Fast Track: urgent care within a teaching hospital emergency department: can it work?

Investigating racial disparities within an emergency department rapid-triage system

OBJECTIVES

Racial disparities in emergency medical care are abundant, and processes aimed to increase throughput, such as a rapid triage fast-track (FT) systems, may exacerbate these inequities. A FT strategy may be more susceptible to implicit bias as subjective information is obtained quickly. We aim to determine whether a FT model was associated with greater disparities between Black and White emergency department (ED) patients.

METHODS

Triage-related outcomes were compared across race using a cohort selected from encounters in an ED that uses a FT model. White and Black patient encounters were exact-matched on potential confounders including sex; presence of abnormal vital signs; ED arrival time; insurance type; age category; and chief complaint. The primary triage-related outcome was use of the FT area (versus the main ED), and the secondary outcomes were wait time and assigned encounter acuity.

RESULTS

Encounters for 5151 Black patients were exact-matched with 7179 encounters for White patients. Weights were applied to address differential numbers of encounters from each group. Within this matched cohort, Black patients were more likely to be triaged to FT than White patients (odds ratio = 1.28, 95% CI: 1.12; 1.46) and less likely to be given a high acuity score (odds ratio = 0.73, 95% CI: 0.66, 0.81). Among the high-acuity patients, Black patients were 40% more likely to be triaged to the FT area.

CONCLUSIONS

These results suggest that, after controlling for potential confounders, racial disparities may have been exacerbated in a FT ED triage process. In a FT model utilizing physicians and midlevel providers, this may create tiered levels of care between Black and White patients - an unacceptable side-effect of an effort to increase ED throughput.

Queueing Problems in Emergency Departments: A Review of Practical Approaches and Research Methodologies

Problems related to patient scheduling and queueing in emergency departments are gaining increasing attention in theory, in the fields of operations research and emergency and healthcare services, and in practice. This paper aims to provide an extensive review of studies addressing queueing-related problems explicitly related to emergency departments. We have reviewed 229 articles and books spanning seven decades and have sought to organize the information they contain in a manner that is accessible and useful to researchers seeking to gain knowledge on specific aspects of such problems. We begin by presenting a historical overview of applications of queueing theory to healthcare-related problems. We subsequently elaborate on managerial approaches used to enhance efficiency in emergency departments. These approaches include bed management, fast-track, dynamic resource allocation, grouping/prioritization of patients, and triage approaches. Finally, we discuss scientific methodologies used to analyze and optimize these approaches: algorithms, priority models, queueing models, simulation, and statistical approaches.

The influence of a fast-track service on case flow and client satisfaction in a high-volume veterinary emergency department

OBJECTIVE

To assess the benefit of a fast-track service in the emergency department of a large, high-volume veterinary hospital.

DESIGN

Prospective, observational, clinical study.

SETTING

Emergency department of an urban, tertiary referral veterinary hospital.

ANIMALS

All animals presented to the emergency department between April 1 and April 30 in 2017 and 2018 were eligible for inclusion. Only patients seen on days in 2017 corresponding to those days of 2018 during which the fast-track service was available were studied.

MEASUREMENT AND MAIN RESULTS

Triage case logs were collected and reviewed for April 2017 (prefast-track) and 2018 (fast-track). The fast-track service was launched as a pilot program in April 2018 to provide expedited care to low acuity patients presented to the emergency department. The median number of daily emergency department cases did not differ between 2017 (45, range 26-64) and 2018 (47, range 38-64; P = 0.3). The median time from presentation until first discussion with a doctor for low acuity cases was lower in April 2017 (29 min, range 1-163) than in April 2018 (24 min, range 1-100; P < 0.001). This reduction in wait time was observed despite a 40% increase in low acuity case presentations in 2018. Wait times for high acuity patients did not differ between study periods. The number of cases that left without being seen was higher in April 2017 compared to April 2018 (77 and 45 cases, respectively P < 0.001).

CONCLUSIONS

Implementation of a fast-track service reduced wait time for low acuity cases without adversely impacting wait times for sicker patients and led to a reduction in clients leaving without being seen. By introducing the fast-track service in a large volume veterinary hospital, limited resources can be distributed to improve speed of care, case flow, and client satisfaction in the emergency department.

Adjusting patients streaming initiated by a wait time threshold in emergency department for minimizing opportunity cost

Purpose Two different systems for streaming patients were considered to improve efficiency measures such as waiting times (WTs) and length of stay (LOS) for a current emergency department (ED). A typical fast track area (FTA) and a fast track with a wait time threshold (FTW) were designed and compared effectiveness measures from the perspective of total opportunity cost of all patients' WTs in the ED. The paper aims to discuss these issues. Design/methodology/approach This retrospective case study used computerized ED patient arrival to discharge time logs (between July 1, 2009 and June 30, 2010) to build computer simulation models for the FTA and fast track with wait time threshold systems. Various wait time thresholds were applied to stream different acuity-level patients. National average wait time for each acuity level was considered as a threshold to stream patients. Findings The fast track with a wait time threshold (FTW) showed a statistically significant shorter total wait time than the current system or a typical FTA system. The patient streaming management would improve the service quality of the ED as well as patients' opportunity costs by reducing the total LOS in the ED. Research limitations/implications The results of this study were based on computer simulation models with some assumptions such as no transfer times between processes, an arrival distribution of patients, and no deviation of flow pattern. Practical implications When the streaming of patient flow can be managed based on the wait time before being seen by a physician, it is possible for patients to see a physician within a tolerable wait time, which would result in less crowded in the ED. Originality/value A new streaming scheme of patients' flow may improve the performance of fast track system.

