New-York Presbyterian Morgan Stanley Children's Hospital

The Alexandra & Steven Cohen Children's Emergency Department  

Poltronieri Tang & Associates, in association with Davis Brody Bond, has designed the new Pediatric Emergency Department at theNew-York Presbyterian Morgan Stanley Children’s Hospital.  A constrained, below-grade site on Broadway was transformed into a surprisingly engaging and light-filled Pediatric Emergency Department design. The functionally flexible two-level configuration allows for adaptive staffing and operational changes in response to shifting census and acuity needs. 

The family friendly layout is based upon numerous innovative care concepts, including triage first/registration second, roving registrars, self-registration kiosks, universal private treatment rooms and discharge lounge. The need to quickly and clearly distinguish the children’s ED entrance from the adult ED entrance, and an understanding that most ED families arrive during evening hours, led to the bold, colorful, eye-catching entrance design which includes an installation by artist Sol Lewitt.  

The new strategic location developed beneath the existing Morgan Stanley Children’s Hospital Tower allows for efficient, private transfer of patients directly to all diagnostic and treatment services and bed units. A responsive two-zoned mechanical system addresses isolation/IAQ issues and disaster preparedness.

Design Goals

As the only Level 1 Pediatric ED in NYC, the unit had experienced enormous utilization growth with the opening of the pediatric inpatient tower which opened in 2004 – the department needed to expand to accommodate 60,000 annual visits. Operational goals were outlined during extensive programming and planning phases, and included:

• Reduced triage wait-time
• Reduced examination/treatment wait-time
• Reduced ED transfers-out for diagnostic/treatment services
• Reduced steps in patient care; minimized redundancy of patient information exchange
• Reduced “left-without-being-seen” patients
• Reduced medications errors
• Development of operational plans accommodating increased patient load during high utilization periods and potential disaster events
• Increased frequency of staff/patient hand-washing
• Increased housekeeping focus on treatment room cleaning and turnover efficiency
• Improved location of supplies, equipment, medications, etc. to minimize staff time away from patients
• Improved overall effectiveness and efficiency by exploiting capabilities of new technologies, e.g. wireless nurse call, paperless charting

Program Components

Project leadership understood that “right-sizing” the pediatric ED was a complicated issue.  The planning team knew that proper sizing needed to respond to the unique needs of the pediatric ED, which has greater variation in utilization patterns than the adult ED throughout a 24 hour cycle and throughout the year.  The planning team benchmarked peer children’s emergency departments and developed pediatric specific functional space program guidelines. 

The 30,000 SF program ultimately included:

• 4 triage rooms that operationally convert to a fast-track suite during utilization peaks

• 26 universal treatment rooms, decentralized nursing stations, and rigorous enforcement of supply cart replenishment implemented to minimize nursing time away from patients
• 4 specialty exam rooms
• 2 trauma rooms
• Asthma treatment suite
• General radiology and CAT scan rooms
• Orthopedic and cast procedure rooms
• Dedicated point-of-care testing laboratory and pharmacy
• Discharge lounge, allowing patients to wait for test results outside of treatment rooms and improving patient throughput  
• Both negatively and positively-pressured treatment rooms, with a sophisticated two-zoned mechanical system affording department-wide isolation and purge capabilities in case of air-borne catastrophic or infectious event
• Main waiting area with individualized family seating nooks

Design Concepts

Design of the ED strives to bring as much outside light as possible down to its lower level location.  This was accomplished by transforming a dingy existing areaway into an open, double-height, 15-foot wide entrance and clerestory zone with expansive glass storefront along Broadway which provides large amounts of natural daylight year-round.  The street-level storefront is also the setting for a vibrantly colorful mural by internationally acclaimed artist Sol Lewitt. This spatial “display case” effect results in an eye-catching community landmark during daytime and a visually stunning beacon at night.

From the street level walk-in entrance vertical access to the ED is attained by a gracious stairway or dedicated glass-enclosed elevators – both of which maintains visual connection with the outside street and inside lobby waiting area.  The glass elevators have the added benefit of being an engaging kinesthetic distraction for the children.

Public areas utilize vivid floor-to-ceiling illustrations from familiar children’s books.  This children’s storybook imagery, tabletop Nintendo stations, Kinect play wall and other interactive activities helps to distract children and family members from stress and anxiety. The children’s literature theme-ing implemented in this project is an extension of the approach used elsewhere in the children’s hospital and was conceptualized early during planning. Most notable are the 12-foot high, two-sided illustration graphic walls which separate lobby waiting area from triage rooms. From the waiting side these graphics are a striking and engaging sight; from the triage side they are “a world to escape into”.  iPads are also used to distract children during painful procedures.  All these elements were developed in close collaboration with clinical and child life staff representatives.

Special attention was also given to the design scale. Instead of a large group waiting room families are situated in smaller seating nooks located close to treatment rooms with intimate reading areas. Adjustable lighting at nursing stations and in treatment rooms that can be dimmed during busy nighttime hours was also a key interior design consideration.

Lessons Learned

A detailed follow-up POE of this project was also undertaken. Preliminary findings have proven very positive and beneficial, including:

• Increased census volume 
• Clinical ED volume before and after project completion has increased from 48,000 to 54,000
• Hospital admissions have increased from 4,050 to 4,998  in 2011
• Decreased turnaround time for ED patients
• Average length-of-stay for “treat-and-release” has dropped from 4.0 hours to 3.4 hours
• Average length-of-stay for “treat-and-admit” has dropped from 9.2 hours to 8.4 hours 
• Decreased walk-out “without-being-seen” rates (as %)   
• Increased patient safety    
• Improved compliance with regulatory requirements, i.e. patient identification, hand washing, meds/sharps locking
• Medication errors decreased by 35.5% 
• Increased employee satisfaction and retention (staff vacancy rate near zero)
• Decrease in operational costs 
• Improved design configuration and flows resulted in supply stream savings in the first year of $200,000

We loved working with PT on our pediatric emergency department project. They are passionate about improving children's healthcare through design and that comes through in the process they use as well as their product. Their commitment to innovation in children's healthcare is evident in all of their work. We give them our highest recommendation.”

Meredith Sonnet, MD
Medical Director,
Pediatric Emergency Department,
Morgan Stanley Children’s Hospital

"Davis Brody Bond has enjoyed a very productive and collaborative relationship with Poltronieri Tang & Associates over the last several years. We highly value their expertise and detailed knowledge.  We also value their commitment to design conscious planning and their dedication to improving the quality of life for the patients, families, and staff members of children's hospitals.  Poltronieri Tang's value begins during programming and planning and carries through to the details of final construction. In this way the goals and objectives elicited from clients at the very first programming meetings are actually achieved in the built projects. The client's goals and expectations are met and exceeded."

Will Paxson, Principal,
Davis Brody Bond

"Laura has the creativity and innovative thinking that make an architect exceptional, and make her work extraordinary."

Bernadette O'Brien,
VP Operations, Morgan Stanley Children's Hospital