Abstract
The Emergency Department (ED) is a specialized area that treats acutely ill patients that may require immediate treatment. The ED is equipped to manage an increase patient load and a variety of acuity of patients. Although equipped, the emergency department overcrowding is an ubiquitous issue; the effectiveness of treatment, patient satisfaction, and safety are compromised. In this paper, it will determine if the implementation of a fast track system will improve Emergency Department effectiveness. The following areas will be reviewed: patient satisfaction, patient flow, length of stay (LOS), and quality measures (revisits and mortality rates). In addition to the fast track system, strategic recommendations were reviewed–identify appropriate patients, a separate area with separate staff, and the hours of operation– to help execute the idea of a fast track system. The following research hypothesized that the implementation of a fast track system not only improve patient satisfaction and decrease LOS, but also contributed to the management of flow within the ED to prevent overcrowding.
Keywords: Emergency department; patient flow; effectiveness; quality of care; wait times; fast track; length of stay; Emergency Department overcrowding
Introduction
Emergency departments (ED) can be know for their high risk and high stress environments. It incorporates what is called a triage process which the goal is to take more severe urgent patients opposed to non-urgent patients. With this process, it causes prolong patient waiting times and length of stay, the flow of the ED is compromised which results in overcrowding in the unit (Lutze, Ross, Chu, Green, Dinh, 2014). Overcrowding is where ED function is compromised primarily due to—the quantity of patients waiting, undergoing assessment and treatment, or waiting for a disposition—which exceeds the physical and/or staffing capacity of the ED (Madavan Nambiar, Nedungalaparambil, Aslesh, 2017). Not only is overcrowding in the ED is detrimental to patient safety, it can also impact the quality of care due to those incidents where the ED is not properly equipped with the right amount of staff. When the ED is not adequately staffed the longer patients length of stay (LOS) increases due to patient requiring more staffing time and attention. Due to longer LOS, this concludes in reduced numbers of available beds, in which, the nurse has to factor in the increased workload created due to the patient longer LOS (2017). The American Academy of Emergency Medicine (AAEM), suggest that for moderate acuity EDs, 2.5 patients per hour should not be exceeded for physcian staff and the nurse to patient ratio should be at most 1:3, depending on patient influx (AAEM, 2017).
In the article, “Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of an Education and Research Hospital,” it defined the three major components that results from overcrowding in emergency department. This includes: “degradation of the quality of care (prolonged waiting times, delays to diagnosis and treatment, delays in treating seriously ill patients), increased costs (leading to unnecessary diagnostic investigations), and patients’ dissatisfaction (Erenler, Akbulut, Guzel, Cetinkaya, Karaca, Turkoz, Baydin, 2014). Based off the articles reviewed, studies have shown that these factors plus other factors like– inappropriate use of the ED by the patients, recurring ED visits, and hospital specific factors (size/location) all correlates with ED overcrowding. Emergency department overcrowding is a complex problem that encomasses ‘internal and extrental factors,’ those in which non-urgent patients contribute to the overcrowding.
Due to all these contributing factors and the constant high pace and high pressure cases, Emergency Departments began to incorporate what is called a “fast-track” system. The idea of a fast track system is to bring an innovative way to be able to see high volumes of patients in an efficient and safe manner; all while improving patient satisfaction. The fast track team is staffed with a ‘mid-level’ practitioner and designed to treat lower acuity patients in a rapid manner (Sanchez, Smally, Grant, Jacobs, 2005). This paper will explore the potential solution to the overcrowding of the emergency department. It will examine the effect of a fast track system within various ED and see if the above factors improved because of the implementation of a fast track system.
Purpose
The purpose of this research is to assess the implementation of a fast track system within the emergency department (ED). The following aspects were reviewed—patient satisfaction, patient flow, patient length of stay, overcrowding, and quality of care in the emergency department. The goal of this research was to see if incorporating a fast track system will decrease overcrowding in the ED and improve patient satisfaction. In addition to the fast track system, strategic recommendations were reviewed to help execute the idea of a fast track system. The following areas were also reviewed— a defined criteria to identify appropriate patients, a separate area with separate staff, and the hours of operation.
PICO Question
Among the patients seen at a level two trauma center, what is the effect of the implementation of a fast track system compared to a system without a fast track. How would this implementation affect patient safety, satisfaction, reduction in length of stay, and prevention of overcrowding?
Review of Literature
According to “Agency for Healthcare Research and Quality,” emergency departments reported managing at or above capacity, while 9 out of 10 facilities reported holding admitted patients in the ED until their room was ready on the floor (2011). It was reported that 500,000 ambulances are redirected from the closest agency yearly due to overcrowded EDs (2011). On this site, “Agency for Healthcare Research and Quality,” it digs deeper into the effect of overcrowding in the emergency department. Five subtopics were reviewed: “ED crowding compromises care quality, ED crowding is costly, hospitals will soon report ED crowding measures to CMS (Centers for Medicare & Medicaid Services), ED crowding compromises community Trust, and ED crowding can be mitigated by improving patient flow” (2011). When in this rigours environment, there is a complex of acuity ranking patient all while the ED is over capacity heightens the risk for errors to be made. The website makes a point that Institute of Medicine (IMO’s), reported that one area warranting special attention at Academic Medical Centers (AMCs) was “the need to address AMC emergency department crowding and its adverse effect on quality of care and patient safety.” IOM's, six dimensions of quality—safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity—are at risk to be compromised when patients experience long wait times to see a physician, patients who stay in the emergency department while waiting for a bed on the general floor, or ambulances that are diverted away from the hospital closest to the patient (2011).