The effect of vertical split-flow patient management on emergency department throughput and efficiency

BACKGROUND

To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction.

METHODS

Prospective pre/post-interventional cohort study of all intend-to-treat patients presenting to the emergency department during a two-year period before and after the implementation of a vertical flow model.

RESULTS

In total 222,713 patient visits were included in the analysis with 107,217 patients presenting within the pre-intervention and 115,496 in the post-intervention groups. The results of the regression analysis demonstrate an improvement in throughput across the entire ED patient population, decreasing door to departure time by 17 min (95% CI 15-18) despite an increase in patient volume. No statistically significant difference in patient satisfaction scores were found between the pre- and post-intervention.

CONCLUSIONS

Initiation of a vertical split flow model was associated with improved ED efficiency.

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background

Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.

Aims

To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.

Methods

The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.

Findings

Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.

Conclusions

This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

The flex track: flexible partitioning between low- and high-acuity areas of an emergency department

STUDY OBJECTIVE

Emergency departments (EDs) with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to identify the best operational strategy for subsequent implementation.

METHODS

A discrete-event simulation was used to model patient flow through a 50-bed, urban, teaching ED that handles 85,000 patient visits annually. The ED has historically allocated 10 beds to a fast track for low-acuity patients. We estimated the effect of a flex track policy, which involved switching up to 5 of these fast track beds to serving both low- and high-acuity patients, on patient waiting times. When the high-acuity beds were not at capacity, low-acuity patients were given priority access to flexible beds. Otherwise, high-acuity patients were given priority access to flexible beds. Wait times were estimated for patients by disposition and Emergency Severity Index score.

RESULTS

A flex track policy using 3 flexible beds produced the lowest mean patient waiting time of 30.9 minutes (95% confidence interval [CI] 30.6 to 31.2 minutes). The typical fast track approach of rigidly separating high- and low-acuity beds produced a mean patient wait time of 40.6 minutes (95% CI 40.2 to 50.0 minutes), 31% higher than that of the 3-bed flex track. A completely flexible ED, in which all beds can accommodate any patient, produced mean wait times of 35.1 minutes (95% CI 34.8 to 35.4 minutes). The results from the 3-bed flex track scenario were robust, performing well across a range of scenarios involving higher and lower patient volumes and care durations.

CONCLUSION

Using discrete-event simulation, we have shown that adding some flexibility into bed allocation between low and high acuity can provide substantial reductions in overall patient waiting and a more efficient ED.

Effect of a triage team on length of stay in a pediatric emergency department

OBJECTIVE

This study aimed to determine the impact of a triage team on patient length of stay (LOS) overall and by patient acuity in a pediatric emergency department (ED).

METHODS

We conducted a cluster randomized controlled trial in which existing ED staffing was reallocated to include a triage team. The study was conducted in an urban children's ED Monday through Friday, from 6:00 P.M. to 2:00 A.M., for 4 weeks in February 2008. Twenty study periods were randomized according to the absence or presence of a triage team (physician, nurse, and nurse assistant) that initiated evaluations of nonurgent and urgent patients. We compared patient LOS between study periods with and without triage teams, using generalized estimating equations to allow for the clustering of effects by day.

RESULTS

Of the 1726 patients, 843 were seen during nontriage team times and 883 during triage team times. Overall, there was a 21-minute decrease in LOS during triage team times compared with nontriage team times, but this was not statistically significant. Stratifying by patient acuity level, LOS was significantly decreased during triage team times for nonurgent (25 minutes, P = 0.001) and urgent patients (50 minutes, P = 0.047) but prolonged for emergent patients (79 minutes, P = 0.019) and unchanged for critically ill patients.

CONCLUSIONS

Overall, although we did not find a statistically significant decrease in the LOS with the use of a dedicated triage team, we did find statistically significant decreases in the stratified analysis for urgent, nonurgent patient, and discharged patients. An important reason statistical significance may not have been reached in this study may have been our hospital's current staffing model, and therefore, the use of a triage team as additional staffing versus reallocation of existing staffing may depend on an institution's current level of staffing and its ability to meet patient demand.

Accuracy of triage nurses in predicting patient disposition

OBJECTIVE

Increasing demand to reduce patient waiting times and improve patient flow has led to the introduction of a number of strategies such as fast track and patient streaming. The triage nurse is primarily responsible for identifying suitable patients, based on prediction of likely admission or discharge. The aim of the present study was to explore the accuracy with which triage nurses predict patient disposition.

