Evaluation of the

Fast Track Unit of a University

Emergency Department

R E S E A R C H

Authors: Kathleen Nash, PhD, RN, FNP, Brian Zachariah, MD,

Jennifer Nitschmann, RN, MSN, and Benjamin Psencik, RN,

BSN, Galveston, Tex

Kathleen Nash is Assistant Professor, University of Texas MedicalBranch School of Nursing, Galveston.

Brian Zachariah is Medical Director, University of Texas MedicalBranch School of Nursing, Galveston.

Jennifer Nitschmann, Gulf Coast Chapter, is Administrative Director,University of Texas Medical Branch School of Nursing, Galveston.

Benjamin Psencik is FNP Student, University of Texas MedicalBranch, Galveston.

For correspondence, write: Kathleen Nash, RN, FNP, PhD, Universityof Texas Medical Branch School of Nursing, 301 University Blvd,Galveston, TX 77555-1029; E-mail: kanash@utmb.edu.

J Emerg Nurs 2007;33:14-20.

Available online 30 November 2006.

0099-1767/$32.00

Copyright n 2007 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2006.08.003

14

Earn Up to 9.5 CE Hours. See page 90.

Introduction: The purpose of this study was to evaluate

the efficacy of the newly developed fast track (FT) area in a

University-affiliated emergency department. The goals of the

FT unit included reducing patients’ length of stay, improving

patients’ satisfaction, and decreasing ED overcrowding.

Methods: An exploratory descriptive design used to investi-

gate length of stay in the emergency department, the rate of

patients who left without being seen, unscheduled return visits

to the emergency department within 72 hours of being seen,

and patient satisfaction.

Results: During the evaluation period, 5995 patients were seen

in the ED fast track area. The average time patients spent in

the emergency department was 4.36 hours. The average time in

room for the FT area was 1.97 hours. The left-without-being-

seen rate for this time period for the main emergency depart-

ment was 7%; the rate for the FT area was 4%. Additionally,

100% of respondents who completed a patient satisfaction

survey in the FT area rated the care received by the nurse

practitioner (NP) as good or excellent.

Conclusions: Although the average time in room and overall

length of stay did not meet expectations, patients did move

more quickly through the department after the addition of the

FT unit. Patient satisfaction data suggested that the FT staffed

by NPs is a welcome addition to the emergency department.

The findings provide direction for the future study of NP utili-

zation in the emergency department.

JOURNAL OF EMERGENCY NURSING 33:1 February 2007

R E S E A R C H / N a s h e t a l

Emergency departments usually place the highest

demands on hospital services. Social, political, and

financial pressures force uninsured and underin-

sured patients to seek care in these facilities.1 Moreover,

ED personnel have no control over the type of patients that

present for care, the pace of their arrival, or their acuity

level. No one is refused emergency care even when the hos-

pital is at capacity, resulting in long wait times, overworked

staff, overcrowded departments, and patient dissatisfaction.

In the emergency department at a large Southwestern

University-affiliated hospital, with an average daily census

of 200 patients, wait times were routinely exceeding

5 hours, and up to 7% of patients left without being seen

by a provider. Subsequently, administration and staff de-

cided to explore options for increasing efficiency and de-

creasing overcrowding in the emergency department.

In September 2004, the minor care area of this level 1

trauma center converted to a fast track (FT) unit staffed by

nurse practitioners (NPs). In the previous minor care (MC)

area, patients with generally minor acute problems were

seen, although many of the patients had complaints that

required extensive workups prior to deciding a disposition.

This situation often led to overcrowding in the MC area.

When all 8 MC rooms were full with patients undergoing

diagnostic workups, the area would come to a virtual stand-

still. The MC area was staffed by an ED faculty physician

and 2 or more internal medicine residents doing their clinic

rotation in the emergency department, in addition to nurs-

ing and registration support. During the spring and sum-

mer of 2004, the MC area of this emergency department

was evaluated as part of an ongoing quality improvement

process. The decision was made to change from MC to an

FT concept. This decision led to reassignment of ED fac-

ulty physicians to areas of the department where higher

acuity patients were seen and reassignment of the internal

medicine residents outside of the emergency department.

