Good afternoon and welcome to the Architecture for Hell Friday lecture series.

It's great to have you with us again.

And you're in for a special treat today.

We've been inviting leadership associated with the Center for Health Systems and Design this semester to come and share some of their interests and research Horizon ideas.

Today, you're going to hear from Dr. Michael SPOHN, and I'm going to look closely at his bio so that I don't miss the details.

I understand from him that these details are connected to what he has to share with us today.

So I want you prepared and to know how to listen to his remarks.

Dr. SPOHN is an emergency medical physician, a researcher and educator with 20 years of service in the U.S. Air Force.

Thank you for your service, sir.

Since 2009, Dr. SPOHN has served as an emergency medicine physician at CHB St Joseph Health Regional Hospital, and Brian, a level two trauma center that sees you ready.

More than 50,000 emergency department patients annually and is recognized as a major stroke chest pain and trauma center.

He's received the hospital's Reverence award steward Ship Award and many other honors, and he is consistently ranked among the nation's top medical professionals for patient care and compassionate service.

And I'll testify to that personally from recent experience.

A frequent guest lecturer on stroke research and emergency medical expertise, Dr.

Spawn also serves on the National Clinical Governance Board for U.S.

Acute Care Solutions, which gathers some of the nation's top emergency medical professionals to provide clinical guidance to a company that stewards more than 6 million annual emergency visits nationwide.

He has also led phase two clinical trials in snakebite antidotes, emergent warfarin reversal agents and emergent Noac reversal agents, among many other studies.

So without further delay, would you help me welcome Dr. Michael Spong?

I always thank you very much for having me.

It's an honor and a privilege to be invited to speak in front of you today.

Hours I very humbled to be asked.

And so I was trying to think of, you know, what can I bring to the table here?

And so I ended up going down several rabbit holes to try to figure out what would be the best way to present and just kind of a day in the E.R.

with an emergency doc and just some of the lessons that I've learned and some of the things that I've seen over the last 15 years that I've been practicing here.

It really is a wonderful opportunity to be here with you guys today.

Your impact is above and beyond because of the form.

The function truly follows the form.

And for you guys in the architecture, specifically within the health design arena, to create spaces that allow patients to be treated with dignity.

And many times it may be the last place they see on this earth.

Then there will be times where they'll be huddled in a room and they're waiting for the answers for what happened to their loved ones.

Okay, so what you guys are doing is very, very important.

And so we're going to be diving into all sorts of different ways to approach this problem.

I'm going to give you vignettes.

I'll give you war stories.

I gave you picks.

I'll give you a kind of big ticket items to kind of look for and then also some challenges at the end.

So we're going to be kind of double in this on two sides.

Terrified.

I'm off on lecture or anything like that.

Just raise your hand if it doesn't pop up.

Okay.

As we're going through this.

Okay.

So how facility design could be used to reduce specific emergency department challenges?

Learning objectives.

I'm going to skip through these.

We have to have these because of the sea use.

And then this is introduction.

So do you want to spend the rest of your life selling sugar water or you want a chance to change the world?

That's what John Sculley said to our good friend here when he was first enlightened on it.

And I can't tell you enough of just how much of an impact that that has made for us.

So out of climbing out of the rabbit hole, we're going to go ahead and get started.

So a typical day in the emergency department, 51 year old male presents to room three with the snake bite that occurred over 2 hours ago.

His face is swollen, but his airway is intact.

In obvious pain of distress, however, he's remarkably sober.

You ask him how this happened and he pulls out a smartphone and shows you what he's been doing for a fundraiser in the local community.

Okay.

Does anybody happen to know where this might be?

Okay.

In the room.

Okay.

This is the famous rattlesnake roundup in Tyler, Texas, and it's just outside of Temple.

I mean, between there and Austin.

And what they do is the Jaycees have their annual fundraiser, and this is how they make their money for their charities.

Okay.

So one guy will be in the middle of the ring with a burlap sack and they'll drop ten rattlesnake eggs in this particular area.

And then the other guy will shovel the snakes into the burlap bag.

And whoever gets it the quickest is the winner.

So needless to say, we used to get a few patients from this particular area.

So after insurers, Airway's not immediate demise, you can compliment him on his devotion and love for his local community and working in this raiser.

And then you inform him that the antivenom and the cost of the medicine is going to be in the range of 20 to $30000.

And he responds, That hurts worse than the snake bite.

Case number two, while you're working with this gentleman, a 75 year old male is flown in by helicopter, arms coming into room for Trauma Bay after he is fishing with a lifelong friend as a true case.

He tripped on the dock and struck his head.

His friend called 911 when the patient was not arousal.

The local EMS then called for the helicopter when the patient became unresponsive.

Of note the patient is oxybutynin, which is a blood thinner for atrial fibrillation.

Irregular heartbeat is supposed to prevent strokes.

