Entry Strategy

Published on February 7, 2013
In part II of EPI’s ED design series, Dr. Manuel Hernandez explains the importance of rethinking your emergency department’s front door experience.

In the 1970’s there was an American shampoo commercial that coined the phrase, “you never get a second chance to make a first impression.” This Madison avenue catch-line applies as much to emergency departments as it does hair products. The experience patients have upon entering an ED can impact the overall length of stay, for better or worse. Many clinicians are unaware of the steps in the patient care process that occur at the “front end,” out of the sight line of the clinical areas. Yet often, it’s these very first elements of the patient encounter that contribute to over-crowding, declines in clinical quality, lower patient satisfaction, and spiraling costs.

The impact of ED overcrowding cannot be over- stated. Regardless of its cause, crowding has been demonstrated to have deleterious effects on morbidity and mortality, particularly for patients requiring inpatient hospitalization. Effects ranging from increased length of stay in the ICU and increased mortality have been tied directly to ED crowding (Richardson, Bernstein, Pines, Sprivulis).

You might think that EDs just need to be bigger, but you’d be wrong. A 2007 study evaluating ED expansion showed that increasing treatment stations did not impact targeted performance metrics. ED treatment station expansion actually resulted in increases in total length of stay and length of stay tied to admission holds (Han). Studies such as this point to the need to fundamentally rethink how patients access and utilize the ED with a focus on accelerating the phases of care under the control of the ED while we continue to wage war on access block.

There’s no better time to rethink the patient arrival process than during the design and construction of a new or renovated ED. Planned properly, a new patient arrival experience can accelerate care, reduce overall length of stay and mitigate crowding. The most optimized emerging ED designs are those that are informed by and responsive to processes, human capital models and technology acquisition strategies in such a manner that the ED is designed to support each effortlessly.

The remainder of this article will review recent innovations in the patient arrival process from entry through the point of placement in a treatment station while discussing the best-in-practice design implications of these innovations.

Clinical Greeters

The first step begins at the front door through the use of a clinical greeter. In the clinical greeter model, a healthcare professional is positioned at the walk-in entrance of the ED to greet all arriving patients. Typically, the intention of this role is multifactorial. First, the clinical greeter is able to immediately identify obvious emergencies without delays associated with waiting for registration and triage. Combined with the direct bedding model (to be reviewed shortly), the clinical greeter can escort patients to treatment stations without delay. Finally, the clinical greeter, when positioned within proximity to the waiting area, serves the vital role of providing continuous surveillance of the waiting areas to rapidly identify any patients in the waiting rooms that might be experiencing clinical decompensation. Design considerations of the clinical greeter model are relatively simple. As illustrated in the figures above, it’s important that the greeter have a direct line of sight to the walk-in entrance. This creates an intuitive wayfinding process for newly arriving patients. Ideally, the ED would also be constructed such that the greeter can have a direct line of sight to the entire waiting room and, for security and communication purposes, direct access to the secured clinical areas of the ED.


Planning for technology solutions that provide both accelerated time to evaluation and diagnosis and clinical decision support is critical when planning tomorrow’s ED. This is particularly important in moderate-to-high-volume EDs where such technology solutions can facilitate parallel streaming of multiple patients simultaneously. Electronic kiosks similar to those found in many airports have begun to be used in multiple roles in many EDs.

The most common use of electronic kiosks is self-directed patient registration. Allowing patients to self-register has been shown to reduce overall registration time with user satisfaction rates in excess of 90% (Welch). Electronic kiosk systems can also be tied to the larger electronic health record and tracking boards to allow for rapid recognition of patients requiring immediate assessment with subsequent notification of nursing staff. Such systems have been tried at Parkland Hospital in Dallas, Texas and at Newark’s Beth Israel Hospital.

Electronic kiosks are also beginning to be utilized for direct clinical decision support. In a study supporting this approach, randomized females with symptoms suggesting a UTI were guided to a kiosk where a series of questions identified the likely presence or absence of an uncomplicated UTI. The responses were then reviewed during a brief clinical encounter and appropriate treatment initiated. Using this model, length of stay was reduced by 57 minutes with similar time to illness resolution, number of return visits and satisfaction with care as patients not using the kiosks (Stein).

From a design perspective, electronic kiosks re- quire minimal space. Regardless of the number of kiosks employed, they should be positioned in a manner ensuring proper patient privacy and access by patients with mobility issues.

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