The FT unit is open daily from 8 am to midnight and

is staffed by 4 full-time NPs, with 1 or 2 NPs working each

shift. The goals of the FT unit included reducing patients’

length of stay (LOS), decreasing ED congestion, decreas-

ing the number of patients who leave without being seen

(LWBS) by a provider, and improving patient satisfaction.

A review of the literature on the operations of FT areas

across the United States provided support to the initiation

and evaluation of an FT area in this emergency department.

February 2007 33:1

This study examined whether an FT unit staffed only by

NPs can be run efficiently while maintaining a high level

of patient satisfaction.

Background and Significance

FT AREAS, PATIENT FLOW, AND THROUGHPUT TIMES

Evidence exists that FT areas are a positive addition to busy

emergency departments. Studies have shown significant de-

creases in wait times in the emergency department after the

initiation of an NP-run FT area.2 Others have examined

wait time in relation to presenting complaint and found

that many of the ED patients had minor, nonemergent, or

self-limiting problems that ideally would be suited for an

FT setting. FT areas have been shown to increase ED flow,

decrease wait time, and use resources more efficiently.3

One approach to improving throughput times for FT pa-

tients included the immediate placement of all patients

who met FT criteria in a room, which decreased overall ED

wait time and increased overall patient satisfaction.4 Other

researchers concluded that FT areas are an effective sys-

tem for maintaining patient f low and decreasing over-

crowding while realizing a cost savings for the hospital and

for society.5 Some researchers suggested that process im-

provements, such as improving throughput time in radi-

ology and the laboratory, may further improve throughput

time in FT areas, thereby increasing patient satisfaction.1,6

PATIENT SATISFACTION AND NPs IN THE

EMERGENCY DEPARTMENT

Patient satisfaction research strongly demonstrates that

ED patients’ dissatisfaction is linked to delays. Therefore,

implementing a process to decrease long wait times should

increase patient satisfaction. Also, high rates of patient

satisfaction are believed to lead to improved health out-

comes and less litigation and may inf luence the selection of

the emergency department for future visits.7 NPs and physi-

cian assistants have been shown to provide competent, cost-

effective health care without sacrificing patient satisfaction.2

Further research demonstrated the public’s acceptance of

midlevel providers in the ED setting.8,9 Studies have been

conducted exploring the relationships between patient acu-

ity, perceived and actual throughput time, and ED patient

satisfaction; and in emergency departments where the non-

urgent patients were seen in the FT, throughput times were

JOURNAL OF EMERGENCY NURSING 15

R E S E A R C H / N a s h e t a l

reduced and patient satisfaction was high.10 The literature

on FT areas and patients’ satisfaction with NPs shows that

generally patients are satisfied with the care provided by

NPs and that patient outcomes were equivalent for NP and

physician providers.11 Another measure of satisfaction is the

number of patients who LWBS by a provider. Research has

demonstrated that a decreased LOS due to the presence of

an ED FT is associated with a lower ED LWBS trend.12

The literature suggests that FT areas increase through-

put time and thereby affect overall ED overcrowding. Fur-

ther, studies support the use of midlevel providers in the

emergency department. Overall, the literature supports the

establishment of an FT unit staffed solely by midlevel pro-

viders. The purposes of this study were to evaluate the ef-

fectiveness and efficiency of a newly developed NP-staffed

FT unit at a Southwestern level I trauma center. Specifi-

cally, we looked at unscheduled return visits, LWBS rate,

and patient satisfaction for the newly developed FT unit

and compared time statistics for the FT area with the pre-

viously run MC area of the department.

Methods

PROTECTION OF HUMAN SUBJECTS

Prior to data collection, Institutional Review Board ap-

proval was obtained. In an effort to protect the confidenti-

ality of participants, identifying information was removed

prior to aggregating medical record data for this study.

Additionally, the satisfaction surveys were anonymous and

data are reported in the aggregate. Because this study in-

volved review of charts retrospectively, informed consent

was not obtained from individual participants, with the

exception of those who filled out satisfaction surveys, and

completion of the survey indicated consent to participate

in the study.

