Research shows that emergency departments (EDs) continue to be undersized, understaffed, and challenged with operational issues that cause decreased patient and provider satisfaction. The ED is at times the initial point of contact for a patient with the healthcare system and may be their first hospital experience. The role of design is significant to support the overall care experience within the built space.
This systematic literature review examined features within the emergency department environment that influence patient experience and identified methods used to determine challenges to patient-centered design.
Eight databases were used for the search: Web of Science, Scopus, PubMed, CINAHL, Medline
[Ovid], Compendex, IEEE Xplore, and PsycInfo. A supplemented search occurred via Google Scholar. No publication date limits were applied; however, only English language articles were included. Keywords used were variations based from the following: ‘emergency department,’ ‘emergency room,’ ‘ED,’ ‘ER’ and ‘health facility design,’ ‘health environment,’ ‘patient experience,’ and ‘patient satisfaction.’ After duplicates were removed, records were appraised for three inclusion criteria: English, full text availability, reported in a peer-reviewed academic journal, and presentation of evidence about ED patient experience. Articles were rejected if findings were not specific to the patient experience or if they were determined to lack rigor. Given that identified articles were from a variety of different disciplines, a co-citation analysis was also conducted. This means that the citation becomes a unit of analysis, and journals that were cited at least twice within the accepted articles were included. This method permits an examination of literature across diverse sources and maps the connections between these sources.
After a final group of articles was determined, researchers extracted the title, abstract, journal name, and publication year. If an article was determined eligible, researchers completed a full text review which included study type, research methodology, and geographic location. Independent coding and subsequent agreement was achieved between the two authors. A qualitative synthesis of findings occurred instead of a meta-analysis because of the heterogeneity of the studies.
A total of 35 papers were included in the review of publication dates and geographic region of the authorship. Eighteen of the articles were published in the last five years, 20 in the last decade, and half were authored by investigators in the United States. Co-citation analysis was conducted for 33 of these articles, which showed that literature is concentrated in emergency medicine and healthcare environments research journals, as well as some nursing journals. Themes were as follows:
Physical and operational dimensions: Overcrowding and wait times were associated with the perception of service value. Distance between the clinician area and treatment rooms substantially delayed assessment times, as well as presence of doors rather than curtains. Reorganizing process flow and providing rapid assessment services were more effective for improving patient experience than facility expansions and renovations, which tended to increase overall length of stay. Multiple articles described use of lean techniques and tools to evaluate throughput and augment the facility layout (e.g., process mapping, value stream mapping). Privacy and security were commonly mentioned as having a direct correlation to patient satisfaction. Provider satisfaction pertaining to privacy and security included workspaces, de-stressing rooms, and traffic management.
Sociopsychological dimensions: The changing acuity of patients is associated with differences in wait times. Changing ambient lighting and including small interventions (televisions, coffee machines, and other spatial details) support physical comfort during periods of waiting in the seating area while in different emotional states/discomfort levels associated with different acuities.
Implementation and evaluation dimensions: Physical elements of design must be taken into consideration during the initial design stage, given the impracticality of changing them once the facility is built. Multimethod approaches should be taken to garner insights that inform design decisions (e.g., surveys, interviews, walkthroughs, journey mapping).
Only articles written in English were included and articles may have been inadvertently omitted given variations in the way emergency departments are described and health design is conceptualized. The search strategy omitted terms associated with specific design attributes (e.g., lighting), as they were beyond the scope of a single review. Because articles focused on staff experiences were deemed ineligible for this review, issues related to usability, burnout, and violence toward ED staff that might impact the patient experience should be considered in future work related to patient experiences in the ED.