, now essential to effective medical care, have become omnipresent in the exam room. However, they can take your focus off the patient. We wanted to mitigate that so we used wall mounts selected for their ability to allow the monitor and keyboard to fit onto the user’s lap. While the computer folds nearly f lush with the wall, it extends up to six feet into the room when in use. This makes it possible to access our robust electronic medical records from a patient-friendly seated position, making frequent eye contact while taking a history. Wall mounting also frees floor space to stow the Mayo stand under the computer, which keeps the bedside uncluttered.

Placing items needed for patient care in a consistent and easily accessible place in the exam room also facilitates great patient care. This includes items the physician needs such as otoscope/ophthalmoscope, tongue blades, guaiac cards and reflex hammers as well as nursing items such as Band-Aids, glycerin swabs, urinals and 4x4s. With so many items in every room, order is paramount (more on this below). Everyone’s job is easier and gets done more reliably if supplies are always readily at hand.

Make rooms universal to avoid bottlenecks in flow
The old ED had rooms for low-acuity patients and rooms for high-acuity patients, rooms for patients needing procedures and for those who did not. If the patient flow did not match the room mix, a bottleneck resulted, even when the department was not full. Suture rooms were a particular problem as we had only two.

In the new ED every room has an overhead procedure light, full monitoring capability, med gases and suction. Except for the ENT/Eye room, with its specialized equipment and supplies, every room is set up for nearly every type of patient complaint. Three mobile procedure carts are dispersed strategically around the department and can turn any room into a suture room.

Create distinct work and family zones in each room
In the old ED, lack of consistent room layout caused staff and visitors to frequently bump and apologize for being in each other’s way.

In the new ED, the left side of the room (to the patient’s right) is set up as the “work zone.” The right side is set up for family/visitors. The head wall (and thus the gurney) is slightly biased to the right to give ample room for a doctor and nurse to work (on the left side) simultaneously. This extra space also facilitates bringing EKG and ultrasound machines to the bedside. Because the sink is always on the left in the work zone, hand washing never means moving very far or asking family to move. Linen/supply cabinet, sharps containers and wall-mounted “tilt-out bins,” which hold all the items needed for patient care, are also in the work zone.

The right side of the room is optimized for visitors. Two folding chairs are provided in the right rear corner. This comfortably positions visitors at the bedside but out of the way of physicians and nurses. Clothing hooks with belongings bags mean that Mayo stands and exam stools don’t get used for this purpose. There is a TV in the left front corner of every room, with the speaker and control on the nurse-call device, allowing volume to be kept to a minimum.

While TVs are a great patient satisfier, their real value lies in the future. We hope to connect the TVs to the electronic track board someday. This will turn them into real-time status boards keeping patients informed of the names of their care team and what tests are pending. In the future Marin Medicine they will also bring instructional videos to the bedside.  

Encourage physician collaboration without creating a barrier between physicians and staff
A space for physician collaboration was a feature of the old ED that we wanted to keep. A physician workroom allowed up to six ED docs and consultants to work side by side. This encouraged a natural clinical collaboration. Thus, patients with challenging problems benefited from collective experience. It also contributed to professional satisfaction and prevented isolation and its attendant burnout.

In the new ED we wanted to maintain and improve upon this. We provided a work area with eight stations at the center of the ED core, partitioned by a half wall. This provides physicians with privacy while seated but a view of the entire critical care area when standing.

The old workroom, completely enclosed by full-height walls, had a single door. This tended to separate physicians from nurses and created an area that some staff found intimidating. The new area is open on two ends and is much more comfortable to enter. In addition, nurses and physicians can easily communicate over the half wall, kept to 52 inches for that purpose. The physician work area is flanked on both ends by nursing workstations. This arrangement greatly enhances communication.  

“A place for everything, and everything in its place”
While I am no fanatic for organization at home, at work, I have to be. With approximately 120 people sharing a workplace, there is simply no room for individuality when it comes to where to put things. Without order there is chaos.

A new department space was a great opportunity to create order. Every drawer and shelf is compartmentalized to hold a single item type. Every bin is labeled. Items frequently needed in the treatment rooms are stored in clear, wall-mounted tilt-out bins or in the linen cabinets. Less frequently needed items are stored in the clean utility room on large carts or shelving units.

Small minor-procedure carts are dispersed throughout the department. Alcoves are abundantly provided so these carts do not sit in the hallways. Stackable wheelchairs are stored “grocery cart style” in alcoves in three corners of the ED so they are always at hand but do not clutter up the department. Similarly, EKG machine, ultrasound units, suture carts, crash carts and even hall gurneys have dedicated, labeled alcoves.

In the resuscitation rooms there are airway carts and critical-procedure carts. These are “stocked and locked” with an individual tear-away lock on each drawer so that, at a glance, nurses can see that their rooms are ready for critical patients.

In every room there is a rectangle of different-colored flooring indicating exactly where to position the gurney. In the resuscitation rooms, this means the gurney is always four feet from the headwall. This, and the strategic running of all IV, O2 and monitoring cables from the left side mean that a physician always has an unimpeded path to the head of the bed for critical airway management.  

Other features
Just behind the greeter desk are “rapid care rooms.” There, patients with minor problems can be treated without being brought into the hustle and bustle of the main treatment core. A family conference room, also outside the core, is designed to provide a warm, non-clinical feeling for sensitive conversations between family and staff. An administrative wing accommodates management offices, a lounge, staff lockers, restrooms, showers and a conference room for meetings and education.

While it was long in coming, we think our new ED is a model for providing optimal, efficient patient care. If you have occasion to need it, we hope you will agree!

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Dr. Meyer is chief of the Department of Emergency Medicine at Kaiser San Rafael Medical Center.
Email: thomas.meyer@kp.org