Fast Track - A Plan to Reduce Waiting Times in an Emergency Department

Sydney South West Area Health Service

This project was entered in the Baxter 2006 NSW Health Awards, Best innovation to improve Patient Care and Patient Journeys category.

 Presentation given at the 2006 NSW Health Expo.

Contact: Debra Fox

Abstract

Delays in patient assessment and treatment in Emergency Departments occur for a number of reasons.  After wide consultation, the Emergency Department (ED) at Bankstown-Lidcombe Hospital created a mixed nursing / medical model of care, called 'Fast Track', that allows lower complexity patients to be progress through their ED visit in a more timely fashion.  Once triaged the patient's suitability for Fast Track is determined based on a set criteria. The model enables patient assessment and treatment by experienced nurses using appropriate clinical protocols and standing orders, with the support of a dedicated senior medical officer.  The average waiting times for triage categories 3, 4 and 5 improved significantly following implementation of the new model. The percentage of patients that did not wait for treatment reduced together with the levels of aggression in the waiting room.  Patient and staff satisfaction increased.

What was the problem?

NSW Department of health benchmark performance indicator thresholds for the Australian Triage Scale (ATS) categories 3 - 4 and 'did not wait for treatment' could not be reached. 

How did you know?

For the 04-05 financial year, the percent of patients seen in triage categories 3 and 4 was 38% and 45% respectively.  The benchmark threshold for these categories is 75% and 70% respectively.  During the same period, patients in triage category 3 waited 71 minutes for treatment, on average, and 84 minutes if they were triaged to category 4.  As a result, 7.5% of patients did not wait for treatment.  Patients in the waiting room were often dissatisfied with the delay, although few made formal complaints.  Clerical and clinical staff in the ED regularly experienced verbal abuse and aggression from frustrated clients.

What did you do?

A team brainstorming session was held to workshop possible solutions. It became evident that a dual process was needed; one that responded to high care patients and another for patients that required predominately ambulatory treatment. A literature search highlighted a system, commonly called Fast Track, that had been introduced successfully in English, North American and Victorian EDs (Cooke et al, 2004, Darrab et al, 2006, Sedlak & Roberts, 2004 & Taylor et al, 2004).  Currently, similar processes are being trialled at four other NSW EDs; Concord, John Hunter, Port Macquarie and Nepean.  It was decided that a similar concept could be introduced into our ED.

The team agreed that the most appropriate model of care for the Fast Track system was a predominantly nursing model with 16 hours per day designated medical officer support.  The target population and operating criteria were defined that would keep the area safe and functional.  A business case was built around the existing funds for the Nurse Practitioner (NP), Clinical Initiative Nurse (CIN) and Rapid Emergency Assessment Team (REAT). The business case outlined the need for additional funding for senior medical support and ED renovations.  A comprehensive implementation plan was developed to ensure the project's success and that disruption to clients and ED operations would be minimised.   A senior ED nurse took on the role of managing the implementation.  This ensured that there was a single point of communication and that steps occurred in order. An issue escalation process was determined.

The ED was redesigned and a Fast Track area developed.  The refit was undertaken by the Hospital's Engineering Department with input from staff, and supported by management.   Effective recycling of existing physical resources enabled these costs to be kept to under $7000. During the building phase, the team developed inclusion and exclusion criteria for Fast Track patients, standardised forms, orders and reviewed existing protocols.  The EDIS system was modified to capture information on Fast Track patients.

The change was defined as a system of treatment, rather than just a physical area.  Principles of rapid decision-making, minimal duplication and minimisation of delay were integral to the process. The changes were made with the patient journey as the focus, rather than the medical diagnosis.

An ongoing communication and education strategy was developed for staff, clients and key stakeholders.  Regular communication and involvement of all staff in various stages of the project led to a feeling that the change was in the right direction. 

Appropriately skilled and dedicated staff were identified to work in the Fast Track area and staff rosters were configured accordingly. The use of Advance Clinical Nurses and Nurse Practitioners with medical officer support underpins the Fast Track staffing.

The Fast Track process commenced on the 10th of April 2006.

How do you know you succeeded?

The change in the journey for patients triaged to Fast Track has had a significant impact on our ED.  Since introduction Fast Track has managed 34% (n=2414) of the 7019 presentations. The Fast Track journey by ATS breakdown is summarised in Table 1 below.

Table 1. Fast Track Statistics Post-Implementation

During the first 10 weeks of implementation the average waiting time for all ED presentations triaged to categories 3, 4 and 5 dropped significantly when compared with the same period 2005 (see Figures 1, 2 & 3).

The proportion of patients that did not wait for treatment (DNW) was reduced by more than half, from 5.7% to 2.4% across the entire patient population. Within the Fast Track system, the DNW rate was 1%. 

Satisfaction surveys of the ED clinical and clerical staff and patients using Fast Track have shown high levels of satisfaction with the improved efficiency within the ED. Overall staff morale increased.  Clerical staff reported lower levels of aggression in the waiting room, night staff were happier as there was a greatly reduced backlog, the emergency physicians were able to focus on more of a consultant role and the Advanced Care Nurses that worked in the Fast Track team enjoyed their role.

Compliments were received from clients and from the inpatient units, especially the Obstetrics & Gynaecology unit.

Improvement in Waiting Times by Triage Category

Figure 1

Figure 2

Figure 3

What did you learn?

Keys to success of this project included good project management, good functional planning prior to implementation, focus on patient journey and clinical service, additional senior staff dedicated to the Fast Track system, and involvement of key players in the planning and implementation. For the system to continue to be successful, the dedicated senior staff must be preserved. The functional system and the additional staff had to occur together. As the implementation philosophy was to start with a manageable amount of change, there is scope to expand the role and fine-tune the policies of the Fast-track system as it evolves over time.

What plans have you to sustain the change?

Staff support is being sustained through ongoing evaluation, issue identification and problem solving of the entire Fast Track process.  The health service hopes to sustain the project financially over the next three years through submissions for 'Way Forward' Funding. The initial support given by the hospital Executive to Fast Track has continued through supporting this submission.

Suitable ED Registered Nurses are being identified and supported to undertake training for certification as Advanced Clinical Nurses. This will ensure a pool of certified nurses on staff to work in Fast Track.

References

Cooke MW, Wilson S & Pearson S, 2002, The effect of a separate stream for minor injuries on accident & emergency waiting time. Emergency Medical Journal, 19, 28-30.

Darrab A, Fan  J, Ferandes C, Zimmerman R, Smith R, Worster A, Smith T & O?Connor K, 2006, How does fast track affect quality of care in the emergency department. European Journal of Emergency Medicine, 13(1). 32-35.

Sedlak S & Roberts A, 2004, Implementation of best practices to reduce overall emergency department length of stay. Topics in Emergency Medicine, 26(4). 312-321.

Taylor D, Bennett D & Cameron P, 2004, A paradigm shift in the nature of care provision in emergency departments. Quality & Safety in Health Care, 21. 681-684.