Why FAST TRACK is wrong

  1. EDs have x resources.
    When we allocate any of those limited resources to treat those with conditions better treated in non-ED settings, we are 1. diverting limited resources away from more acute cases, and, 2. sending the message that EDs are for conditions other than emergencies.

    Abolish the Fast Track. Treat each patient according to acuity. If that stubbed toe has to wait 16 hours to be treated because all the patients who came in after him were more acute, so be it. Screw Press-Gainey.

    EDs, it's time to decide and focus: are you EMERGENCY DEPARTMENTS or PRIMARY CARE CLINICS?
    It's time to stop trying to be all things to all patients.
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  2. 14 Comments

  3. by   BSNtobe2009
    I personally believe that Emergency Rooms should be able to turn away certain patients, depending on condition, however, on the flip side, some doctors have created their own problems.

    Not all areas have Urgent Care clinics...what happens if you don't have a primary care physician and every doctor you have called isn't taking new patients or won't work you in? That is when you find yourself in the emergency room for things like colds and strep throat..things that are not immediate emergencies.

    I also feel that it takes too long for people that have pain-related emergencies, but their condition is minor. I cannot tell you how many times I have had to go to the ER over migraines (about 4x per year), that Darvocet (sp?) will not cure in order to get something stronger, because my doctor refuses to call me in a prescription for anything without seeing me, even though I have a chronic condition. Urinary Tract Infections...which can cause maddening pain...very simple, yet, I have had to sit in an ER for 6 hours before when one hits in the middle of the night b/c I couldn't stand the pain anymore.

    I think if someone went through the ER, they would be suprised on how many cases are pain related, and these folks pretty much don't need anything more than a script and be sent out the door, and would WELCOME it.
  4. by   Email4KH
    Quote from BSNtobe2009
    I personally believe that Emergency Rooms should be able to turn away certain patients, depending on condition, however, on the flip side, some doctors have created their own problems.

    Not all areas have Urgent Care clinics...what happens if you don't have a primary care physician and every doctor you have called isn't taking new patients or won't work you in? That is when you find yourself in the emergency room for things like colds and strep throat..things that are not immediate emergencies.

    If you find yourself with a minor ailment and no primary care physician or Urgent Care clinic, expect to wait in the ED for a long time to be treated. I've never heard of a PCP who won't work in a sick established patient if it's at all possible. Moral: Don't wait 'til you're sick to get a doctor.

    I also feel that it takes too long for people that have pain-related emergencies, but their condition is minor. I cannot tell you how many times I have had to go to the ER over migraines (about 4x per year), that Darvocet (sp?) will not cure in order to get something stronger, because my doctor refuses to call me in a prescription for anything without seeing me, even though I have a chronic condition.

    Most docs won't even prescribe medications based solely on the diagnosis of another physician, much less the patient, himself. A history of a chronic condition is frequently not the cause of "exactly the same pain." Your doctor won't accept your diagnosis because he doesn't want to miss something other than your chronic condition which may be causing the pain. If your "migraine" turns out to be a massive hemorrhage, will your family release the doc from all liability? I doubt it. So does he. So does his liability insurance underwriter.

    Urinary Tract Infections...which can cause maddening pain...very simple, yet, I have had to sit in an ER for 6 hours before when one hits in the middle of the night b/c I couldn't stand the pain anymore.

    A UTI which could just as easily have been a kidney stone or a dissecting aneurysm.


    I think if someone went through the ER, they would be suprised on how many cases are pain related, and these folks pretty much don't need anything more than a script and be sent out the door, and would WELCOME it.
    Again, most docs aren't willing to base treatments on "pretty much..." They're correctly concerned that the patient would get the script, walk out the door and DIE from an undiagnosed condition.
    In any case, the patient with the severe headache or the abdominal pain shouldn't be treated AFTER the patient with the wrist sprain, just because the facility has erroneously allocated its resources to a Fast Track.