So this is a CT scan and I don't have sex.

I'm sorry, guys.

I have missed my mark.

I'm just going to go off the top here because it's easier to coordinate.

All right.

Can you guys see that?

Okay.

That was the the burlap sack.

And that's where they're picking up the rattlesnakes.

Okay.

And then these are kind of what he has to do when he comes in to see us.

This is the air flight.

And then this is the the CT scan of the gentleman that fell while I was on Coumadin.

Now, what you can appreciate here is that there's a large bright spot over there on your screen.

It'll be on the left side.

Okay.

On the patients will be on the right side.

And what it's doing is it's pushing up against his brain.

Okay, so he's got a large collection of blood.

And if that blood is not evacuated, he is not going to survive.

Okay, So here he was fishing on the dock, and next thing you know, he's here in the E.R..

Okay.

So he was on a Coumadin.

And before recently, Coumadin took about 24 hours before it would be reversed down to normal because coming at thins, your blood like water.

So if you were to operate on him, why was high with his Coumadin levels, then what would happen is he would continue to bleed and you'd kill him that way.

So it's kind of like you're kind of darned if you do and darned if you don't in those cases.

Okay.

So we have another case that comes in this case number three, a 45 year old female that comes into room nine with transient chest pain and very shortness of breath complaints.

She has a history of hypertension, but no other risk factors for EKG is normal with no acute heart attack.

And she's perc negative, which means she has a low criteria for pulmonary embolism.

The question is, does she need to be admitted to the hospital for further risk stratification and workup, or can she be safely discharged home, thus avoiding significant time and cost to the patient?

Another case is a little girl that comes in and we were concerned about appendicitis with the right quadrant pain.

So we're also concerned about the amount of radiation a young child would have with a CT scan.

So is there a better way to do this besides radiation?

And finally, have a gentleman that comes in with a possibility of a stroke, a 70 year old who has facial droop and slurring of a speech that began about one hour ago.

And after extensive and quick testing, you tell the family that they are eligible for Thrombolytic treatment to treat a stroke.

Okay.

So this is when basically we try to thin the blood to where it would dissolve, theoretically, the clot that's there.

Okay.

The problem is, is that if it turns the blood too much, it will kill the patient.

And about 7 to 10% of the time.

Whereas if we just let it be and try to do rehab, he gets better 30% of the time.

Okay.

So basically, looking at the benefit of a 30% increase in their function versus a 10% chance of killing them with that medicine.

So is there a better way of doing it?

That's what we're trying to get to.

And then finally, you get a trauma that rolls in.

Now, look at this picture.

Okay.

This picture is very interesting because there's a lot going on here.

And at first, you know, you're kind of concentrated on seeing what is going on with the patient.

But then you also see all the other personnel that surround the patient.

So one thing that strikes me in this, there's a helmet, there's a long board.

So that tells you that the patient's been brought in by EMS.

There's also a strap around the right lower extremity, which shows that probably has a long leg injury and the other thing is look at where everybody is right now.

You have somebody up at the top of the head who's about to take care of airway.

But look, it's a little bit they've got some space, but you can kind of tell it's kind of hard getting in and around there.

Okay.

And there are a lot of critical time sensitive tasks going on here.

And so it's very important that you have a set up in these trauma bays that will not only take care of the patient, but also take care of the staff in an efficient manner because there needs to be other folks in here as well.

There's probably needs to be an ultrasound.

There probably needs to be some way to put in a fast transfusion machine which takes up space.

There also needs to be space for the nurses and the pharmacists in the lab to be able to come in there.

And then there also needs to be where radiology can come in there with the portable machines.

So they're doing a nice job here, but it's pretty pretty cramped on this one.

Okay.

So let me back up and just tell you a little bit about who I am.

Who am I?

I'm going to skip this, though, because Rae kind of already covered a lot of it, but I have the privilege to be here at the School of Medicine as a campus dean, where I get to shepherd the next generation of physicians into this wonderful world of medicine.

This is my grandson.

I think he's going to be class at 2036 here at A&M.

We recruit early.

Okay.

And then I also graduated from the Air Force Academy.

These are my then little girls, the one in yellow.

She's a graduate at Texas A&M 2018 maroon coat.

And then she's a schoolteacher and a mother of my grandsons.

And then the other one in purple.

She's actually up at Notre Dame today giving a lecture to them.

She flew over there from Oxford, where she's a Rhodes Scholar.

And then these are some some plain pictures.

I also did some other duties while I was in the Air Force as well.

I graduated out of Tennessee.

We had the memorial trauma center there.

Elvis Presley and War trauma center.

And then I graduated out of chief residency for Scott White over at Temple.

And I have a fantastic program.

And then I actively see patients and teach in emergency department now, which is really wonderful.

So the background of emergency medicine is pretty unique.

It's really become an essential component of the health care system and to provide timely access to care for evaluation and stabilization and treatment of the patient who may be seriously ill or injured.