DESIGN

An exploratory descriptive design utilizing a retrospective

electronic chart review and prospective patient satisfaction

survey were used to collect data. The patient satisfaction

survey included open-ended questions seeking patient input

on satisfaction with the FT unit. A qualitative analysis of

the open ended questions was done to gain a greater un-

derstanding of patients’ views of the unit. Content and

thematic analysis strategies were used to identify themes in

16 J

the data.13 Fittingness or generalizability is not appropriate

for an exploratory qualitative study and the findings re-

ported here are not meant to generalize beyond the context

of the current study.14,15

PARTICIPANTS AND SETTING

Setting: The study was conducted in a level I trauma center

that has approximately 80,000 visits annually. Of those

visits, it is estimated that 21,600 are nonurgent and would

be appropriate for an FT unit. In 2005, the racial ethnic

diversity of the outpatient population to the ED was 54%

non-Hispanic Whites, 19% Hispanics, 24% African Amer-

ican, and 4% were unknown.16

Participants: For the retrospective chart review, all charts

were included for patient visits to the FT area from Sep-

tember 1, 2004, through February 28, 2005 (N = 5995),

and charts were included for patient visits to the MC area

from September 1, 2003, through February 28, 2004 for

comparison (N = 9130).

PROCEDURES

Using the electronic ED tracking system EMSTAT, all re-

cords were electronically extracted for the evaluation period

by the ED data manager. The records were reviewed for

place of service within the department. All visits in the

FT area from September 1, 2004, through February 28,

2005, are included in the study. The historical comparison

data included records from the MC area of the department

from the previous year. The MC area occasionally saw

patients whose triage acuity rating would make them in-

eligible for care in the FT area. For this reason, only MC

visits with a triage acuity rating of 3 or nonacute were

kept in the historical control data set for the comparison

analysis. This was done to make the data sets as equivalent

as possible for comparison.

Demographic data including age, ethnicity, and payer

status were collected from the FT and MC charts. Data

were collected regarding time in the department and time

in the room for both the FT and MC areas.

Data collected specifically for the FT area included

the LWBS rate, unscheduled return visits, and patient

satisfaction. Unscheduled return visits are tracked in our

department for all providers as one measure of quality

of care. Normally, patients are not expected to have an

OURNAL OF EMERGENCY NURSING 33:1 February 2007

TABLE 1

Demographic data for fast track and minor care sample

VariableFast track(N = 5995)

Minor care(N = 9130)

Mean age (y) 39 (range 1-90) 46 (range 16-94)

Sex

Males (%) 51 48

Females (%) 49 52

Ethnicity

White (%) 50 47

AfricanAmerican (%)

27 25

Hispanic (%) 22 24

Other (%) 1 1

R E S E A R C H / N a s h e t a l

unscheduled return to the emergency department within

72 hours of a visit.

Additionally, patient satisfaction surveys were made

available in the FT area during the prospective study pe-

riod. The satisfaction surveys were not available until Jan-

uary 2005. Patients self-selected to fill out the survey if

they desired to give feedback on their experience in the FT

area (N = 90).

PATIENT SATISFACTION SURVEY

The patient satisfaction survey was developed by the in-

vestigator (K.N.) to collect quality improvement data for

the department. The survey consisted of 6 questions about

the quality of care received in the FT unit. The scale used

a Likert-type format with the anchors Poor (1.00) to Ex-

cellent (4.00). Mean scale scores were calculated for each

item, ranged from 1.00 to 4.00, and were calculated for

each item on the scale. The a coefficient for this sample

was acceptable at .83. Table 1 presents the data from

the survey.

DATA ANALYSIS

Data screening and a check of the plausibility and dis-

tribution of scores were conducted before performing de-

scriptive statistics to ensure the data met the statistical

assumptions necessary for data analysis. The data screening

included removing cases from the historical control data

set with a triage acuity higher than 3. Also, if the date

range was outside the range of the study period, the case

was removed. If dates and times of service were out of

sequence, attempts were made to reconcile the data. If ac-

curate data could not be assured, the case was deleted from

the data set. Data analyses were performed using SPSS

version 11.5 for Windows. Descriptive data were used to

delineate characteristics of the sample and to evaluate the

following research questions:

1. What percentage of patients will have an unscheduled

return visit to the emergency department within 72 hours

of discharge from the FT area?