    End Fast Track
    Triage Continuously
    Treat Accordingly
  5. by   traumaRUs
    Actually, I just left an ER which had abolished its fast track or minor ER. Info was gotten at the triage desk for quick registration: name, date of birth and complaint and then if there was an open room, back they went. (Two/three rooms always kept available for emergent cases and two trauma bays were always available too).
  6. by   lozza81
    We've just changed our fast track system a little bit, just be using our extended care unit as our fast track area, it has area for 6 beds area for seats and has a dr's station, we're also using 2 cubicles for anyone needing gynae exams. So far, it's working better than when we weren't using the area, our waiting times for fast track pt's are considerably lower than they used to be. But the thing is we still get abused by other patients who need acute care because the people with the ankle injury are going in before them and they arrived afterwards, same old same old there.

    Why is it that we have to take the abuse, but if we were to go anywhere else, bank, supermarket etc, the abuse is not acceptable?!!!
  7. by   CrazyPremed
    It's funny that I'm reading this post because a midlevel was complaining about the same thing today.

    I used to think that fast track was a way to make more money, and to lessen wait times. It seems to be, and - until working in an ER - I thought that it was a great idea.

    Unfortunately, just because ER opens up more rooms for fast track, this doesn't mean more people to staff it. Our fast track is opened based upon the nursing census. If we have enough techs and RN's/LPN's, then it opens. Surprisingly, we don't add a PA/NP (It is staffed with one tech, one nurse, and one PA/NP). The unfortunate PA that is pulled over has to see pts in FT and in the 'minor' medicine side. Although the pts in fast track are sped up, the pts in the other areas are slowed down. The docs profit because more pts are seen. The nurses and pts 'profit' because of the seemingly decreased wait times. Realistically, it seems that all we have done is doubled the work for the midlevels who don't see any more revenue.

    Truthfully, I need more info before I rule out fast track as a bad thing. What do the rest of you think?

    CrazyPremed
  8. by   scribblerpnp
    I would like to make my complaint from a primary care provider point of view. I am continually amazed at the amount of our patients who go to fast track in the middle of the night and during our after-hours (The ED is nice enough to send our office a sheet or two describing the visit). And we have 24 hour doctor call and hours on Saturday (I have sent non-critical pts to the ED on Sunday due to our lack of office hours, so you can blame me for that!) Most of the patients have used the call service and was informed by the MD or NP on call how to treat at home and that we would see them in the morning! When I've been on-call, I would even give them a time to come into the office during the first 2 hours we were open to be seen. Stilll, there they are at the ED.

    I do get a secret satisfaction sometimes. Our local fast track is very slow with long waiting times. Usually if a pt calls after 10PM and I offer them an appointment, which they will take, then go to fast track, not tell us and no show for their appointment- . At the ED they will be awake all night in the waiting room and are usually seen about the time I offered them to come to the office. I know this because the fast track tells them to follow-up with us, so they come to the office and complain about how they were up all night at the ED and weren't seen for 10-12 hours. I then get to say in my NICEST voice, "ED waiting areas can be pretty bad, that is why I tried to offer you an early appointment time here."

    I can understand going to fast track for terrible pain, etc, but it seems the majority of our pts/ families just don't want to get out of bed in the morning and usually don't start waking up until the afternoon and by that time, there is no WAY we can fit you in before we close for the day.

    I for one wouldn't mind getting rid of the fast track since it would mean our pts would actuallty go to the primary care provider!
  9. by   swartzrn
    Our ED runs fast track most days from 12pm-2200. We have a PA and an LPN or medic (work in military hospital) that runs the fast track and the primary treatment rooms are left open for the sicker patients. I think it has its ups and downs. My argument is that it opens up the door for more patient complaints b/c they see patients who may have have signed in after them (and they feel that they are more emergent) going back before them. For example, a lady comes in with chest pain, signs in and then she sees a child with an ear ache come in after ear and sign in. She sees the child running around in the ED, laughing, playing with siblings, etc. The next thing she knows is that the kid gets called back first and the charge nurse is now in the lobby explaining that there is a fast track for non-emergent/urgent patients. It causes some dissatisfaction. On the flip side, I think fast track is beneficial because it does take away some of the non-emergent patients from the stack of 20 that need to be brought back who may be more urgent. The PA can see them (we have 4 rooms set aside for fast track) and they take less nursing care b/c we often can put a medic back there with the PA to take vital signs, etc. The presciptions are put in the computer for pharmacy. We do try to make appointments for patients at times with their primary care which has helped in wait times also. As far as active duty military which are non-urgent, the doctor can write an order for them to go to their sick call. I think that there are arguments that can be said for having and not having fast track. Julie
  10. by   EDValerieRN
    Not a fan of the fast track. When I have 12 ESI III's in the waiting room that can't be evaluated because there aren't enough nurses, but I have one nurse dedicated to "fast track" junk that doesn't need to be there, I get peeved. People who come in with stupid complaints should wait. If some dude has a stubbed toe and has been waiting for six hours, and right before he goes back an abd pain comes in, I'm going to bed the abd pain, just out of principle. And I'll tell stubbed toe guy why, too.