METHODS

Over two separate 1-week periods, triage nurses at two urban tertiary hospitals electronically recorded in real time whether they thought each patient would be admitted or discharged. The patient's ultimate disposition (admission or discharge), age, sex, diagnostic group, triage category and time of arrival were also recorded.

RESULTS

In total, 1342 patients were included in the study, of which 36.0% were subsequently admitted. Overall, the triage nurse correctly predicted the disposition in 75.7% of patients (95% CI: 73.2-78.0). Nurses were more accurate at predicting discharge than admission (83.3% vs 65.1%, P = 0.04). Triage nurses were most accurate at predicting admission in patients with higher triage categories and most accurate at predicting discharge in patients with injuries and febrile illnesses (89.6%, 95% CI: 85.6-92.6). Predicted discharge was least accurate for patients with cardiovascular disease, with 41.1% (95% CI: 26.4-57.8) of predicted discharges in this category subsequently requiring admission.

CONCLUSION

Triage nurses can accurately predict likely discharge in specific subgroups of ED patients. This supports the role of triage nurses in appropriately identifying patients suitable for 'fast track' or streaming.

Effects of a fast-track area on emergency department performance

To determine if a fast-track area (FTA) would improve Emergency Department (ED) performance, a historical cohort study was performed in the ED of a tertiary care adult hospital in the United States. Two 1-year consecutive periods, pre fast track area (FTA) opening-from February 1, 2001 to January 31, 2002 and after FTA opening-from February 1, 2002 to January 31, 2003 were studied. Daily values of the following variables were obtained from the ED patient tracking system: 1) To assess ED effectiveness: waiting time to be seen (WT), length of stay (LOS); 2) To assess ED care quality: rate of patients left without being seen (LWBS), mortality, and revisits; 3) To assess determinants of patient homogeneity between periods: daily census, age, acuity index, admission rate and emergent patient rate. For comparisons, the Wilcoxon test and the Student's t-test were used to analyze the data. Results showed that despite an increase in the daily census (difference [diff] 8.71, 95% confidence interval [CI] 6 to 11.41), FTA was associated with a decrease in WT (diff -51 min, 95% CI [-56 to -46]), LOS (diff -28 min, 95% CI [-31 to -23]) and LWBS (diff -4.06, 95% CI [-4.48 to -3.46]), without change in the rates of mortality or revisits. In conclusion, the opening of a FTA improved ED effectiveness, measured by decreased WT and LOS, without deterioration in the quality of care provided, measured by rates of mortality and revisits.

Redesigning emergency department patient flows: Application of Lean Thinking to health care

OBJECTIVE

To describe in some detail the methods used and outcome of an application of concepts from Lean Thinking in establishing streams for patient flows in a teaching general hospital ED.

METHODS

Detailed understanding was gained through process mapping with staff followed by the identification of value streams (those patients likely to be discharged from the ED, those who were likely to be admitted) and the implementation of a process of seeing those patients that minimized complex queuing in the ED.

RESULTS

Streaming had a significant impact on waiting times and total durations of stay in the ED. There was a general flattening of the waiting time across all groups. A slight increase in wait for Triage categories 2 and 3 patients was offset by reductions in wait for Triage category 4 patients. All groups of patients spent significantly less overall time in the department and the average number of patients in the ED at any time decreased. There was a significant reduction in number of patients who do not wait and a slight decrease in access block.

CONCLUSIONS

The streaming of patients into groups of patients cared for by a specific team of doctors and nurses, and the minimizing of complex queues in this ED by altering the practices in relation to the function of the Australasian Triage Scale improved patient flow, thereby decreasing potential for overcrowding.

[Effect of the incorporation of a general practitioner on emergency department effectiveness]

BACKGROUND AND OBJECTIVES

To know the effect that the presence of a general practitioner (GP) has on emergency department's effectiveness, efficiency and health care.

PATIENTS AND METHOD

Prospective interventional study carried out in the emergency medicine unit fast track area (FTA), which is ideally opened from 8 am to 12 am, and staffed by 2 residents.

INTERVENTION

8 resident hours (from 4 pm to 12 am) were substituted by 8 GP hours. The study period was August 2002 (GP presence), and the control period, October 2002. From each period, 10 days and 100 patients were randomly selected. From each day, FTA census (P), percentage of revisits and patients leaving without being seen, elapsed time to FTA actual closing (OT), percentage of patients moved to the observation area, and percentage of admissions were recorded. From each patient, epidemiological and clinical characteristics, waiting time to be seen (WT), number of tests performed, elapsed time to treatment (TT), and length of stay (LOS) were collected along with the number of patients finally discharged without hospital specialist consultation and those discharged with no test ordered. To assess perceived care quality, a telephone survey was performed. Three effectiveness indexes were defined and determined: P/WT (E1), P/OT (E2), and perceived care quality/perceived WT (E3). Finally, fixed and variables costs (C) from both periods were calculated, and cost-effectiveness analysis for each effectiveness index and period performed.

