I had the charge nurse get upset with me while working in our ED’s fast track yesterday. I wasn’t seeing enough patients and the waiting room was standing room only. There was a list of about 20 patients waiting to be seen the whole day. Patients in carts and on chairs lined the halls.
I don’t like arguing with my staff. I just go about doing my job. But I was a little upset that both the triage nurse and the charge nurse didn’t seem to understand the concept of “fast track.” At one point I was getting sick of the eye rolling and told the charge nurse that things would probably move a little quicker if I was actually seeing “fast track” patients.
A “fast track” is generally intended to evaluate and treat patients with minor problems so that the patients can get in and out of the ED more quickly. Coughs, runny noses, sprained ankles, rashes are all examples of good “fast track” candidates.
If patients requiring more extensive workups are put in fast track, it slows down the process because there is only a nurse and a doc there. No tech or other ancillary staff. On patients who need big workups, either the doc or the nurse has to start IVs, draw blood, do EKGs, give medications, bring the patient to x-ray and enter all the information into the computer to prove to the Medical Marijuana Advocates that we are doing our job correctly. All of these actions take away from time we could be seeing other patients.
Disposition is also delayed because the patient has to wait for all of the tests results to come back before being admitted or discharged. If a patient has to be admitted from fast track, it slows things down further as the doc has to contact other docs and write admitting orders while the nurse has to call report to the floor nurses.
At one point in the 4-bed “fast track” yesterday, I had one guy who had “a can of asswhoop opened up on him” and who needed multiple x-rays, another patient who fell down a flight of stairs and who needed multiple x-rays and CT scans (and who ended up having a brain bleed), two female patients with severe abdominal pain (both of whom needed pelvic exams and CT scans), and a younger patient with pre-existing heart disease and chest pain. We were juggling patients between beds as they would come and go from the x-ray department. A patient with flank pain and “possible kidney stone” was next to be seen in the rack.
Meanwhile, patients with “coughs” and a patient who needed a gastrostomy tube replaced were being sent to the main ED.
The triage nurse made a valid point, stating that it’s better to have serious patients seen first – even if it is in fast-track. Would I prefer to have had the brain bleed sitting in the waiting room so that I could see the patient needing the G-tube replacement? Possibly true, but then why have a “fast track”?
So is it better to stick to the stated purpose of a “fast track” and juggle the sicker patients between rooms and hall beds in the main ED? Or is it better to turn the fast track into a “remote ED” treating the same types of patients as the main ED with less staffing?
By the way — overcrowding sucks.
What I really hate is when I tell the charge RN that a certain patient is not fast track due to the nature of their complaint and the reply is “I know, but just get him started there”. Ummmmm. That screws up the whole idea of fast track!!!!!
In my opinion the “stated purpose” of an emergency department is to evaluate and stabilize patients with emergent conditions. Period.
I understand that having a Fast-Track may be lucrative from the hospital’s standpoint and even necessary for some to remain solvent. I don’t think however that someone with a more serious complaint should wait for a bed in the “acute” side of the ED when there is a bed available and an EM trained doc even if they are in the Fast Track.
At the end of the day the people with the more urgent complaints should be seen first – obviously. If this creates “less than acceptable” wait times for the less-than-urgent complaints, then perhaps the ED is not the most optimum place to seek treatment after all.
The problem with Fast Tracks, and expanding EDs for that matter – is that it seems no matter how many beds you have in the department the patient population seems to achieve equilibrium somewhere just north of the “filled-to-capacity” line. Perhaps a change in thinking is in order.
Just my $0.02
I tend to only put fast track patients in fast track, but on the rare occasion that a doctor is back there (vs. PA/NP) and we’re getting killed, sorry, dood, a bed’s a bed. If we have some FTeurs going left without being seen, that’s fine, but having a brain bleedeur waiting is not fine.
