Low-Fidelity ED Design Solutions

Published on October 29, 2015
Just because a hospital lacks reliable electricity, adequate staff numbers or fancy machines doesn’t mean it can’t take advantage of high design. Enter “frugal innovation.”

Keeping Cool: (TOP) The roof overhang protects the south facade from direct sunlight during the hottest part of the day. Air is brought in from low windows while operable clerestory windows and openings in the ceiling allow warm air to escape. Basic fans in the plenum facilitate air movement.

Winter Warmth: (BOTTOM) A lower sun angle allows direct sunlight and heat gain deep into the patient room. Baseboard units provide radiant heat, while fans bring in tempered fresh air and circulate it throughout the building.

Talk to anyone who designs healthcare environments about what needs to be included in a new emergency department (ED), and you will hear very strong opinions about what constitutes the “best” in ED design. Many in the industry have advanced recommendations for all-private treatment station models, in-house imaging, ceiling-mounted equipment booms, observation units, and utilization of new technologies. While these recommendations can result in successful solutions, they assume access to a number of resources that facilities in the developed world take for granted. Hospitals in many parts of the world are questioning how to design and operate an ED when reliable access to electricity, clean running water, wired or wireless high bandwidth telecommunications, medical gasses, and even capital for design and construction, is limited. In many cases, conventional solutions, such as large photovoltaic farms, wind generators, and drilling deep wells are not only impractical but cost-prohibitive as well.

Enter low-fidelity design. Enter frugal innovation.

Notions of low-fidelity design and frugal innovation are front of mind in many parts of the world. In an article penned in Harvard Business Review, the authors contend that many organizations are turning to frugal innovation in response to over-engineered and costly products, as well as the reduced availability of a number of natural resources including water, minerals and wood.(1) However, healthcare solutions cannot simply be about doing more with less; rather, it is the necessity of creating affordable, quality, reliable, and sustainable solutions that help advance performance.

How exactly does a hospital in a low-resource environment design an ED that can function even when the power supply fails? The answer rests in leveraging what is available in abundance, determining what can function without other prerequisites, and identifying what does require significant financial resources to build, own, operate, or repair.

RETHINKING PATIENT ACCESS AND COMMUNICATIONS

In many parts of the world the technology revolution has leapfrogged hardwired voice and data communications in favor of wireless technologies. In 2013, the China Internet Network Information Center reported that 79% of citizens in rural China relied on mobile phones to access the Internet.(2) In 2014, mobile phone ownership rates were at 83% in Ghana, 82% in Kenya, 73% in Tanzania, and 65% in Uganda.(3) In parts of Latin American and the Caribbean, mobile phone penetration has exceeded 100%, based on the number of phones per resident.(4) Understanding this, healthcare innovators have been exploring how wireless communication technologies can support virtual patient access. The ED is well-positioned to take full advantage of these emerging technologies.

“Do I really need to go to the ED?” Redefining patient access for emergency care can be as simple as rethinking who does and does not need to seek emergent, in-person care. Phone calls, mobile technologies with clinical capabilities, and real-time “virtual” appointments can all help assess patients’ need for emergent care well before they arrive in the ED.

Early studies using telephone consultation for non-serious emergency ambulance service patients in the UK has demonstrated that decision support in conjunction with telephone consultation can be a safe way to provide support to lower-acuity patients requesting ambulance service.(5)

Designers in India have been focusing on helping patients identify when it is time to seek in-person medical care through technologies such as LifePhonePlus, a mobile device that allows anyone with a mobile phone connection to obtain an electrocardiogram, evaluate blood glucose levels, and communicate with clinical specialists, avoiding unnecessary travel. Using Bluetooth or WiFi technologies, the LifePhonePlus device collects information, transmits it to the user’s mobile phone, and then on to a health provider. The provider can then transmit medical advice back to the user’s mobile phone or instruct the user to seek medical care as soon as possible.(6)

Does that laceration really require a visit to the ED? A study assessing the efficacy and patient acceptability of using mobile phone images of acute wounds to transmit information to a remote physician for diagnosis and treatment demonstrated strong patient acceptance for the approach with few concerns regarding privacy and security.(7) The advantages to this approach are clear: in remote and resource-limited environments, leveraging tele-technologies can reduce unnecessary ED visits with concomitant reductions in overall cost of care delivery, as well as patient inconvenience stemming from excessive travel distances and diagnostic delays.

Recent research has turned to assessing the feasibility and efficacy of patient-initiated internet-based urgent care visits via Skype®. One such study looked at 16 different chief complaints, each with a list of “red flag” symptoms warranting an immediate in-person clinical evaluation. The study demonstrated that none of the patients using the online encounter approach required referral to an ED.(8) Other studies have demonstrated the effectiveness of leveraging telemedicine to manage chronic diseases such as diabetes, hypertension, and hyperlipidemia.(9) The time is not far off when we will use these technologies for things like ED post-discharge follow-up and remote-ED management of chronic disease decompensation for conditions such as congestive heart failure and asthma or chronic obstructive pulmonary disease.

In many parts of the world, the infrastructure for remote monitoring and follow-up already exists. For example, a study of children presenting to an ED in resource-limited western Kenya showed that 89% had access to a mobile phone, and, in 84% of those instances, successful post-discharge follow-up was made using the mobile phone.(10)

LEVERAGING TECHNOLOGY FOR EMERGENCY MEDICAL DECISION-MAKING, CARE DELIVERY AND DIAGNOSTICS

In many clinical environments, significant monies are spent during the design process to acquire expensive technologies to support patient care and diagnostics. This is done sometimes at the expense of investments in facilities, human capital, or other equipment and technologies that would yield a higher return on investment. At the same time, the use of lower-cost technologies in supporting care delivery and diagnostics may not be fully realized.

