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: [email protected].
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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