Now, some rely on AEDs as their primary or sole provider due to economic constraints or limited access to primary specialty care physicians often refer patients to AEDs when their offices are overbooked or when their patients could benefit from the testing services provided by AEDs, particularly during business hours.

So my emphasis is I got a couple of stats on this.

If you called your physician today or your primary and said I had chest.

I have chest pain, 96% will go to the E.R..

Okay.

If you have belly pain, 88% of patients will go to the E.R.

for the evaluation.

It's because the emergency departments have the base to take care of those particular complaints, whether it's appendicitis, whether it's a heart attack.

But it's part of a whole system.

So it's not just the E.R., it's also the hospital system as well.

And a clinic is not going to have a CT scanner.

It's not going to have the ability to run troponins or other specialized tests or seat or CTAs that are hospital care.

And so to get the best care and those kind of emergent complaints, then you need outpatient presentations.

Then you need to have that E.R.

They're at your side to help you out.

So AEDs are often utilized to perform the initial evaluation process in patients admitted to the hospital.

And they account for nearly half of all hospital admissions.

So when we see patients on a regular, you know, during the day, we typically admit about 20 to 25% of those patients.

So out of every hundred 2025 will come into the hospital.

And then out of that, about 15% of them will be critical care patients.

Okay.

Which ones?

That if you don't do anything right now, could be a loss of life or limb or serious disablement.

Now, we're also an effective safety net for the medical care in the United States.

But the ability of the ED is to provide timely and efficient care is far too often hampered by the lack of capacity due to crowding and boarding in particular.

And that's kind of my my call out to the School of architecture.

And today now modern history of emergency medicine, essentially began in the 1960s.

Typically, an E.R.

was just staffed by the nurse, and then she called local physician to come down and take a look.

And then even the ambulances there are really just down by either a pickup truck or a hearse.

So they started to deliver a little bit more funding through the government.

And then they also had more public expectations.

And during this time, they developed a trauma designation system for rapid transport of critically ill patients.

They increased advances in radiology and decreased dances and medicines and acute interventions to prevent diseases such as heart attacks or strokes, increasing population and increasing age of population, and then medical expectations from communities to continue to raise the level of care.

And they all landed at the doorstep of emergency medicine.

Now, the CDC data shows that we see as of 2011, the combined ERs in the United States saw over 136 million visits.

Okay.

Now, just to give you an idea that there's 300 over 310 million in the United States for its population.

So almost half.

And that's not just I mean, there's repeat visits, I'm sure.

But that's an amazing amount of the number for that particular.

And the these are not just benign visits.

CDC said that if they're not seen within 2 hours, you know, 92% of them could suffer an emergent condition.

So you need to be at least be able to be evaluated.

So we also provide mass casualty responses.

And so I'm just trying to get checking my time covered.

Okay.

Who in here had covered OC for OC?

I treated over 6000 patients for COVID, and that was just me.

Okay.

And these are terrible times.

The patients, they would come in and everybody would be isolated from their family members because they didn't want it to give it to, you know, their family members, even though they'd probably already had it just because they were living with them.

You also had your fellow physicians and nurses who would also get COVID.

So here you are treating the sick and then you get sick.

And some of my friends didn't make it.

Some of them passed away from COVID.

Many other ones came in and they were in the ICU for weeks and weeks getting treated for this.

There are also lots of holds.

I've heard stories from friends that work out in rural departments down in South Texas.

They were holding patients in a rural hospital for over four days, intubated in the E.R., which is just unheard of.

And the reason why is because they couldn't find another hospital to transfer them because all the other hospitals were at capacity.

We even had one call from Brazil for a patient to be transferred to Bryan College Station.

It's it's amazing all the different places.

And then you had your free standing and they would have to hold patients as well, because they couldn't transfer them out.

Freestanding E.R.

and I'll talk about those in just a second.

And they would almost run out of oxygen.

They're in danger of running out of oxygen for their patients because they're having to hold them for so long and they increase.

And then you had family risk.

So it's not very often where you go to work.

And then you can bring something home to your family that could potentially harm your family or even in in worst case scenarios, kill them.

We also deal with mass shootings.

We had one a couple of years ago.

Thankfully, we haven't seen too many, but we see too much of this in the news.

Okay.

Unfortunately, we saw it up in Maine already and that lands at the doorstep of the air plant explosions, whether it's chemical plants, Petra Petroleum plants down in Houston area or West Texas, fertilizer, or we see those major vehicle and plane accidents.

And the public health is a disaster such as hurricanes, tornadoes and massive fires.

So when the hurricanes hit Houston, they come up here.

And at one point we even had to set up a mini hospital and a veterinary hospital because there are so many patients from Houston at one point.

So it really is amazing all the things that can be pulled together, you know, in these times of crisis that we can do.