RESULTS

Periods showed no differences regarding daily census and patient characteristics. In the study period (GP presence), all time variables significantly improved: 20% reduction in WT, 25% in TT, 36% in LOS, and 17.5% in OT. A decrease in the number of tests ordered (41% less), in the percentage of patients moved to the observation area (78% less), and in the revisit rate (75% less) was also noted. Finally, E1 improved in 77% and E2 in 51%. Cost-effectiveness analysis clearly supported the study period, showing a decrease in C/E1 (55% less), in C/E2 (33% less), and in C/E3 (6% less). From the telephone survey, no differences between periods were detected except a perceived WT in the study period lower than that in the control period.

CONCLUSIONS

The presence of a GP in a FTA leads to an improvement in the effectiveness and quality of care received by attended patients. In addition of these important features, this presence is also efficient. Therefore, it is an intervention that could be taken into account by administrators to better manage emergency departments.

The effect of a separate stream for minor injuries on accident and emergency department waiting times

INTRODUCTION

To decrease waiting times within accident and emergency (A&E) departments, various initiatives have been suggested including the use of a separate stream of care for minor injuries ("fast track"). This study aimed to assess whether a separate stream of minor injuries care in a UK A&E department decreases the waiting time, without delaying the care of those with more serious injury.

INTERVENTION

A doctor saw any ambulant patients with injuries not requiring an examination couch or an urgent intervention. Any patients requiring further treatment were returned to the sub-wait area until a nurse could see them in another cubicle.

METHOD

Data were retrospectively extracted from the routine hospital information systems for all patients attending the A&E department for five weeks before the institution of the separate stream system and for five weeks after.

RESULTS

13 918 new patients were seen during the 10 week study period; 7117 (51.1%) in the first five week period and 6801 (49.9%) in the second five week period when a separate stream was operational. Recorded time to see a doctor ranged from 0-850 minutes. Comparison of the two five week periods demonstrated that the proportion of patients waiting less than 30 and less than 60 minutes both improved (p<0.0001). The relative risk of waiting more than one hour decreased by 32%. The improvements in waiting times were not at the expense of patients with more urgent needs.

CONCLUSIONS

The introduction of a separate stream for minor injuries can produce an improvement in the number of trauma patients waiting over an hour of about 30%. If this is associated with an increase in consultant presence on the shop floor it may be possible to achieve a 50% improvement. It is recommended that departments use a separate stream for minor injuries to decrease the number of patients enduring long waits in A&E departments.

Physician satisfaction and emergency department laboratory test turnaround time

OBJECTIVES

To determine the length of time for the components of the emergency department (ED) turnaround time (TAT) study in 1998 and to ascertain physician satisfaction concerning laboratory services to the ED.

METHODS

Using forms supplied by the College of American Pathologists Q-Probes program, participants conducted a self-directed study of ED TAT over a 4-week period. Data requested included various times of day associated with the ordering, specimen collection, laboratory receipt, and result-reporting stages of stat ED TATs for potassium and hemoglobin. Additionally, practice-related questions associated with the laboratory were asked. Participating laboratories also provided a physician satisfaction survey for up to 4 physicians who were users of ED services. Results of both the TAT study and the physician satisfaction survey were returned by mail. Participants were drawn from the 952 hospital laboratories enrolled in the 1998 College of American Pathologists Q-Probes study on ED TAT. The main outcome measures included the components of the ED TAT process, factors associated with decreases in ED TAT, and the results of the physician satisfaction survey.

RESULTS

Six hundred ninety hospital laboratories (72.4% response rate) returned data on up to 18 230 hemoglobin and 18 259 potassium specimens. Half of these laboratories responded that 90% of potassium tests were ordered and reported in 69 minutes or less, whereas the TAT for 90% of hemoglobin results was 55 minutes or less. Comparison of the components of TAT for both potassium and hemoglobin with similar studies done in 1990 and 1993 showed no change. Factors found to statistically contribute to faster TATs for both tests were laboratory control of specimen handling and rapid transport time. When whole blood specimens were used for potassium determination, TAT improved. Emergency department physicians chose the study-defined lower satisfaction categories of Often, Sometimes, Rarely, and Never for the questions concerning the laboratory being sensitive to stat testing needs (39.1%) and meeting physician needs (47.6%). Many of the physicians surveyed believed that laboratory TAT caused delayed ED treatment more than 50% of the time (42.9%) and increased ED length of stay more than 50% of the time (61.4%) when compared with other specialty users of the ED.

CONCLUSIONS

Laboratory ED TATs have remained unchanged for almost a decade. Emergency department physicians are not satisfied with laboratory services. Although it appears that one issue may relate to the other, the interaction between the laboratory and the ED is quite complex and has been evolving for at least 30 years. Improvement in interoperability between the departments is essential for operational efficiency and patient care. Effective communication channels need to be established to achieve these goals.

Using the online and offline change model to improve efficiency for fast-track patients in an emergency department

BACKGROUND

In 1998 the emergency department (ED) Work Group at Johns Hopkins Bayview Medical Center (Baltimore) worked to reinvigorate the fast-track program within the ED to improve throughput for patients with minor illnesses and injuries who present for care. There had been two prior unsuccessful attempts to overhaul the fast-track process.

