The Origins of the Fast-Track Concept
In the early 1980s, a number of progressive emergency departments, including Broward General Medical Center in Fort Lauderdale, Florida and Lakeland Regional Medical Center in Lakeland, Florida, had a fundamental insight. They recognized that low-acuity patients were being treated not only in the same physical space as the high-acuity patients, but also with essentially the same procedures and protocols. The lower-acuity patients were “at the mercy of,” and considered secondary to, those patients with more time-sensitive higher-acuity problems. Those with less urgent problems often had to wait long periods of time to be seen, as the emergency physicians and nurses were “pulled away” to treat those with potentially life- or limb-threatening diseases. In addition, the majority of ED nurses and physicians were drawn to the acute patients, who were largely the reason these talented and highly trained professionals had chosen the “adrenaline-fueled” environment of the emergency department. The progressive EDs understood that all EDs see a large number of patients with lower-acuity illnesses and injuries and that these patients vastly outnumber those with time-sensitive, high-acuity problems. The ratios in many EDs were 70% to 80% lower-acuity to 20% to 30% higher-acuity patients.
With these fundamental data in mind, a number of EDs created an alternative pathway or system of care. The goal was to treat patients with lower-acuity illnesses or injuries using a process that was separate from and paralleled the process of the higher-acuity patients. This separate process typically occurred in a physically distinct area, often called a “Fast Track” (a “noun”). More importantly, these patients were treated according to screening, evaluation, treatment, and disposition protocols, which were developed specifically for their presentations. They were “fast-tracked” (a “verb”).
“Fast Track” was thus not simply a place in which low-acuity patients were seen, but far more importantly a system and set of processes by which these highly predictable patients were treated. In many respects, the evolution of fast-track programs was one of the earliest examples of the principles of demand-capacity management in emergency medicine. The fundamental concepts of this demand-capacity management system approach are
- The number of low-acuity patients is predictable (demand prediction).
- The times of day that these patients arrive are predictable (demand timing).
- The patient's clinical problems are highly predictable (demand anticipation).
- The resources needed to evaluate, treat, and make a clinical disposition are predictable (capacity recognition).
- For patients requiring diagnostic studies (laboratory, radiology, etc), there are predictable conflicts or competition (with the acutely ill or injured patients) for the ED's scarce resources (capacity competition).
- Certain low-acuity patients have “rate-limiting” needs for laboratory and imaging studies, while the needs of higher-acuity problems are not time- or rate-limiting (capacity triage). For example, patients with ankle injuries may have their progress limited by the timing of the completion of an imaging study (rate limiting). A second more acute patient with chest pain and ECG changes requiring a CBC is unlikely to be progress limited by the timing of the completion (not rate limiting).
The understanding of these fundamental issues has led to the concept of “Fast Track” as a distinct process by which these patients could be expedited was born (fast-track as a verb—a way in which patients are processed). Currently, most moderate- and large-volume EDs have created a separate area in which such patients are evaluated and treated (Fast Track as a place or a noun). Stated another way, fast-track is most appropriately and meaningfully viewed as a set of processes (a verb) rather than simply a place where such patients are seen (a noun).
With this background, ED crowding is a problem, which has faced healthcare professionals for over 30 years. While the number of annual ED visits has risen to over 120 million patients in 2010, the number of hospital EDs has decreased—adding to the problem.1 The risks associated with ED overcrowding have been well documented and include long wait times, patient and staff dissatisfaction, decreased productivity, and safety concerns.2 Developing an area within the emergency department where patients can be “fast-tracked” is one strategy used to alleviate overcrowding in the nation's EDs.
Traditionally, the ED's primary function has been to provide care for patients with life-threatening medical conditions. In fact, these serious illnesses and injuries are “fast-tracked,” as their care is expedited. Multiple examples of “fast-tracking” patients, that is, code stroke, trauma code, code STEMI are increasingly implemented through the use of evidence-based protocols. Fast track is thus not a noun—a place in which certain patients are evaluated and treated—but instead is a verb—a set of processes that allow ED personnel to evaluate and treat patients more effectively and in a more efficient fashion. Fast-tracking uses the science of patient segmentation to divert a specified group of patients to treatment pathways, usually by a specific group of ED staff in a specific area.
Most EDs also provide care to those who may need treatment for less serious nonemergent conditions, which constitute 10% to 66% of all ED visits.3
The “fast-track” concept in emergency departments was initially begun to address the treatment of the growing numbers of nonemergent patients and currently involves defining a designated area in or near the main ED where care is provided in a proficient manner to a specific group of lower-acuity patients. This process is often referred to as a patient being “fast-tracked.” Merriam-Webster notes that “fast track” can be defined as “a course of expedited consideration” (noun) and can also mean “to speed up the processing, production, or construction in order to meet a goal” (verb).4 In order to be successful, fast-tracks in emergency departments must both provide a course for minimal diagnostics and speed up the process to achieve defined goals. Simply put, fast-tracks are designed to increase value to patients through 3 fundamental means:
- Decreasing the turnaround time (TAT) for less acute patients who present to the ED for care
- Providing a dedicated group of emergency physicians and nurses who are not distracted by other, higher-acuity patients
- Ensuring that care is guided by evidence-based protocols geared toward maximizing speed as well as quality of care
A well-planned and well-operated fast-track can increase both patient and staff satisfaction by relieving the bottleneck of patients that occurs during times of rapid patient influx. Long wait times, delays in care, and delays in admissions are all among the reasons for decreased patient satisfaction in the ED.5 By reducing these delays, fast-tracks improve overall satisfaction. One study that evaluated patient satisfaction with length of stay, time with provider, skills of provider, personal manner, satisfaction score, and overall satisfaction found significant improvement in overall satisfaction after initiation of a fast track.5 In addition, fast tracks can alleviate the stress on staff that often results from constant interruptions by less acute patients inquiring, “When will I be seen?”
The criteria used to determine who should be treated in the fast-track are typically based on an assessment of the resources needed to treat the patient. Accurate triage is a vital factor that is frequently overlooked when developing and managing a successful fast-track area. It is essential to implement a triage practice that is reliable, valid, and based on the use of the anticipated resources necessary to complete the patient's care. In order for the triage process to succeed, all staff (physicians, nurses, nurse practitioners, physician assistants) must learn how the triage system works. These triage categories become the language of simultaneously communicating the acuity and resource needs of patients in the ED. The goal is to get the right patient to the right place seen by the right provider in the right amount of time.6
- Reviews guidelines necessary to develop a fast-track system within the ED
- Describes the importance of defining and tracking measurable goals
- Reviews how to successfully implement a fast-track program
- Provides strategies to avoid common pitfalls
- Discusses the crucial role of a triage system based on resource allocation
In order to achieve these goals, the entire ED is considered as the overall “system,” with the fast-track being an integral part of that system.