On the second-worst shift of all time in my career, I was the FT nurse with cardiac chest paineur (portable monitor), DKAeur, and someone who passed out with a temp of 106 while running who was hanging out back there getting 8, yes, 8 liters of IVFs. Yeah, it sucked, but there was nowhere to put these people.
last week our FT took 82 patients over the 12 hours it was open. everyone had to go over and help out- how in the hell can one doctor see 82 patients in 12 hours??
oh, and “because it’s busy” is NEVER an adequate excuse to send someone potentially unstable to fast track!
a few weeks ago i saw a guy in fast track who came in for headache and turned out to have a dural sinus thrombosis. admitted him to ICU!
I think the bigger issue, isn’t patient placement, but whether a “fast track” should exist at all, it seems contrary to what an ED should be. If you’re not providing services for ED abusers, any chance they break their cycle. If a hypochondriac/frequent flyer had to wait 12 hours rather than being put in the fast track, does it deter their behavior? The only way to maintain a fast track, as a fast track, if you have to have one would be to make it a seperate department, not sharing staff, We’ve had to do that in a couple of sections of our lab. Our micro and blood bank departments had to be seperated and changed into individual entities to keep staff from being pulled. Anyway, I guess If the fast track is part of the ED then the most emergent case has to go first, if it’s a seperate entity then it should maintain it’s purpose to a quick in quick out cash machine for the hospital.
In all seriousness, does a hospital have to have a fast track area to remain solvent? Do you have to guarantee yourself that low reimbursement rate rather than let a patient sign in, sit and wait? I’m not real aware of the economic issues.
Huh. I thought the big win for the fast track was having a cheaper NP/PA work it rather than an expensive doctor. If the guy working it is qualified to handle the hard stuff, then I don’t see the point.
Regardless of our feelings on low acuity and misuse of the ED, these are the (typically insured) patients that generate income for the hospital (and ultimately our paychecks). To keep them from walking out the door due to long waits, the fast track is there to get these people in and out. When ED’s are closing nationwide, you best believe that hospitals are going to do what they have to do to generate revenue, and if it means having 4-8 beds to handle BS so you can keep the other 20 open, so be it. The end justifies the means, in my opinion.
While I do think that the most acute patients need to be seen first, to place patients there that are big workups does more harm than good. Before everyone goes, “Well don’t the people who are really sick deserve beds first?!?!” acknowledge that when you do this, fast track patients end up in the Main ED getting ignored by their nurses and the big-workup patients end up in the fast track also being ignored, in the form of no cardiac monitor and a typically higher patient to nurse ratio.
Here’s an often little considered angle, though: If a patient codes in the waiting room or suffers a negative outcome, Triage and Charge will likely be held responsible. If a patient suffers a negative outcome in Fast Track, the nurse and doc back there will likely have to answer. So when push comes to shove, what would you do if you were Triage?
Freedom isn’t free. What the left doesn’t understand is that everything has an associated cost. How does this relate to the ER? Well, ER staff fall into one or both of two categories: 1. They wholeheartedly support the global ‘Medical Industrial Complex’ conspiracy and/or 2. They are your garden variety idiots.
Let’s examine the more benign variant first. The idiot’s position is: “I’m just stepping up to fill a void … I’m just trying to do the right thing for the patient in front of me.” !!! Loser !!!! I’ll paint a mental picture for the cognitively impaired: An F-16 based in Iraq is tasked to transit from one forward operating facility to another in preparation for an operation. The left wing bleeding heart liberal pilot says to himself “wow, what a waste of fuel … I’m destroying the planet with my exhaust stream … Al Gore would be so disappointed …. Hey, I’ll do my bit by loading my plane up with mail, spare parts, etc. to make the trip worthwhile — I’ll do more with less !!!! 50% over the allowed weight limit and cramped into a letter filled cockpit the pilot takes off. 20 minutes into the flight he is engaged by an Iranian MIG and he is blown out of the sky. Lesson ??? You can’t have it all — contrary to what Dr. Spock and Gloria Steinem would have you believe. Why don’t police officers provide social work services in between law enforcement calls [they know as much about social services as ER clinicians know about primary care medicine]? They don’t because it would blunt their ability to fulfill their intended responsibilities. Mission creep is dangerous … it resulted in our soldiers being dragged through the streets of Somalia. Would mission creep be possible without the complicity of weak minded front line troops who want to invaginate all the ills of society in an effort to ‘save the planet’? I think not !!
