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Effects of fast-track in a university emergency department through the National

Emergency Department Overcrowding Study

Article  in  Journal of the Pakistan Medical Association · July 2014

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ORIGINAL ARTICLE
Effects of fast-track in a university emergency department through the national
emergency department overcrowding study
Gokhan Aksel,1 Fikret Bildik,2 Ahmet Demircan,3 Ayfer Keles,4 Isa Kilicaslan,5 Sertac Guler,6 Seref Kerem Corbacioglu,7
Asli Turkay,8 Burak Bekgoz,9 Nurettin Ozgur Dogan10

Abstract
Objective: To determine the impact of a fast track area on emergency department crowding and its efficacy for non-
urgent patients.
Methods: The prospective cross-sectional study was conducted in an adult emergency department of a university-
affiliated hospital in Turkey from September 17 to 30, 2010. Non-urgent patients were defined as those with
Canadian Triage Acuity Scale category 4/5. The fast track area was open in the emergency department for one whole
week, followed by another week in which fast track area was closed. Demographic information of patients, their
complaints on admission, waiting times, length of stay and revisits were recorded. Overcrowding evaluation was
performed via the National Emergency Department Overcrowding Study scale. In both weeks, the results of the
patients were compared and the effects of fast track on the results were analysed. Continuous variables were
compared via student's t test or Mann Whitney U test. Demographic features of the groups were evaluated by chi-
square test.
Results: A total of 249 patients were seen during the fast track week, and 239 during the non-fast track week at the
emergency department. Satisfaction level was higher in the fast track group than the non-fast track group (p<0.001).
The waiting times shortened from 20 minutes to 10 minutes and length of stay shortened from 80 minutes to 42
minutes during the fast track week. Morbidity and mortality rates remained unchanged.
Conclusion: Owing to fast track, overcrowding in the emergency department was lessened. It also improved
effectiveness and quality measures.
Keywords: Emergency service, Crowding, Patient satisfaction. (JPMA 64: 791; 2014)

Introduction Many emergency departments (EDs) in the United States

Even though the term Emergency Department (ED) and Turkey are critically overcrowded, and this hampers
overcrowding has been defined in diverse ways in the the delivery of high-quality medical care.1,2 Due to the
literature, the simplest and the most effective description continuing pressure to see increasing number of patients
was published in the "Emergency Department Crowding: efficiently and safely, EDs have sought innovative ways to
High-Impact Solutions" report by the American College of accomplish this goal. The creation of a fast track (FT)
Emergency Physicians (ACEP) in 2008 which defined ED programme staffed by mid-level practitioners has been
overcrowding as lack of inpatient bed availability in the assumed to increase ED effectiveness for non-emergency
ED for patients waiting to receive emergency healthcare. patients.3 FT areas can potentially improve patient flow
Delays in urgent healthcare practices due to increasing without detrimentally affecting quality of care.3,4
numbers of patients cause overcrowding in EDs. When ED
overcrowding occurs, patients, who wait to receive In this study, our aim was to determine whether FT area
emergency healthcare, lie on gurneys, sit in chairs and was a high-impact solution for the problem of ED
often fill every available space. This situation certainly has overcrowding. Keeping this primary aim in mind, we also
negative effects on patient safety, comfort and endeavoured to find the effects of FT area on patient
satisfaction.1 satisfaction, patients' costs, waiting times (WTs) of the
patients in triage area and total length of patients' stay
(LOS) in ED, number of patients leaving without being
Department of Emergency Medicine, 1Baskent University School of Medicine, seen (LWBS), mortality and morbidity rates. Moreover, we
Bahcelievler, Ankara, Turkey, 2-5,9Gazi University School of Medicine, Besevler, intended to indicate the most convenient times for FT.
Ankara, Turkey, 6Ankara Training and Research Hospital, Ankara, Turkey,
7Antakya State Hospital, Hatay, Turkey, 8Mersin State Hospital, Mersin, Turkey, Methods
10Kocaeli University, Faculty of Medicine, Kocaeli, Turkey. The prospective cross-sectional study was conducted in
Correspondence: Gokhan Aksel. Email: [email protected] Turkey at the adult ED of a university-affiliated hospital