METHODS

The work group used a change model intended to improve both processes and relationships for complex organizational problems that span departments and functional units. Before the first work group meeting, the work group evaluated the institutional commitment to address the issue. The next step was to find data to fully understand the issues and establish a baseline for evaluating improvements--for example, patients with minor illnesses and injuries had excessively long total ED (registration to discharge) times: 5 hours 57 minutes on average for nonacute patients. ONLINE AND OFFLINE MEETINGS: The work group identified process problems, but relationship barriers became evident as the new processes were discussed. Yet offline work was needed to minimize the potential for online surprises. The work group leaders met separately in small groups with nursing staff, lab staff, x-ray staff, registrars, and physician's assistants to inform them of data, obtain input about process changes, and address any potential concerns. The group conducted four tests of change (using Plan-Do-Study-Act cycles) to eliminate the root causes of slow turnaround identified previously.

RESULTS

Total ED time decreased to an average of 1 hour 47 minutes; the practice of placing nonacute patients in fast track before all higher-acuity patients were seen gained acceptance. The percentage of higher-acuity patients sent to fast track decreased from 17% of all patients seen in fast track in January 1998 to 8.5% by February 1999. Patients with minor illnesses and injuries no longer had to wait behind higher-acuity patients just to be registered. The average wait for registration decreased from 42 minutes in January 1998 to 14 minutes in February 1999. Physician's assistant, nursing, and technician staff all report improved working relationships and feeling a team spirit.

DISCUSSION

The offline component of the integrated model helped to improve organizational relationships and dialogue among team members, thereby facilitating the effectiveness of online efforts to improve processes. This model has also been applied to improve patient registration (revenue recovery) and the emergency transfer and admissions process.

The influence of an Urgent Care Center on the frequency of ED visits in an urban hospital setting

We examined the effect of a visit to an Urgent Care Center (UCC) on emergency department (ED) use by patients with nonemergent complaints. A study population of 1,629 patients with no previous visit to a UCC were identified and served as their own controls. The ED and clinic usage 6 months before and 6 months after a UCC visit were examined. After the UCC visit for adults there was a 48% reduction in ED visits (P = .0001) and 49% increase in clinic visits (P = .0001). After the UCC visit for children there was a 28% reduction in ED visits (P < .005) and 65% increase in clinic visits (P = .0001). Moreover the majority of clinic visits occurred within 90 days after the UCC visit. There was no substantial change in patterns of hospitalization 6 months after the UCC visit. We conclude that UCC usage decreases nonemergent ED use without adverse effects of increased patient hospitalization.

Fast track and the pediatric emergency department: resource utilization and patients outcomes

OBJECTIVE

To examine differences in the evaluation, management, and outcomes for patients seen in an on-site "fast track" (FT) vs the main ED.

METHODS

Over a three-month period, patients presenting to an urban pediatric ED were prospectively assessed. Patients included were: triaged as "nonurgent"; aged 2 months to 10 years; not chronically ill; and had fever, or complaint of vomiting, diarrhea, or decreased oral intake. Evening and weekend care was provided in the FT; at all other times these low-acuity patients were seen in the ED. Seven days after the visit, families were interviewed by telephone.

RESULTS

Four hundred seventy-nine and 557 patients were seen in the FT and ED, respectively. The patients in the two settings did not differ in age, clinical condition, race, or commercial insurance status. Patient mean test charges were $27 and $52 for the FT and ED, respectively (p < 0.01). Twenty-four percent of the FT patients vs 41% of the ED patients had tests performed (p < 0.01). Average length of stay was 28 minutes shorter in the FT (95% CI = 19 to 36, p < 0.01). Follow-up was completed for 480 of 755 families with telephones (64%). The FT and ED patients did not differ at follow-up: 90% vs 88% had improved conditions (p = 0.53), 18% vs 15% had received unscheduled follow-up care (p = 0.44), and 94% of the families in both groups were satisfied with the visit (p = 0.98).

CONCLUSIONS

Compared with those in the main ED, the study patients seen in the FT had fewer tests ordered and had briefer lengths of stay. These findings were not explained by differences in patient ages, vital signs, or demographic characteristics. No difference in final outcomes or satisfaction was detected among the families contacted for follow-up.

VESAS: a solution to seasonal fluctuations in emergency department census

STUDY OBJECTIVE

To design and implement a plan for emergency department staffing and additional space to reduce waiting time and the rate of patients leaving without being seen during the viral epidemic season.

METHODS

The study was conducted in the ED of a tertiary care children's hospital. We compared 24,657 children who presented for care between November 1996 and March 1997 (VESAS plan enacted) with 24,012 children who presented for care during the same period in the preceding year. VESAS (Viral Epidemic Supplemental Attending and Staff), an additional team of personnel, was on call for the viral epidemic season and was called to work if the hourly ED census that day was 25% or more of the past year's average hourly patient volume. Extra examination rooms were made available in space contiguous to the ED. Interval data, "left without being seen" rates, and ED census were monitored and compared with the previous year's data.