How can we perform lab studies without a lab analyzer? Prick finger, apply blood to a device with a paper filter, view results on bottom side of device, digitize results, send images to technician via telemedicine, and incinerate hazardous waste. Micropatterned devices currently exist that can assess aspartate aminotransferase (AST), alkaline phosphatase (ALP), alanine transaminase (ALT), lactate dehydrogenase (LDH) or total bilirubin levels.(11) Similar devices exist for assessing hemoglobin levels. Hemospec is a portable device that can assess hemoglobin levels to within 2 g/dL. Using inexpensive chromatography paper costing less than $0.01USD per test, the portable technology, currently in testing, can deliver fast, reliable diagnostic information.(12)

Even when whole blood for laboratory analysis is required, low-fidelity innovation can play a role. In many resource-limited environments, technologies as simple as a blood centrifuge are limited in availability. In others parts of the world, the equipment is available but the power to operate it is either absent or unreliable. Seeking a solution that will provide reliable capabilities in these environments, a team of undergraduate students developed a hand-powered centrifuge designed from a “salad-spinner,” hair combs and a round plastic container, all assembled using hot glue. Using a reader card adjusted to the outputs of the hand-powered centrifuge, the technology provides packed cell volume measurements that correlate with conventional centrifuges.(13)

What if I need to take the care to the patient? Backpacks housing mobile technologies are another novel solution appropriate for highly remote clinical environments. A number of different configurations of backpacks have been used in South America and Africa to bring diagnostic and management resources to resource-limited settings. The backpacks, some of which are powered by battery packs affixed with solar panels, allow providers to address conditions ranging from hypertension to diabetes, anemia and malaria, and can include technologies such as glucometers, urinalysis strips, and first aid supplies.(14)

We really want to incorporate ultrasound in the ED, but can we afford it? With ultrasound taking on a greater role in ED care, finding low-cost, low energy solutions can help further advance this vital technology. Portable, hand-held ultrasound technologies are already in use today. Clinical users in resource-constrained environments have found these technologies to be valuable in practical clinical application.(15-17) Portable ultrasound solutions provide battery-powered scanning capabilities at a fraction of the cost of a traditional ultrasound unit.

DELIVERING CARE WHEN ELECTRICITY OR ACCESS TO CLEAN RUNNING WATER IS UNRELIABLE

No electricity? No problem. A team from Rice University in the US has developed a technology that uses nanoparticles to convert solar energy directly into steam, operating with efficiency levels that allow even ice-cold water to be used in the process.(18) The technology facilitates sanitation and water purification and can be employed easily in remote locations and developing countries. The space requirements for the technology are limited compared to traditional photovoltaics, which can be cost-prohibitive and require acres of solar panels. Students at Rice University have already used this technology to develop steam-powered autoclaves for sterilization of medical and dental instruments in clinics lacking electricity.

In Nigeria, a physician struggling to operate a medical clinic with unreliable electricity supply has been designing innovative solutions to respond to the unreliability of the power grid, and the high cost of purchasing fuel to operate electrical generators. Among his design solutions are blood centrifuges operated by bicycle pedal-powered ingenuity, bicycle pedal-powered surgical suction pumps, and a boiler fueled by corncobs that feeds steam to homemade autoclaves.(19) In parts of the world without reliable electricity supply, these design innovations have the ability to support more advanced diagnostics and management in the ED. An added benefit of these self-designed technologies is the ability to make repairs when malfunctions occur without having to rely on expensive and often delayed replacement parts.

In situations where access to clean water is limited, portable solutions exist that can use any available water to produce sterile water for injection, sterile purified water, and water for dialysis. These devices can provide an alternative to the transport and storage of packaged sterile water in remote locations.(20)

DELIVERING SUPPLIES TO DIFFICULT-TO-ACCESS LOCATIONS

For some EDs in highly remote or isolated locations, replenishing needed supplies and medications can prove daunting. Flirtey Inc. has developed experimental unmanned aircraft technologies—drones—that facilitate deliveries of medications and other supplies and equipment to remote locations. The technology, currently in the testing phase, can accelerate delivery of necessary care. Several companies, including Google and Deutsche Post DHL AG, are testing similar unmanned aircraft technologies around the globe.(21,22)

MAKING ROOM IN THE ED FOR NEW INNOVATIONS

How does all this inform the design of a new ED in a remote or resource-limited environment? Planning an ED in such an environment requires exploration of available resources, known limitations, and low-cost, low-fidelity solutions that respond to the conditions of the physical environment.

Simple design solutions can support better environments of care. Naturally-ventilated architecture can be designed to respond to both warm and cool environments. Well-placed windows and skylights can afford natural lighting and cross-ventilation. Water collection and storage devices can hold rainwater run-off for medical and non-medical use, while shaded courtyards can pull natural light deeper into a building while providing shaded areas for patients and staff, and cooler air to support internal building ventilation. Each of these solutions can be enacted without electricity and without access to running water.

In conjunction with these facility-based solutions, the remote or resource-limited ED needs to support the burgeoning use of wireless, mobile, and unmanned technologies that support improved access, diagnostics, and medical decision-making. Spaces for telemedicine consultation, storage of portable devices and supplies, and ample locations for wired or photovoltaic charging of battery-operated devices is essential. The ED of tomorrow will be as much about virtual care and consultation as it is about in-person interactions today. New EDs should be planning for the eventuality of the unmanned aircraft deliveries. We must give careful consideration to how low-fidelity design solutions and frugal innovation can and will prove transformative for patients and providers alike.

Disclaimer: The author of this article has no financial or academic interest in any of the products or technologies presented and the contents of this article should not be considered endorsement.

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