2. Will the LWBS by a provider rate be different for the

FT area compared with the main emergency department?

3. What percentage of patients seen in the FT area will

report the quality of care received by the NP as good or

excellent as measured by an investigator-developed pa-

tient satisfaction survey?

February 2007 33:1

4. Is there a difference in time in department for patients

seen in the FT area compared with time in department

for patients seen in the previous MC area of the emer-

gency department?

5. Is there a difference in time in room for patients seen in

the FT area compared with time in room for patients seen

in the previous MC area of the emergency department?

Results

DEMOGRAPHIC DATA

A total of 5995 patients were seen in the ED FT area from

September 1, 2004, through February 28, 2005, and there

were 9130 patient visits to the MC area from September 1,

2003, through February 28, 2004. The population of these

patients included roughly equivalent numbers of females

and males. The majority of the patients was classified as

self-pay or had no insurance (67%). The ethnic distribu-

tion of the sample was diverse. Complete demographic

data for the patient visits to the FT and MC areas are

presented in Table 1.

UNSCHEDULED RETURNS

Of the 5995 patients seen in the FT area, 172 had an

unscheduled return to the emergency department within

3 days (2.3%), although none required hospital admission.

By comparison, the overall return rate for the main emer-

gency department during the same time period was 4.2%.

JOURNAL OF EMERGENCY NURSING 17

TABLE 2

Patient satisfaction survey data

Variable rated

Mean score foritem (range 1.00to 4.00) (N = 90)

Percent rating asgood or excellent

Quality of the FT visit 3.71 97.8

The courtesy of the FTstaff

3.85 100

The amount of timespent in the FT area

3.45 89.8

How privacy washandled

3.83 100

The care provided bythe NP

3.87 100

The overall FTexperience

3.78 97.8

R E S E A R C H / N a s h e t a l

LEFT WITHOUT BEING SEEN

The LWBS rate during the study time period for the main

emergency department was 6.7% (95% CI 6.45-6.97),

whereas the rate for the FT area was 3.9% (95% CI 3.70-

4.10). This was a statistically significant difference (Z = 21,

P b .001).

PATIENT SATISFACTION

One hundred percent of patients seen in the FT area during

the study period reported that the quality of care given by the

NP was good or excellent as measured by an investigator-

developed patient satisfaction survey (see Table 2 for a more

detailed listing of finding from the satisfaction survey).

Respondents also were asked to write comments by

hand on the patient satisfaction survey about the care re-

ceived by the NP and to make suggestions for improvement.

Ninety surveys were received during the study evaluation

period. Of those, 20 contained handwritten comments. The

comments were transcribed verbatim by the principal

investigator. The data were analyzed for themes. Preliminary

themes that emerged from the data on care received were

labeled: ‘‘Excellence in Caring’’ and ‘‘Taking Time to Care.’’

Instances of data supporting those categories are partici-

pants’ comments, such as the following: ‘‘She has been the

best nurse out of all the times I’ve been here.’’ Another said,

‘‘The care provided was excellent.’’ Other comments in-

cluded, ‘‘Extremely genuine and caring, talked with me, not

at me’’ and ‘‘Professional, able to explain what treatment

was needed in a practical, easily understood manner.’’

TIME IN DEPARTMENT AND TIME IN ROOM

Time in department is the entire time the patients are in

the emergency department from initial presentation at tri-

age to discharge. The average time in department for pa-

tients seen in the FT area was 4.36 hours. Time in the

department ranged from less than 30 minutes to 20 hours,

with 15% of the patients having a time in department of

less than 2 hours. Comparison data from MC visits 1 year

prior to the implementation of the FT area showed similar

results, with an average time in department for the MC

area of 4.68 hours. This was not a statistically significant

difference (t = 1.75, P = .08, 95% CI –.009 to 0.16).

Time in room (TIR) calculations start when the pa-

tient moves from the waiting area into a treatment room

in the emergency department. Average TIR for the FT area

18 J

during the study period was 1.97 hours, and 19% of the

patients had an average TIR of less than 1 hour. The

TIR statistics for the MC area for the previous year was

2.64 hours. There was a statistically significant difference

in TIR between the FT and MC areas (t = 1.96, P = .05,

95% CI .004 to 0.12).

