Fast Track Systems in the Emergency Department

From NursingWiki

The use of a ‘Fast Track’ process in an Emergency Department (ED) has been progressively introducted since the early 1990’s, targeting problems related to waiting time, ED length of stay and access block. The earliest cited use of fast-track was in 34% (n=185) of EDs on the mid-Atlantic coast of the USA prior to 1991(1). Further reports on the use of fast track in USA EDs were published in 1992 (2, 3, 4). The use of Nurse Practitioners and ‘physician extenders’ in fast track has also been reported in USA EDs (5, 6, 7). The paediatric application and ‘social’ cost benefits of fast track has also been reported (8). In 1997 a report was published on the use of fast track in a Canadian ED (9). The use of fast track was introduced in Australia in some Victorian EDs after 1998 (10). The use of fast track and a separate ambulatory section has been also reported in the UK(11) .

Reviews of published reports of fast track implementations have shown that traditionally the focus of patient allocation to such areas has been based on the expediting treatment of low acuity ED presentations. Work done on the implementation of an ED Fast Track process at Bankstown Hospital, in Australia, has shown that the focus should rather be on the level of nursing and medical complexity required based on the patient’s presenting complaint.

Fast Track systems by nature have limited resources, in terms of staffing and space, to manage low complexity and/or low acuity patients. It is therefore essential that the right patients be allocated to the process at triage. A patient placed in the main ED section will be cared for regardless of their complexity. A high complexity patient placed in Fast Track may not receive the level of care and supervision they require. Such situations can result in referrals back into the main ED, insufficient observation or in the worst cases poor patient outcomes.

Where an ED fast track system has been utilised successfully there has been significant improvements on ED length of stay, waiting times, ambulance off-load times and the number of patients leaving without being seen (12, 13).

To successfully implement a fast-track system in the ED the following features need to be present:

1. A physical redesign of the ED to enable a main ED, for high complexity patients, and a highly visible fast track area, for low complexity patients. Wherever possible patients should be managed in clinical treatment chairs and when not being actively treated be placed in the waiting room.
2. A change in the mind set of the ED staff to view treatment pathways in terms of complexity, not just acuity. Acute patients can be triaged to a fast track so long as their required treatment can be commenced in the appropriate time frame and once stabilised can be quickly and easily reviewed to determine need for admission or discharge.
3. Staffing of the fast track with appropriately skilled nurses and medical officers. This is best achieved through a mixed nurse : medical treatment model. Such a model enables nurses with advanced clinical skills to instigate protocol devised treatment pathways and/or standing orders, nurse practitioners to completely manage appropriate patients and suitably skilled doctors to support, guide, review and treat patients. The additional benefit of such an approach is that it facilitates a higher level of collaborative communication and synergy in patient care.
4. A clear set of inclusion and exclusion criteria for who should be referred from triage to a fast track system. In line with this is ensuring the acceptance of the inclusion / exclusion criteria through staff input in development, appropriate reviews and education. At a suitable time such criteria should also be tested for reliability.

Reference

1. Purnell LDT, A survey of emergency department triage in 185 hospitals: physical facilities, fast-track systems, patient classification, waiting times and qualification, training and skills of triage personnel. Journal of Emergency Nursing 1991; 17(6): 402-7.
2. Covington C, Erwin T & Sellers F, Implementation of a nurse-practitioner staffed fast track. Journal of Emergency Nursing1992; 18(2): 124-31.
3. Romanelli N, We put ED patients on the fast track. RN, 1992; 55(7): 17-8,20.
4. Cardello DM, Implementation of a one-hour fast-track service: one hospital’s experience. Journal of Emergency Nursing 1992; 18(3): 239-43.
5. Barger CQ, Mary Hale: serving her community…NP in the ‘Minor Trauma-Fast Track’ area in the Harbour/UCLA Medical Center. Nurse Practitioner Forum 1993; 4(4): 182-3.
6. Buchanan L & Powers RD, Establishing an NP-staffed minor emergency area. Nurse Practitioner: American Journal of Primary Health Care1997; 22(4): 175-6,178,183.
7. Ellis GL & Brandt TE, Use of physician extenders and fast tracts in United States Emergency Departments. American Journal of Emergency Medicine 1997; 15(3): 229-32.
8. Simon HK, Ledbetter DA & Wright J, Societal savings by ‘fast tracking’ lower acuity patients in an urban pediatric emergency department. American Journal of Emergency Medicine 1997; 15(6): 551-4.
9. Griffiths H, Standards in action. Putting the ‘fast’ back in ‘Fast Track’. Nursing BC 1997; 29(5): 13-4.
10. Taylor D, Bennett & Cameron P, A paradigm shift in the nature of care provision in emergency departments. Emergency Medicine Journal2004; 21: 681-684.
11. Cooke MW, Wilson S & Pearson S, The effect of a separate stream for minor injuries on accident & emergency waiting time. Emergency Medical Journal 2002;19: 28-30.
12. Wilson M & Nguyen K, Bursting at the seams: improving patient flow to help America’s emergency departments. Urgent Matters, 2004; 2(5).
13. Darrab A, Fan J, Ferandes C, Zimmerman R, Smith R, Worster A, Smith T & O’Connor K, How does fast track affect quality of care in the emergency department. European Journal of Emergency Medicine 2006; 13(1): 32-35.

Weblinks

[[Category:]]