    If people with BS complaints had to wait longer, maybe they would think twice about coming in the next time with something stupid. That nurse that is dedicated to fast track should be seeing sicker patients. That's why there is an ESI system. Those who are sicker should go back first. Fast track defeats the purpose.

    This is coming from Inner-city level one nurse here... so I don't know about smaller facilities.
  11. by   Email4KH
    Valerie,
    The problem is not unique to inner-city, Level I facilities. I'm in a 21-bed (28, if we counted the wasted beds in Fast Track) small-town ED, and the problem is here, too.

    In my opinion, the root of this problem is not the patient who doesn't go to a primary provider for non-urgent care. The enabler of this problem is the hospital management that puts so much emphasis on survey ratings from Press-Gainey and the like. If we'd focus on treating the most acute presentation first, and ignore (i.e. "stop subscribing to") surveyors, like you said, many WOULD think twice before coming to the ED for non-urgent cases. If nothing else, stop surveying ED patients. It's an emergency room, not an inpatient unit and not a McDonalds.

    Further, there needs to be legislation that protects a facility/triage nurse when they tell the stubbed toe "your presentation does not warrant emergency room treatment. Follow up with a primary care facility during their operating hours." Call (or better yet, write) your state and federal representatives and suggest it. Of course, we realize that the manipulative patient will quickly figure out that all he has to say is "my chest hurts, and, while I'm here, check out my toe."

    As much as many try to deny it, there ARE places for EVERY patient to receive non-urgent care, even if they are uninsured/homeless/transient/illegally immigrated/destitute/whatever. If we continue to deliver primary care (via the most expensive route possible (the ED), the whole system is going to collapse.

    I urge all who read this who are in a position to make such decisions to assign resources to treat the most acute patient first. It's time to decide: what is your facility gonna be- an Emergency Room or a Primary Care Clinic?

    Triage continuously
    Treat accordingly
    Reject Press-Gainey



    Quote from EDValerieRN
    Not a fan of the fast track. When I have 12 ESI III's in the waiting room that can't be evaluated because there aren't enough nurses, but I have one nurse dedicated to "fast track" junk that doesn't need to be there, I get peeved. People who come in with stupid complaints should wait. If some dude has a stubbed toe and has been waiting for six hours, and right before he goes back an abd pain comes in, I'm going to bed the abd pain, just out of principle. And I'll tell stubbed toe guy why, too.

    If people with BS complaints had to wait longer, maybe they would think twice about coming in the next time with something stupid. That nurse that is dedicated to fast track should be seeing sicker patients. That's why there is an ESI system. Those who are sicker should go back first. Fast track defeats the purpose.

    This is coming from Inner-city level one nurse here... so I don't know about smaller facilities.
  12. by   santhony44
    Quote from scribblerrn
    I would like to make my complaint from a primary care provider point of view. I am continually amazed at the amount of our patients who go to fast track in the middle of the night and during our after-hours (The ED is nice enough to send our office a sheet or two describing the visit). And we have 24 hour doctor call and hours on Saturday (I have sent non-critical pts to the ED on Sunday due to our lack of office hours, so you can blame me for that!) Most of the patients have used the call service and was informed by the MD or NP on call how to treat at home and that we would see them in the morning! When I've been on-call, I would even give them a time to come into the office during the first 2 hours we were open to be seen. Stilll, there they are at the ED.