And even during COVID freeze, remember the really bad freeze that knocked out a lot of the power in Texas.

But there were a lot of unfortunate patients that couldn't get to the E.R., especially over in the Austin area.

And they were hit particularly hard and they would end up passing away at home because they couldn't get dialysis or other immediate care because of the power outage.

So it's very, very difficult, guys.

And then, of course, the national opioid crisis and then continued chemical, biological and radiation effects.

It's a good friend of mine, Stephen Saint Pierre, Dr. Stephen Saint Pierre, who treated a lot of patients over in the Maryland area.

So, long story short.

Out of all of those 136 million visits, you're looking at about 2% overall cost of the health care dollar goes to those 136 million visits.

That's pretty good.

Bang for your buck on it.

Okay.

But the financial system is set up and the medical reimbursement system is so Byzantine in the U.S., I don't really know what the answer is on that one, but this is kind of a busy slide.

But there's a couple of things I want to point out.

All right.

1947, Congress started funding expansion and construction community hospitals, Medicare, Medicaid, established in 65 that coincided with the growth of the emergency department.

In 1975, there were 7170 100 hospitals in the US and 1.5 million beds in 2015.

Okay.

There were 5600, almost 5700 hospitals containing less than 1 million beds.

That's a 33% drop.

Okay.

So why was that a drop?

Well, they surmised a lot of it was the advent of expensive new treatments and technologies driving the cost factors up.

And then all the other insurance and Medicare trying to drive the cost down.

It was very difficult for a lot of these hospitals to remain profitable.

Now, there's different types of emergency departments.

I don't know if you guys are familiar with them or not, but I kind of want to give you a little bit of a basic, especially if you're going to be designing the different types, because they all have a little bit different needs, but they also have some commonalities.

You have tertiary referral centers, which are your level one trauma centers, and those are the ones like at Bien Top and Parkland and Baylor, Scott White and Temple.

So they've been designated it as because you want to try to have your critical resources mass together in a certain spot.

So if you have certain injuries, they can take them, especially in your high population areas like San Antonio.

They have three of them down in that area.

So typical be greater than 100,000 annual visits and then typical is greater than 78 rooms.

And then you also have large suburban hospitals, of which we kind of classify ours here at Saint Joseph and then Baylor Scott and right over here in College Station.

And then most of the other Houston kind of suburban suburb area, surrounding areas and then Hermann Memorial.

And they typically see anywhere from 30 to 70000 annual visits and typically have about 30 to 40 rooms.

Then you have your rural hospitals and then they're the ones that are critical access because they're trying to keep open for folks that live in the rural areas so that they can have access to care.

And they typically have less than 10,000 annual visits and they'll have about 6 to 10 rooms much older.

And it's age for the most part as well.

Then you have freestanding emergency departments.

So those kind of came into vogue over the last 10 to 15 years and they kind of exploded almost like gas stations.

But now it's down to about one out of every three has gone away.

So there's just a few of them compared to what they had before.

But they do provide a good service to kind of take out a little bit of the offload.

And so those would include first choice like Methodist has quite a few and then said care, and then typically they'll have less than 5000 annual visits.

Okay.

And then they'll have about 8 to 10 rooms.

And you have your specialty hospitals such as cancer, psychiatric and boutique hospitals.

Now, what happens with each of these emergency departments, they all have similarities but different capabilities to treat patients.

So similarities and broad strokes include immediate, basic life saving skills.

Okay, so that's Intubations, ACLs codes, THROMBOLYTIC CT scans and x rays are there, but typically not MRI.

But your differences are basically a reflection of the hospital population and for which they need supports.

So if it's a large hospital, you're going to have more capabilities within there to help your patients.

And then if it's a small hospital, they're going to transfer out more.

And if it's a specialty hospital, they're going to have more specifics within them, but they'll also take a lot more transfers.

So you get somebody like a Texas children's hospital, they're going to be taking transfers from all over the state because of it being a pediatric center.

So you can imagine the kind of pressures that they have to not only take care of their patients that are coming in their E.R., but then also to take care of the patients that are being transferred to the important thing out of all this is all emergency departments are affected by the overcrowding.

So why is the overcrowding issue?

Okay.

It decreases the access to emergency care for others.

It decreases patient satisfaction.

It delays patients pain control.

It increases hospital mortality.

There's a large burnout factor to the staff.

You just you can't squeeze more blood from the turnip.

Okay.

Opportunity costs left without being seen.

This is a real thing because there's a lot of folks that don't want to wait yet.

They're really, really sick and they never got a chance to see a doctor because they just didn't want to wait.

And then they come back even worse than what they were.

Safety to patients and staff.

So leads to more frustration, more stress, more violence, and then decreases ability to flex for mass casualty events.

So if you've got a full emergency department and then you have a mass casualty event, it makes it for a big mess.

So what causes the overcrowding?

Fundamental is decreased hospital beds and increased ed visits.