RESULTS

The VESAS team was used for 32% of the days during the 4-month intervention period. The left-without-being-seen rate was reduced by 37% (95% confidence interval, 33% to 41%). The average time from arrival to consultation with a physician was decreased by 15 minutes (95% confidence interval, -10 to -20) for all patients. Waiting times were most markedly reduced for less acutely ill or injured patients, although a modest decrease was also observed in patients with more severe illnesses or injuries (-10 minutes). The percentage of lesser-severity patients seen in an urgent care area was increased from 35% to 51%.

CONCLUSION

VESAS, a plan for providing space and personnel to handle an increased volume of patients that can be activated on the basis of hourly census data, was successful as judged by waiting times and percentage of patients who left without being seen.

Impact of gowning on visit length and physical examinations

We evaluated the effect of a randomized trial of gowning on length of visit and number of physical examinations performed in an outpatient clinic. Nineteen senior internal medicine trainees saw 110 patients without gowns and 113 patients with gowns. Patients without gowns were with the trainees 25.2 +/- 11.9 (mean +/- SD) minutes versus 24.2 +/- 10.3 minutes for gowned patients (p = .51). Ungowned patients were in the examination room a total of 38.5 +/- 15.9 minutes versus 42.9 +/- 17.6 minutes for gowned patients (p = .06). The number of patients that underwent physical examinations was the same (89) for gowned and ungowned groups, and the distribution of the number of examinations by patient group differed only slightly (p = .88). Gowning did not significantly decrease the length of visit or increase the number of physical examinations performed.

Societal savings by "fast tracking" lower acuity patients in an urban pediatric emergency department

To evaluate the cost-effectiveness of a "fast track" system for diverting lower acuity patients away from the pediatric emergency department (ED), 4,060 patients triaged to the fast track area of an urban pediatric ED with the 10 most common discharge diagnoses from 1/1/94 through 12/31/94 were retrospectively evaluated. Patients triaged as having nonurgent concerns qualified for treatment in a separate fast track area for 8 hours per day (fast track patients). These patients were compared with 5,199 seen in the main pediatric ED for the same concerns during the remaining hours when the fast track was not in operation (ED patients). Computer records were reviewed for demographics, acuity levels, diagnosis, and collection ratios (revenues/charges). The societal savings was calculated as sigma $ [(delta mean revenue of diagnosis1-10 in the main ED - mean revenue of diagnosis1-10 in the fast track) x the number of patients seen in fast track for diagnosis1-10] stratified by acuity. Collection ratios were comparable between groups (57% v 62%), but the average charges (physician and facility) were significantly less for patients seen in the fast track by a ratio of 1:2.4 (P < .0001). The average net revenue was also significantly less for all patients seen in the fast track by a ratio of 1:2.6 (P < .0001). When stratified by diagnosis and acuity, the savings to society was $101,313, or an average of $25/patient seen in the fast track ($101,313 per 4,060). A fast track is an effective system for maintaining patient flow at a cost savings to society. It can help the hospital in its negotiations with payors because it curtails charges. It is also a potential means for maintaining overall departmental revenues as payors increasingly deny traditional pediatric ED visits for patients with lower acuity concerns.

Use of physician extenders and fast tracks in United States emergency departments

To describe current practice regarding the use of physician extenders (PEs) and the "fast track" (FT) concept in United States emergency departments (EDs), a telephone survey of 250 US health care facilities offering emergency services was conducted. Of the EDs surveyed, 21.6% were using PEs at the time of the survey, and of those not using PEs, 23.5% intended to do so within the next 2 years. Those using PEs had been using them for a mean duration of 3.5 years (the mode was 2 years). The mean number of hours of PE coverage was 11.4 hours on weekdays and 11.5 hours on weekends (the mode was 12 hours both on weekdays and weekends). In general, the use of PEs increased with increasing hospital size and ED census, in more urban settings, in teaching facilities, and in the Northeast region of the country. Thirty percent of EDs surveyed had FT, and of those that did not have FT at the time of the survey, 32.8% intended to institute FT within 2 years. Of those that had FT, the mean number of years in use was 2.4 (the mode was 2). The use of FT increased with increasing hospital size and ED census, in teaching hospitals, and in the Northeast region. FT was most common in the suburban setting. The mean estimated percentage of ED patients going through FT was 30.1%. The mean number of hours per day of FT operation was 13.4 hours on weekdays and 13.7 hours on weekends (the mode was 12 hours/day both on weekdays and weekends). Of hospitals using PEs in the ED, 56.0% had FT; of hospitals without PEs in the ED, 23.5% had FT.

"Fast tracking" patients in an urban pediatric emergency department

Modern health care reform emphasizes efficient resource and facility management and the need to develop strategies to direct patients with lower-acuity concerns away from the relatively cost-inefficient full-service pediatric emergency department (ED). This study examined a pediatric fast track system for triage accuracy and turnaround times. Egleston Children's Hospital is a regional, urban, tertiary-care academic center which is a major teaching affiliate of Emory University School of Medicine. The pediatric ED has an annual census of more than 30,000 patient encounters. During the 9-month period from December 1993 through August 1994, 2,243 lower-acuity patients were evaluated in the fast track section of the ED. Patients assigned to the fast track system maintained a quicker turnaround time than the aggregate of all patients seen in the ED (107 [95% CI 0, 245] minutes versus 149 [95% CI 0, 341] minutes, P < .01). Their total turnaround time was also less than that for patients with similar acuity levels seen during the hours that the fast track system was not in operation (120 [95% CI 0, 300 minutes], P < .01). Only 63 of the 2,243 (2.8%) patients assigned to fast track were found to have higher acuity levels than suspected at initial triage. In all cases they were appropriately cared for in the fast track area. The fast track system appears to be an effective method by which an urban pediatric ED can efficiently maintain patient flow in light of limited resources, space constraints, limited manpower, and an increasing census.