I’ll tackle the willful conspirators next. They saw the angle early on. America began as a land where hard work was rewarded and slackers suffered. Folks paid for what they needed / wanted. People rise to the level of expectation, so in the early days there were very few ‘bums’. Enter the 20th century. Medicine evolved, and hospitals took on their modern form. The dark ages, however, followed in short order … In an effort to efficiently provide a few life-saving interventions for patients while they waited for the OR team to assemble [to repair gunshot wounds, severed limbs, etc] the ER was born. The emergency ROOM worked well, initially. In the early days people had to pay for their emergency care …. Imagine that !!!! After some time it was decided that emergency care should not be withheld on the basis of ‘ability to pay’ — well intentioned, not a terrible move, but definitely a gateway drug. Enter the greedy, ambitious, ER lobby. They conceived a fantastic plan to get rich quick. “Now that the country is conditioned to pay for everyone’s emergency care …. All we have to do is group all medical care under the rubric of emergency care and ….. drum roll here …… we will have achieved back door ‘free healthcare’. “ The best is yet to come !!!! “We’ll give the people substandard primary care and charge them 20X what they would normally pay for it. We’ll get away with this because we’ll put the ‘emergency’ label on all our services …. We are as Gods !!!! Our pay, status, influence, and lifestyle will all skyrocket in a scant few years . Instead of relegating the dregs of our profession to the ER, in the future, doctors will be competing to be selected for the ER. We win 6 ways to Sunday on this !!!!!”
‘Emergency rooms’, my ass !!! They should be called third world clinics w/ a charged defibrillator on site
If ER clinicians had even a modicum of integrity, the door labeled ‘fast track’ would also be labeled ‘exit’.
Wow,
You dont understand what is going on at all, do you? and you have some kind of chip on your shoulder for er docs, or all docs?
As an er physician, I see fast track as a necessary evil. remember, we are mandated to see ALL patients coming within about 200 yards of hospital property, give them a medical exam, and stabilizing treatment. Fast track is a good way to do this, and often we have mroe serious illness being picked up from the fast track clinic.
Fast track should be reserved for fast track type patients. Sending severe injuries to an area of the ED understaffed/underequipped to handle them is inappropriate. It sounds like FT wasn’t turning over much, and you probably ended up not having much to do for part of the day. If it were up to me, I would have suggested that the doc see some extra patients over in the ED, with occasional trips to FT to see/dispo a few patients over there. FT would have been slower, but patients would have been in an area appropriate for their complaint and you could have eased the burden in the main ED while dispo’ing FT patients as well. I guess a lot of that depends on how quickly you work, though. Most of my friends in FFS practice see about 3.5 pts/hr on the low end and stretch to 5/hr.
It does create a triage conundrum. On the one hand you have the sickest patients go back first to main ER. And the least sick go back second to the fast track. The middle category go last. It’s backa– triage, but more efficient to move through the waiting room patients.
I often admit my FT patients as they are often mistriaged. So again, not so fast. In your case, your nurses don’t view it as a fast track, they view it as a bed. and that causes the whole system to break down.
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What it sounds like everyone is missing is an experienced, trained triage nurse. They should be able to determine 95 – 99% of the time what truly is and is not an emergent condition or what might and might not be emergent. They should also be able to determine what fits FT criteria and what doesn’t. Kudos to the triage nurse and Charge nurse who don’t waste valuable resources when they are necessary – however it sounds like some of you have put yourselves at the mercy of the nurses in times past. I have been that triage nurse and frequently am a charge nurse, and I work WITH my physicians in the seldomly realized goal to provide the best care to my patients in the most expedient manner. I’m sorry, I do enjoy this blog immensely, but I notice that I tend to see some antagonistic tones prevail when talking about the nursing staff. In my career, there have been times when I’ve saved my physicians bacon, and there are times when they have saved my bacon. Believe it or not, I think the system works best when physicians and nurses have a symbiotic relationship, not an antagonistic one.