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 ...