"Fast tracking" patients with a proximal femoral fracture

OBJECTIVE

To assess the management of elderly patients presenting to the accident and emergency (A&E) department with a proximal femoral fracture.

METHODS

A retrospective audit carried out on 30 patients with proximal femoral fracture showed an unacceptably long waiting time in the A&E department. A new "fast track" system for managing these patients, involving the use of a flow chart for expediting admission, was devised. A prospective study of 100 patients > 60 years of age with proximal femoral fracture admitted by fast track system was then carried out.

RESULTS

Implementation of the fast track system resulted in earlier admission to the ward (median time to admission 2.5 h v 4.5 h in the retrospective audit, P < 0.001). Eighteen patients were not admitted by fast track during the study period, in some cases because of inconclusive diagnosis or because there was no identifiable orthopaedic bed; mean admission time for this group was 4 h 8 min.

CONCLUSIONS

The fast track system was of benefit to all involved, including the patient, A&E staff, ward staff, and orthopaedic personnel.

Continuous quality improvement reduces length of stay for fast-track patients in an emergency department

OBJECTIVE

To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illness/injury in an ED.

METHODS

A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of delay. In Phase I, two solutions were implemented. In this Phase II of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase II intervention 48-hour periods and one post-Phase II intervention 48-hour period were analyzed.

RESULTS

Before the Phase I changes, the mean +/- SD LOS was 92 +/- 46 min. After the Phase I changes, the LOS was 67 +/- 31 min. After the Phase II changes, this was reduced to 57 +/- 34 min (p < 0.05).

CONCLUSION

The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients.

Use of continuous quality improvement to facilitate patient flow through the triage and fast-track areas of an emergency department

Application of Continuous Quality Improvement techniques can identify (a) major causes of delay in evaluation and treatment of ambulatory patients in an Emergency Department (ED) and (b) rational solutions to reduce those delays. To confirm this hypothesis, a prospective interventional study was conducted at a tertiary care teaching hospital with 50,000 emergency visits per year. Participants included all patients discharged from the ED in three separate time periods. A formal continuous quality improvement process was used to document the current process of ambulatory care patient flow and prioritize the causes of delay. Solutions were defined and presented to the hospital administration. Two solutions were implemented immediately. The effect of these changes was assessed by comparing the time interval from presentation to discharge from the ED (length of stay) and the time interval from presentation to generation of a chart (chart generation). These differences were compared by analysis of variance on consecutive patients seen in a 48-hour control period and two postintervention 48-hour periods. The interventions that were identified and immediately implemented were the addition of an admission clerk and the reduction of the Fast-Track nurse function to include only patient placement and vital signs. The length of stay for all patients was significantly reduced from a mean of 163 +/- 170 min to 115 +/- 86 and 122 +/- 105 min in two separate postintervention 48-hour samples. The mean length of stay for Fast-Track patients not requiring X-ray, electrocardiogram, or blood tests was 92 +/- 46 min. After the intervention, this was reduced to 73 +/- 46 and 67 +/- 31 min in the same two 48-hour samples. Chart generation times were significantly reduced from a mean of 21 +/- 18 min to 8 +/- 6 min. We conclude that the formal application of Continuous Quality Improvement techniques in the Emergency Department can result in appropriate changes in the process of patient flow, leading to measurable and significant reductions in length of stay for Fast-Track patients.

The use of a break-even analysis: financial analysis of a fast-track program

OBJECTIVE

To calculate the financial break-even point and illustrate how changes in third-party reimbursement and eligibility could affect a program's fiscal standing.

METHODS

Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast-track program during June 1993. The fast-track program is located within the confines of the emergency medicine and trauma center at a 1,050-bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break-even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect.

RESULTS

Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs.

CONCLUSIONS

Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third-party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break-even volumes.

Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study

STUDY OBJECTIVE

To determine whether nonemergency patients can be prospectively identified by triage nurses and safely triaged out of the emergency department without treatment.

METHODS

All adult patients (16 years or older) who presented to a university ED were provided an evaluation by a triage nurse. For a patient's case to be defined as nonemergency, four criteria were required: vital signs within a specific range, presence of 1 of 50 potentially nonemergent chief complaints, absence of key indicators found on screening examination, and absence of chest pain, abdominal pain, any severe pain, and inability to walk. Between July 1988 and July 1993, patients who satisfied these criteria were defined as nonemergency, refused care in the ED, and triaged out of the ED. Patients were referred to off-site clinics. The clinics had agreed to see patients in advance of the study, and the referral lists were frequently updated. Outcome data were obtained by telephone surveys to both triaged individuals and other health care providers.