Another factor the “Agency for Healthcare Research and Quality,” suggested was the effect of cost due to overcrowding. In 2007, data revealed that 1.9 million people left the ED before even being seen due to long wait times. Due to these “walkouts” along with ambulance diversions, the hospitals lost significant revenue (2011). The year prior, a study was conducted at the AMC which showed that each one hour diversion resulted in $1,086 in “forgone hospital revenues.” An additional $9,000 the hospital would profit from if ED boarding time was cut by an hour due to reducing ambulance diversion and the number of patients that leave without getting care (2011).
Not only does overcrowding increase cost for the hospital, it also compromise the trust within the community. The ED is play a vital role for healthcare for the community. As a community member, it is expected to be able to receive quality care 24/7, especially in the sense when there is an emergency. Evidence shows that the ED is not only utilized in emergency situation, but some of the patients are referred by their PCP or clinics to bee seen at the ED. Reasons include: “convenience during after-hours care, including convenience for reluctance to take on complex cases, liability concerns, and the need for diagnostic testing that cannot be performed in their offices” (2011). Based off the website, the ED is considered the “public face” of the community because it is the most frequent healthcare place the community sees, plus the ED sees high acuity/ high volume patients. So when crowding interferes with the EDs ability to provide timely, effective, and efficient care the community’s “trust and confidence” in the institution is compromised (2011). The last factor the “Agency for Healthcare Research and Quality,” included was how institution can implement strategies to help with the flow of crowding in the ED. It was reported that “a number of hospitals have implemented patient flow improvement strategies, like a fast track system, that have resulted in reductions in measures of ED crowding. As a result, numerous organizations—including the Institute for Healthcare Improvement, the Joint Commission, and the Institute of Medicine—have encouraged hospital leaders to adopt patient flow improvements” (2011).
Emergency departments incorporated a fast track system placed to take non-urgent patients to a designated area separate from the emergency department. Depending on the facility the fast track system has a designated time for hours of operation. In a study performed in the ED of a tertiary care adult hospital, it was shown that waiting times and length of stay were significantly decreased after the implementation of a fast track. Also, patients who left without being seen, mortality rates, and revisit rates all decreased after the incorporation of a fast track (Sanchez et al, 2005).When conducting the study, all of the patients were seen by the triage nurse and then classified by acuity or emergency severity index (ESI) related to the chief complaint—emergent, urgent, and non-urgent (Sanchez et al, 2005). For the non-urgent complaints like—coughs, runny noses, sprained ankles, rashes, etc—they were placed in the fast track area with in the department where they were seen by “mid-level practitioners—Physician Assistants and Nurse Practitioners—who are variously trained and adult-qualified to see fast track area patients” (Sanchez et al, 2005). The results of this study showed that after the implementation of a fast track system both the wait time and the LOS for the total patient population “decreased by 50% and 9.79%” (Sanchez et al, 2005). According to the article, “Effects of Fast-Track in a University Emergency Department Through The National Emergency Department Overcrowding Study,” waiting times decreased from ‘twenty minutes to ten minutes’ and the LOS shorten from ‘eighty minutes to forty-two minutes,’ (Aksel, 2014). The study showed significant improvements within the emergency department after the implementation of the fast track system.
Methods
The methods used to evaluate the effectiveness of the fast track system were literary reviews. The objective was to review multiple sources to see the effect of a fast track area on overcrowding within the ED, patient length of stay, patient flow, patient satisfaction, and quality of care implemented from the hospital. The Press-Ganey questionnaire was also used to measure the following the effect of fast track. The survey questions will be reported in the following domains and the
Results and Data Analysis
In the article, “Effect of an Emergency Department Fast Track on Press-Ganey Patient Satisfaction Scores,” a cross-sectional study of a Press-Ganey questionnaires were sent to 100% of discharged ED patients. The survey focused on the audience that were low acuity patients and ED fast track patients with a ESI of 4 or 5 (Hwang et al, 2015). There were a total of 140 respondents in the ‘Pre-ED Fast Track group and 85 in the ED Fast Track group,’ with an overall 14.8% response rate (Hwang et al, 2015). After reviewing the results of the questionnaire it was seen that there were significant improvements in patient satisfaction after the implementation of an ED fast track. “Patient satisfaction with wait times increased from 68% to 88%, doctor courtesy 90% to 95%, nurse courtesy 87% to 95%, staying informed about delays 66% to 83%, staff caring 82% to 91% , pain control 79% to 87% and likelihood to recommend 81% to 90%” (Hwang et al, 2015).
Conclusion
All in all, the idea of a fast track system was to bring an innovative way to be able to see high volumes of patients in an efficient and safe manner; all while improving patient satisfaction. Based off the research analyzed the usage of a fast track system has contributed to improvement in patient satisfaction, the EDs flow of patients, the quality of care implemented by the healthcare team, decrease in length of stay and waiting time, and the reduction of overcrowding. It was seen how the effect of overcrowding in the ED can compromise the IOM's, six dimensions of quality care–safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity. The Press-Ganey cross-sectional questionnaire showed tangible evidence of improvement in areas of patient satisfaction pre and post fast track implementation.