Okay.

So what happens is if you have 25% of your patients that are going to need a hospital bed and they don't have any place to go, they stay in your E.R..

Okay.

So the lack and this term is called boarding.

Psychiatric holds can also be a very difficult it can be up to 2 to 3 days.

I've seen as long as ten days that a patient's being boarded in the E.R.

for psychiatric.

So sitting in a small little room and I'll have a picture of it in just a bed, but it's almost inhumane for what we do to our patients with psychiatric issues because it doesn't help them at all.

Intolerant federal regulations.

So these are so that you don't have dumping is what we call it.

So basically, if a patient didn't have insurance, you just incentive to another hospital because you didn't want to pay for his care insured versus uninsured.

So our a lot of our patients in Texas, probably about a third to half, depending on which population you're looking at, are not insured.

So the hospital has to do basically it does cost okay.

And it's very difficult to keep things going when you're having such a large amount to take care of.

There's older, more complicated patients.

You have patients that have survived cancer, multiple surgeries, blood thinners.

They're also not as mobile.

It's very difficult to go through their, medicines and their histories.

And it takes a long time to evaluate them when they come in discharge planning.

That's.

So they're okay to go home, but they need an ambulance to take them home or they have to wait for family to come pick them up.

Turnaround time for testing and consultant.

So this is when you order a test.

How long does it take?

And then if you're consulting with someone, how long it would take for a consultant?

Now, but the overall is the EDI board and the EDI boarding is just the the is the key factor for all this.

And you can see this picture.

This picture is not from our hospital.

It's from another one.

But this boarding is only getting worse.

And you're looking at patients staying in the hospital on this journey greater than 8 hours after this session to be admitted.

And from 2012 to 2019, that figure is only risen to 16% and in some cases almost.

This was in academic year 19.

I don't even know what the COVID number was because COVID was 2021.

And a little bit now, but not as much.

But you're looking at 1.4 or 5% of folks were in the E.R.

on one of their stretcher beds without the adequate care for over 24 hours.

So it's a tremendous stress on all parties involved.

So just to get an idea, what if we were to kind of take out 25% of these gates for this particular airport and we were just going to leave them there and then they would have to fly in the rest of their planes.

Okay.

You could see what kind of disruption you would have with your particular flight ops or even we'll just take, you know, Cheesecake Factory, for instance.

Okay.

If you just took this one out on the right and said they're going to be here and these tables are shut down, you couldn't see other patrons.

Okay.

And then if you really want to make the analogy with the E.R., the half that you just blocked out, nobody's paying.

So how do you keep it going?

You know, I mean, it it's really a difficult process.

Add on top of this, the national psychiatric issues mental crisis is up 40% while psychiatric beds are down.

Suicidal ideation and attempts up more than 400%.

I've seen that in the last 15 years.

Just come through overdose cases with the opioid crisis and then also THC abuse, which we see a lot of for having to come into the E.R.

for various elements related to the THC.

And then even after you get a psychiatric patient, because the psychiatric hospitals are under so much pressure to turn over to open beds for for more patients, a lot of times they end up discharging the patient before the patient's really ready for discharge.

And guess where they end up in one or two days, right back in the E.R.

And they just started it.

Yeah.

So it's it's not an easy out, easy one, guys.

So what is the solution?

Okay, so some of them talk about realignment of financial incentives for hospitals to remain 90% capacity in inpatient capacity.

And so this is an interesting concept.

And so many of the hospital systems want to save their inpatient beds for more lucrative elective procedures and more lucrative transfers.

And that's understandable because I gave you the, you know, the analogy before that there's a lot of times where our patients are uninsured.

Okay?

However, 50% of your admissions come from the E.R.

So it's kind of a mixed deal.

But the idea is if you hit that 90%, then you have the ability to flex up to be able to take care of some of the boarding patients.

Sometimes You can decrease admissions by concentrating on most reasons for admission and coordinated outpatient care.

So this is really, really where we're hit hard.

We have a lot of sick older patients and unfortunately they won't do well at home.

So they need to come in when they get heart failure, when it goes bad, when their end stage renal disease goes bad, when their COPD goes bad.

So we'll see them multiple times throughout the year and then they'll be in the hospital for quite a bit of days to get back to their baseline offload to more appropriate treatment facilities such as psych or rehab facilities.

We've been able to work a lot with our rehab and they've been some changes in the insurance industry to be able to pay for those ramps to go to rehab.

So they're not necessarily they don't necessarily need to come to the hospital for acute treatment.

But what they could do is get better with good rehab because they're not well enough to go home.

So it's a nice little step down for them.

We've also had advances for outpatient treatment options.

So this is a little bit like I was kind of talking to you with the different examples that I gave earlier, but you can do DVT treatments with Noacs used to be when you had a deep vein thrombosis, you'd have to come in the hospital for heparin and Lovenox window and then switch over to Coumadin, and that would be 3 to 4 days.