Discussion

We expected our turnaround times to improve dramati-

cally with the opening of the FT unit, and this was not the

case. This may have happened for many reasons. In the

past, the emergency department has not met our bench-

marking time goals; expecting one change in process to

immediately change years of practice may not have been

realistic. Also, all but one of the NPs in the unit were new

hires and did not have previous ED experience. The new

NPs may have needed time to adjust to the FT setting and

learn their roles and responsibilities before being asked to

move patients more quickly. Also, the period of time for

the study corresponded with one the busiest times this

emergency department has seen. Patients routinely were

being held up to 3 days in the department waiting on beds.

Interestingly, even though the FT times were not as ex-

pected, the patients who filled out the satisfaction survey

were satisfied with the wait times and the care they received.

The LWBS data also are encouraging. The patients

triaged to be seen in the FT area had a significantly lower rate

OURNAL OF EMERGENCY NURSING 33:1 February 2007

R E S E A R C H / N a s h e t a l

of LWBS than those waiting to be seen in the main depart-

ment. Furthermore, relatively few FT patients had unsched-

uled return visits (2.3%), and none of the return visits results

in hospital admission, suggesting that the care provided by

the NP was appropriate. The data from the satisfaction sur-

veys are most encouraging; patients report being happy with

the care received by the NP. Their written comments on

the satisfaction survey suggest patients felt well cared for,

that treatments and conditions were explained to them, and

that NPs were kind, compassionate, and professional.

Conclusions and Directions for Future Research

LIMITATIONS

This study is limited because it was conducted in the first

3 months the FT unit was open. Taking a snapshot of the

FT gives a limited view point. Several process issues were

being worked out that probably inf luenced the time in

department and TIR numbers, adversely skewing the data.

Follow-up study is needed to determine the current impact

of the FT area in the emergency department. Collecting

data over time would give a fuller, more descriptive picture

of the department. Also, comparing the FT area to the MC

area as a historical control has some f laws. The MC area

was staffed by faculty physicians and residents, and the

patient mix was somewhat different than what is normally

seen in the FT area. However, in the absence of a perfect

historical control, it was used for this study because in gen-

eral lower acuity patients were seen in the MC area. Also, the

patient satisfaction surveys were not available during

the entire time of the study because of delays in getting

the surveys translated into Spanish and printed. Also, pa-

tients self-selected to fill them out. They were placed in all

patient rooms once they were available, and it is possible

that only patients with either strong negative or positive

feelings chose to take the time to fill out the survey.

Conclusions

The purpose of this study was to determine the effective-

ness and efficiency of a newly developed NP-staffed FT

unit and to compare time data for the FT unit with the

previously run MC area. The LOS data suggests the effi-

ciency of the FT unit has room for improvement. How-

ever, the unit is effectively run in that the LWBS rate is

February 2007 33:1

low, the unscheduled return visits are kept to a minimum,

and patients are highly satisfied with the care they receive.

It will be helpful to collect data on an ongoing basis to see

if time in department and TIR continues to decrease while

high patient satisfaction is maintained. Although the data

presented here from the satisfaction surveys are prelimi-

nary, they point to a need to explore the care provided in

the FT area further with a larger sample.

FUTURE DIRECTIONS

Future studies should specifically examine processes within

the department that may be contributing to long LOS and

overcrowding. Data should be collected on the relation-

ship between presenting complaint, diagnosis, and LOS

to determine appropriate triage criteria for the FT area.

Future studies looking at diagnostic workups ordered for

patients seen in the main emergency department and the

FT area also would provide useful information. Presumably,

patients sent to the FT area have nonacute problems that

should require minimal, if any, diagnostic workup before

a disposition can be determined. If extensive workups are

being done that increase TIR, further analysis is needed.

Identifying the processes that directly affect long LOS is

the first step in the change process. Currently, NP staff are

looking individually at charts for patients whose LOS ex-

ceeds 4 hours to determine underlying causes of long stays.

The FT area was evaluated for this study during its

initial implementation. As the staff becomes more com-

fortable with the FT process, wait times should continue to

improve. As we continue to look at ways to decrease over-

crowding, the data are providing guidance for the future

direction of NP utilization in the emergency department.

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