    I do get a secret satisfaction sometimes. Our local fast track is very slow with long waiting times. Usually if a pt calls after 10PM and I offer them an appointment, which they will take, then go to fast track, not tell us and no show for their appointment- . At the ED they will be awake all night in the waiting room and are usually seen about the time I offered them to come to the office. I know this because the fast track tells them to follow-up with us, so they come to the office and complain about how they were up all night at the ED and weren't seen for 10-12 hours. I then get to say in my NICEST voice, "ED waiting areas can be pretty bad, that is why I tried to offer you an early appointment time here."

    I can understand going to fast track for terrible pain, etc, but it seems the majority of our pts/ families just don't want to get out of bed in the morning and usually don't start waking up until the afternoon and by that time, there is no WAY we can fit you in before we close for the day.

    I for one wouldn't mind getting rid of the fast track since it would mean our pts would actuallty go to the primary care provider!


    I am right there with you, except that they'll go to the ER, fast track or no fast track!!

    I have never understood that preference for the ER in the middle of the night to the clinic in the AM.

    Most of the things I see which have gone to the ER could be treated perfectly well in the clinic and are not emergent. Things like, for example, diaper rashes and vomiting x 3.

    I have been doing this: for years with patient/parent education and sometimes feel like a hamster on a wheel. I think sitting through education on what is or is not an emergency should be a prerequisite to getting the Medicaid card!!

    Even when parents are told that there is someone on call and to call before going to the ER, except in very limited and specific circumstances, many don't bother to call. I've had weekends on call and then on Monday seen the six or eight or ten ER reports from people I never heard from. And most of them were not seen for lacerations, broken bones, or retractions/grunting in an infant.

    I've had parents call, 10 or 11 PM with a problem, ask "Can I take him to the ER?" I ask my questions, give instructions, then offer an appointment: "Can you have him in to the clinic at 8:15?" "Uh. Well, do you have anything after lunch???" I'll give them 1 PM if that will keep them out of ER tonight.

    To those in the ER: Most of us in primary care try to keep our folks out of the ER. We would really rather see them ourselves, because that offers us the opportunity to look at things that you don't have time for and shouldn't be concerned with anyway, like management of chronic problems. Please try to have patience with us when we do send patients in to see you for things you don't think are important. Sometimes what we hear on the phone and what you see in person don't bear much resemblance to one another. That kid taking apart your waiting room might have been described to me as being on death's door. Or, something might have been so "iffy" that I really wanted someone to lay eyes and/or hands on the patient. And I will admit that on occasion, I'll send someone in on a Friday or Saturday night rather than suffer with a UTI over the weekend because I'm not about to call in antibiotics for someone I've never laid eyes on. I haven't done that often.

    All that I know to do is to keep on with the education, and to manage my patients' chronic problems to the best of my ability. I would like for my patients to be strangers to the ER, only seen when they have the misfortune to get injured.

    Thank you to all you ER folks, fast track or no. You do a fantastic job under often difficult circumstances and I do appreciate it!
  13. by   hogan4736
    Long time ER nurse here, did phone triage for a year...

    One thing I learned: people will call me (triage) or you (office) for advice, but 9 times out of 10 will do what they originally wanted to do (go to the ER @ 0200)

    it'll NEVER change...

    oh, and the medicaid patients in NO way have a hold on the 0200 ER visit for a rash...those patients come in ALL socio-economic statuses...Ignorance and stupidity have no financial ties...
  14. by   santhony44
    Quote from hogan4736
    Long time ER nurse here, did phone triage for a year...

    One thing I learned: people will call me (triage) or you (office) for advice, but 9 times out of 10 will do what they originally wanted to do (go to the ER @ 0200)

    it'll NEVER change...

    oh, and the medicaid patients in NO way have a hold on the 0200 ER visit for a rash...those patients come in ALL socio-economic statuses...Ignorance and stupidity have no financial ties...
    I agree with all of that too.

    However, the $50 or more co-pay a lot of insured folks have for ER visits does tend to keep some of them out of ER.

    I did once have a mom with insurance and a $100 co-pay take a conjunctivitis to the ER for convenience.

    I've done the telephone triage thing too. Some parents would call back more than once hoping for different advice from a different nurse. They didn't realize that not only were we working off standardized, computerized protocols, their previous calls were also in the system and would pop right up!

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