Well, now we can do it with just oral medicines and you're able to treat that at home.

And that's a tremendous boon for availability of hospital beds.

Heart score algorithm.

So as another example that I gave at the beginning with the young lady with chest pain, so you can do heart scores and basically accepted protocol, a standard of care for people being able to be discharged home because there are over 10 million visits to the E.R.

each year for chest pain.

And out of those 10 million visits, 6 million of them are admitted.

So that's a lot of patients, the hospital.

So if you're able to kind of slow that part down, home oxygen arrangements and home rehab that really came about during COVID.

So people with low oxygen but otherwise doing okay if you could get them some oxygen as outpatient 24 seven, then they could stay at home and have good follow up psych medicine advances.

We have some medicines out there now that can last up to a month and so say patients are notoriously non-compliant with their medicines because the medicine doesn't make them feel well.

And so they stop taking the medicine and then they drop off into their exacerbations.

So if you can make it for a longer period of time, might be able to help telemedicine.

I don't know.

Sometimes it looks like it helps, sometimes it doesn't, but most of the time it won't help with the boarding.

And that's really the issue that we have with the emergency department.

So anyone done telemedicine?

Yeah.

How was it for you?

Yeah, exactly.

Exactly.

And I can walk into a room and assess a patient very quickly, but I can't get that feeling over over the telemedicine it's, it's really, it's really lacking in and some places it might work, you know, for quick follow ups with patients that you really know well but in an emergency situation it makes it it makes it really difficult.

Insufficient hospital capacity.

Here's the here's the thing right here.

Admissions rose 21%, but inpatient hospital beds decreased by 27%.

Okay.

That's a real key factor in here.

Okay.

Obviously, that makes for a board in crisis right there.

What I don't have and the question you should ask is what about the hospital day stay?

So are they staying longer or are they staying shorter?

Okay.

And that aligned financial incentives, I really believe that if a patient needs to be admitted, then the hospital should not have to lose money to be able to take care of the patient.

Okay.

So how facility design could be used to reduce specific emergency department challenges?

All right.

Who knows?

This one for granted in that.

Beautiful.

Okay, why would I pick this one?

God's architect, Gary, Yeah.

It's still not complete.

It's over 100 years old.

It's absolutely beautiful.

And the thing is, it started out to be a chapel than a cathedral.

And it's neither now.

So maybe it is a good analogy for emergency medicine.

I don't know.

You know?

And so the point being is that, you know, we've come a long way.

Okay?

And we've got a beautiful, beautiful idea.

We've got a beautiful mission and sustain.

But how do we make it better?

How do we complete it?

That's that's really where I'm going.

This I was going to zoom in and zoom out for us, for our department.

I really think that the emergency department that was built for us back in 2014, 2015 really, really, really does a nice job.

And it's design.

I don't have that capability right now due to computer issues.

But what I want to get at is it does a lot of good things.

So again, we just treat our 50,000 roughly 30 beds.

Some of the great things that I love about this layout is that it's got tall ceilings and open spaces and excellent lighting.

I can't imagine if we were in our old dingy ah, okay.

With minimal ventilation, how we would have done with COVID.

Okay, because we were pretty successful overall for our the Kobe rate that we had for our actual staff that took care of patients.

And I do believe a lot of that was just the great ventilation that we have.

We also have closed and quiet patient rooms, so we could really sit down and talk with patients and really deliver expert care to them.

And compassionate care, They're easy to to keep clean and again, great ventilation.

And then we have some flex to to some degree, we have wide hallways that we can temporarily use for if we need to pull a patient out to make room for another one.

There are some issues with the line of sight and flow because it's in a triangular pattern in order to try to maximize the space that was there.

The lack of hospital beds lead to boarding for us in the ED, but when it happens, we have hospital alerts and so then that allows the other parts of the hospital to help us out.

So we're not near as bad as some of the other places that we've seen.

Okay.

Psychiatric colds can be 2 to 3 days.

Again, it doesn't help the patient.

And we had a section in the back that was just for the psych patients.

But unfortunately, regulations forced us to close that down.

So these are areas ripe for a research and architectural design that DC staff's safety and I'm going to quote here from I am physician because we're on the frontline on this and our nurses, everyone quote everyone.

This past weekend I was chased in the E.R.

by combative patient.

It was terrifying for me and I am struggling.

I need to take a break for a short time.

I'm scheduled to work this Sunday through Wednesday.

Please let me know if you work any of these shifts.

Okay.

We're trying to help people.

And so every now and then there are just certain circumstances, circumstances, whether it's a psych patient, incarcerated patients or families with reaction to unfortunate news.

And it's something that needs to be taken care of.

And I think there's a possibility for design that can help in this case.

So, I mean, we get like metal detectors and all the other stuff and it makes it look like Fort Knox with that, with losing compassion.