RESULTS

In this 5-year study, 176,074 adults presented to the ambulatory triage area in the ED, and 31,165 (18%) were defined as nonemergency, were not treated, and were referred elsewhere. Letters and telephone calls to all referral clinics, eight local EDs, and the coroner's office identified no instances of gross mistriage and only a small number of insignificant adverse outcomes. Telephone follow-up to individuals triaged away was successful in 34% of calls and showed that 39% of persons received care elsewhere on the same day, 35% received care within 3 days, and 26% decided not to seek medical care. A group of 1.0% sought care at other hospital EDs for minor complaints.

CONCLUSION

A subset of patients with nonemergency problems can be prospectively identified and triaged out of the ED without significant adverse outcomes provided there is community support for follow-up care.

A randomized, controlled trial of radiograph ordering for extremity trauma in a pediatric emergency department

STUDY OBJECTIVES

The objectives of this study were to determine whether triage nurses using the Brand protocol would order fewer radiographs than would physicians carrying out standard practice procedures, without missing an increased number of joint or bone injuries; the test characteristics and the interobserver reliability of the Brand protocol; and whether having triage nurses order radiographs could reduce total patient waiting time in the emergency department.

DESIGN

Randomized, controlled trial.

SETTING

The ED of a free-standing children's hospital with approximately 55,000 visits annually.

TYPE OF PARTICIPANTS

Children less than 18 years of age who had a history of extremity trauma in the preceding seven days.

INTERVENTIONS

Triage nurses applied the Brand protocol to determine the need for a radiograph.

MEASUREMENTS AND RESULTS

Of the Brand protocol group, 81.9% had radiographs ordered compared with 87.1% of the control group (P = .03). The percent of positive radiographs was 40.8% in the Brand protocol group compared with 42.6% in the control group (P = .21). There were 3.2% (16) missed radiographic findings in the Brand protocol group compared with none in the control group (P < .001). Patients randomized to the Brand protocol group spent 3.3 hours in the ED compared with 3.6 hours for the control group (P < .001).

CONCLUSION

Having triage nurses use the Brand protocol reduced the number of radiographs ordered but at the same time increased the number of missed radiographic findings. However, having triage nurses order radiographs also significantly shortened waiting time in the ED.

Triage of patients out of the emergency department: three-year experience

Because of severe emergency department (ED) overcrowding, the authors initiated a program of referring certain patients who were assessed as not needing emergency care away from the ED. A selected group of patients who presented to a busy university ED were refused treatment and triaged away following a medical screening examination performed by a nurse. In this 3-year study 136,794 patients presented to the triage area in the ED, of which 21,069 (15%) were refused care and referred elsewhere. Letters and calls to all referral clinics, eight local EDs, and the coroner's office identified no patients who had been grossly mistriaged, and only insignificant adverse outcomes could be identified. Additional follow-up on 3,740 individuals triaged away was performed by telephone. Responses from this survey indicated that 42% of persons received care elsewhere the same day, 37% within 2 days, and 22% decided not to seek medical care. A group of 1.6% sought care at other hospital EDs for minor complaints. The authors concluded that a group of patients can be selectively triaged out of the ED without significant adverse outcomes, which may offer one approach to the problem of ED overcrowding.

Fast Track in the emergency department: a one-year experience with nurse practitioners

The use of a Fast Track system in the emergency department is becoming increasingly popular in order to provide fast and efficient service to patients with minor emergencies. In this paper we describe the one-year results of our system staffed by nurse practitioners. During the first year of operation, a total of 4468 patients were seen in Fast Track. Approximately 28% of patients are triaged to Fast Track during its hours of operation. The average patient seen in Fast Track was ready for discharge 94.4 minutes after presentation. Fewer than 1% of patients required admission to the hospital. Overall, patients and medical staff were highly satisfied with the Fast Track system. Our experience demonstrates that nurse practitioners can effectively and efficiently staff a Fast Track in an academic emergency department.

Refusing care to patients who present to an emergency department

In July 1988, our emergency department adopted a policy of refusing to treat patients in the ED if they failed to have what was considered an emergency condition. Screening examinations were performed by triage nurses to determine whether patients were eligible to be seen in the ED. Patients whose vital signs fell within specific categories and who had one of 50 minor chief complaints were refused care in the ED and referred to off-site clinics. The referral of these patients out of the ED after a screening examination falls within the scope of legislation governing ED care and transfer (federal COBRA, Cal SB-12, and Title 22) as determined by the University of California legal counsel. In the first six months of this new triage system, 4,186 patients were referred from the ED; this represented 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 84% were referred to off-site nonuniversity clinics, and 15% were referred to a university-affiliated faculty-staffed clinic. Follow-up letters and telephone calls to their clinics identified no patients who needed retriage to an ED, and only 54 patients (1.3%) complained about their referral out of the ED. Only 42 patients returned to the ED within 48 hours of initial triage, and none had a deterioration of their condition. In conclusion, a selective triage system may be used to effectively decompress an ED, although further study is needed to identify potential rare adverse outcomes.