No.

Okay.

But I think there's another way to look at this for safety for all.

And I'm on a national task force for this with our company because we're nationwide and we'd like to be able to kind of figure this thing out for everyone.

But it's a serious under-reported problem and significant factor in burnout for both nurses and physicians.

Another area ripe for research in architectural design is burnout.

Okay, We have 65% burnout in two 65%.

You're talking about people that have basically given up their twenties to study all day and study all night, give up their weekends, then go to four years of medical, go through four years of undergrad, four years of medical school, and then anywhere from 3 to 7 years of residency.

Okay, In this case ers typically 3 to 4 years.

And then to get out to start practicing and then you realize that this isn't for you.

That's terrible.

Okay, so how much is.

It's the highest profession.

Okay, So how much of that is within the design itself, or is it just related to the job itself?

Nurses, they have a 50% burnout rate and 20% leave the 80 OC They say being emotionally exhausted and a low sense of personal accomplishment.

There's also the high stress for circadian psychologist options are constantly switching time zones.

Okay, so I go from overnights two days and whatnot, two or three times a month giving you give and you don't get that extra return.

Okay.

And it's kind of like being offensive linemen.

You only get recognized when you're call for holding for a penalty.

Okay.

And so you have to kind of really, really be strong in that regard or just have a higher calling.

And but in the end, that's very difficult and so it's also difficult to answer the tough cases.

And those losses stick with you more than your wins.

This particular gosh, I apologize guys I keep thinking it follows me.

So this particular this was architectural design, this particular family, the patient was this young lady in the middle here.

And she came in after she had had this young man and she had had a severe headache.

And she was told to go to the E.R.

for a blood patch, because a lot of times women will get an epidural headache after a delivery, okay, with their spinal epidural for pain.

And this was a little bit different.

And we were very fortunate.

And I walked in the room where we're getting the right diagnosis, and she ended up having what we call a CVT, a cavernous venous thrombosis, a blood clot in the back of her brain.

And here she was a brand new mother, 14 years old and if we wouldn't have found that blood clot, she have come back in about a day or two sneezing and stroke and probably wouldn't have survived.

Okay, So here she is on another visit with her little one from about six months later.

So every now and then we get to have a little bit of follow up with some of the patients that we get to see.

Okay.

And another area ripe for research is an architectural design, a psychiatry.

Okay.

This is just a really sad picture here.

And the numbers are staggering and are only going to get worse.

And it's a lifetime cycle that destroys all relationships over time.

And we're not helping this patient.

There's got to be a there's got to be a better way that we can do this.

Okay.

And not only does it affect the patient, but then it's also the public safety issues as well as personal safety.

So these are the folks that get triggered, the main shooter or whomever.

And then you also have patients that hop in front of traffic or in front of a train.

Okay.

So these are real risks, risk therapies, traditional offerings for overcrowding.

I'm going to skip these because we're just about over.

And then I have I have a little bit here, but we look at different places.

We can do it input.

And so this is just some of the things that people have tried to figure out to see, Hey, how does it help?

And they help to a certain degree, but it doesn't get to the main impact, which is the poverty.

And then we have we talk about throughput, which is basically how to get through the E.R.

and then we have output hospital based solution.

Okay.

And so basically our construction is not complete.

We still have a lot to go on this, but we've come a long way.

And these are some of my references.

Okay.

And then if you guys would like the presentation, I'm more than happy to share that.

Okay.

So thank you.

Okay.

All right.

What kind of questions do you guys have for me?

Yes, ma'am.

So I belong to the division and work life balance is often tough.

And I was wondering, how do you balance work and life and how do you see that translating into patient self care Professional?

Yes, ma'am.

Great question.

What does your mama do?

she's a nutrition machine in part one.

wow.

I bet she's got some stories.

You know, they have one of the highest burnout rates.

Also pediatricians, they're in the top three.

And you're like, how can somebody around kids all the time be?

But it's just the system, though, are they're in right now It's just turn, turn, turn.

They'll see like 40 or 50 kids a day and every day.

And then they'll get calls at night and then they've got around.

So that's a great question.

And I apologize.

The question was, is that her mom's a pediatrician at the Parkland, and so she's wondering about the work lifestyle balance and how that's kept.

And each person's different.

Okay.

For myself, I don't know.

Okay.

I don't know how some folks last two or three years, others last 15, 20 years.

And it I do think you have to have a very strong spiritual whoever you know, that you know, whoever that.

But you have to have something to refill that water that you're giving every day of your patients.

And then the other thing is you have to have it as a mission, a calling.

Okay, It's not a job.

And so I think probably your mom is that way as well, considering where she's working.

So there's a lot to be with it.

And also within medicine, you get the opportunity as you grow older to lose the cynicism and realize there's when you're with that patient and you get to help and then you get to see her a little baby back and a mom is okay and she can take care of that little baby for the rest of her life.

Because you found that diagnosis.

Any other questions?

Okay.

All right.

Well, thank you very much, sir.

Michael, I'm curious, to what extent is the architecture part of the solution to the issues that you've raised and how much of it is an operations class?

We have to work, I know, in concert, but how does that unfold as you look at daily activities?

How can we insert ourselves to try to find solutions?

I like to go back to the airplane operations, aircraft operations because safety OC is paramount, timeliness.

And if you are in a situation where your facility is not effectively built, then you're wasting a lot of redundancies.

Okay.

So for instance, I was can't show you on that grid our CT scanners in the emergency department.

When I was trained in Memphis, the CT scanner was kind of a new thing and it was about 50 yards away.

And so we used to have a common saying that patients who go to the CT scanner to die because what was happening was they had had to be transported out of the department before they came back.

Yeah, well, now it's all part of us.

They're part of the integral flow.

Okay So that's very important as far as that design for the flow to come through.

But we keep running in to that stop sign and that stop sign as it closes down my runways half the time.

Okay, so how can you see more patients when your runways are already closed?

So how can you design?

Is there a way to flex?

Is there a way you can land them or move them over to the taxi so you can land other airplanes?

Is there a way that they can do it upstairs or they can pull out temporary beds help?

But then when you put out those temporary beds, whose going to staffer okay, are the nurses just going to show up or whatnot?

So there's a lot of push and pull and that's where the financial incentives come in.

And so if they're constantly losing money with more patients that they bring in, well, that's not a survivable for the hospital.

Very good question.

We're just about out of time.

Is there one more someone would like to ask?

Yes, ma'am.

what how would you that kind of emergency department to get and how overcrowded they get.

So how when your emergency department is overcrowded, how do you handle regular maintenance, like things that you have to do, like cleaning and changing lights?

So the question is, how do you.

Yes, how do you maintain the E.R.

when it's been busy so often and typically we'll do those, whether it be computer updates, whether it be room updates, room cleaning that goes very much into the initial design because you want it to be able to be durable, clean, sterile anesthetic, yet still have that dignity of life.

So it's a very high calling you know for this.

But so typically they'll come in in the middle of the night.

Okay to do all those services and maintenance.

I do have one funny story for this.

I had a friend and we call it the Zamboni.

Okay?

It comes down to cleaning the floors and the Zamboni is incredibly loud.

Okay.

But thankfully, this young lady that's riding the Zamboni, that's cleaning the floor, she is completely dedicated to making sure every is clean and that emergency department.

So it is a complete noisemaker.

Okay.

And so it's kind of a running joke that it's just like, okay, here it comes again.

And so I had a friend of mine is a fellow physician, and he just like, this is so loud.

And then he started yelling at the girl busybody.

That's what she ended up doing, was she checked herself in for an anxiety attack in the emergency department because he did that.

So it was kind of like it to say to the doctors say they leave her alone.

She's just try to do her job.

Okay.

So it's part of a good cycle and thankfully we got a good situation.

They have a regular maintenance.

We go through maintenance checks throughout.

So great question.

Then we have backup generators as well on the grid.

So it's very important that one large area or anything in particular in the facility that you work in, when you did work in that you like really liked the way that it was designed or like really facilitating your work or like your colleagues work.

Like was there anything in your like maybe the design of the hospital or maybe like practices that the design in the hospital kind of like encouraged that like really helps your workload increase?

I particularly like have enclosed rooms, okay, able to slide sliding doors because it's able you can keep the visual and then you can turn the blinds and then you know, for that and then you can also keep quiet from that one.

I like large hallways because there's always traffic going back and forth and being open.

As far as flow, it's important to keep it the physician at the center.

And if you can keep this thought in mind in your design, when you design something, you want the rate limiting step, okay?

To be the person that is the most critical in the whole aspect of it.

Okay.

Now I can't do my job without my nurses, without my techs, without my radiology or lab or or or even my secretaries and administrators that register.

Okay.

But the point is, if they don't have a physician to run the team, then everything else just falls to the wayside.

So when you're designing a spot, always design it in mind that you're going to take care of the physician and his team throughout.

And when you do that, we might crack the code for the burnout part.

Okay, You want it to set up too, where it's always the the easiest decision is the right decision.

Okay.

That's why they set up with in again, airplane analogies.

You know, for that in the cockpit, they have everything set up and they call it bio.

I forget off the top of my head, but basically the integration between the pilot and the cockpit.

So when you're building that air, you want that integration between the doctor and the patient to become paramount.

And the rest of the support staff is should this fall into it easily, Because that's kind of a long answer.

But that's a very good question that you had to.

Thank you.

yeah.

That's one more time.

Tell me.

Thank you.

Thank you, guys.

Thank you.

Great job.

Thanks for being with us.

Yes.

Thanks for being with us today.

We'll be back with another one next week.