Vol. 64, No. 7, July 2014

792 G. Aksel, F. Bildik, A. Demircan, et al

with 1000 beds, serving annually 45000 patients on track area), 4. number of patients with mechanical
average. Patients older than 18 years of age who ventilation (MV) in ED, 5. the longest time a patient has
presented to the ED between September 17 and 30, 2010, waited for an inpatient bed at the time the score was
were included in the study. Since FT practice aimed at calculated (admit time), 6. number of patients in ED
quick evaluation of the patients whose medical states did waiting for inpatient beds (admit index), and 7. wait time
not require any urgency, patients who were qualified to of the patients in the triage area admitted last to ED in
be assessed within FT were categorised as those with terms of hours (registration time). The 200-point NEDOCS
Canadian Triage Acuity Scale 4 and 5 (CTAS 4/5). Patients scale ranges from 0 to 50 (normal), 51-100 (busy), 101-140
younger than 18 years of age, patients with CTAS 1 to 3, (overcrowded), 141-180 (severe), and >180 (disaster). As 2
and patients who refused to participate, were excluded. A of 7 parameters were invariable (total number of hospital
room in ED, which was being earlier used for patient beds, total number of ED beds), the other 5 variable
examination, was designated as the FT area. One of the parameters were compared.
emergency medicine residents with at least 3 years of
Having been examined in ED and either discharged or
experience conducted the study in each shift. The FT area
admitted, patients were provided with a survey
was open in the ED for one whole week, followed by
comprising 7 questions. A 5-point Likert Scale was used in
another week in which FT area was closed. During the
the satisfaction surveys. According to this scale, 1 was
week in which FT area was open (FT-week), patients with
"very poor" and 5 was "excellent". During the statistical
CTAS 4/5 were defined as Group 1 and having been
evaluation, patients' options 1 and 2 on the Likert Scale
assessed within FT, their information was recorded. In the
were grouped as "poor" and options 4 and 5 as "good".
following week during which there was no FT area (non-
Option 3 indicating "no idea" was excluded from the
FT week), patients with CTAS 4/5 were defined as Group 2
evaluation.
and evaluated in other areas of the ED. The results of the
patients with CTAS 4/5 were compared over the two Finally, wait times of patients who were other than FT
weeks and the effects of FT on the results were analysed patients (CTAS 1-) were recorded.
accordingly. In addition, we studied whether FT had a
For statistical analysis, SPSS 11.0 was used. Of the NEDOCS
negative effect on patients with CTAS 1-3, who were
results presenting continuous variables in groups where
excluded from the target group.
FT area was open and was closed, and the parameters
After approval by the institutional ethics committee and comprising this score, WT of patients in triage area, total
written consent of the subjects, demographic information LOS in ED and patients' costs, the ones conforming to
of the patients with CTAS 4/5, their complaints on normal distribution were compared via student t test and
admission, WTs, LOS in ED, LWBS, total cost and whether the ones non-conforming to normal distribution were
they presented to ED again within 72 hours of their assessed via Mann Whitney U test. Demographic features
discharge were all recorded. of the groups and comparison of satisfaction surveys with
the groups were evaluated by Chi-Square test. P<0.05 was
ED overcrowding evaluation was performed via the considered statistically significant.
National Emergency Department Overcrowding Study
(NEDOCS) scale at 08:00, 12:00, 16:00, 20:00, 00:00 and Results
04:00 hrs. Moreover, in every 8-hour shift, the number of During the study period, a total of 2129 patients
outpatients who left without being seen together with presented to the adult ED among whom 1795 (84.3%)
the ambulance diversions was recorded. NEDOCS, were seen in ED and 308 (14.4%) of the presenting
developed in 2004 by Weiss et al,5 is a tool to outpatients left without being seen. Overall, 26(1.2%)
quantitatively describe the staff's sense of overcrowding. patients brought to ED by ambulance had to be
It is a web-based calculator which converts a simple data
set into a score that correlates accurately with the degree Table-1: Demographic data for CTAS 4/5 patient visits to Emergency Department.
of overcrowding as perceived by the senior staff working
Variable Group 1 - CTAS 4/5 Group 2 - CTAS 4/5 P value
at that time. The NEDOCS includes 7 parameters: 1. total
(FT* week) N=249 (Non-FT week) N=239
number of hospital beds, 2. total number of ED beds, 3.
total number of patients (patient index which is the Age (Median) (min - max) 33 (18-82) 31(18-90) 0.292
number of total patients in the ED at the time the score is Males (N)(%) 118 (47.4) 116 (48.5) 0.654
calculated and which includes all patients in all areas of Females (N)(%) 131 (52.6) 123 (51.5) 0.654
the ED including the resuscitation room, examination FT*=Fast track
rooms, trauma room, waiting room, hallways, and fast CTAS: Canadian Triage Acuity Scale.

J Pak Med Assoc

Effects of fast-track in a university emergency department through the national emergency department... 793
Table-2: Complaints of Canadian Triage and Acuity scale category 4/5.

Chief complaint Groups Total

Group 1 (FT* week) N (%) Group 2 (Non-FT week) N (%)

Ear/nose/throat problems 66 (26.5) 37 (15.5) 103 (21.1)

Minor trauma 44 (17.7) 54 (22.6) 98 (20.1)
Orthopaedic injury 41 (16.5) 45 (18.8) 86 (17.6)
Gastroenteritis, nausea, vomiting 17 (6.8) 16 (6.7) 33 (6.8)
Eye problems 13 (5.2) 20 (8.4) 33 (6.8)
Skin problems 22 (8.8) 11 (4.6) 33 (6.8)
Abdominal pain 10 (4.0) 21 (8.8) 31 (6.4)
Genitourinary problems 9 (3.6) 17 (7.1) 26 (5.3)
Head ache 12 (4.8) 13 (5.4) 25 (5.1)
Psychiatric problems 12 (4.8) 5 (2.1) 17 (3.4)
Gynaecologic problems 1 (0.4) 0 (0) 1 (0.2)
Tooth ache 1 (0.4) 0 (0) 1 (0.2)
Cat/dog bites 1 (0.4) 0 (0) 1 (0.2)
Total 249 (100) 239 (100) 488 (100)
FT*=Fast track.

Table-3: Comparisons between Group 1 and Group 2 in terms of patients' wait time, total length of stay in ED, total costs to patients, patients who left without being seen and
ambulance diversions.

Variables Group 1(FT§-week) Group 2 (Non-FT week) P value

Median (min-max) or N (%) Median (min-max) or N (%)

WT* (minutes) 10.00 (0 - 125) 20.00 (0 - 220) <0.001

LOS† (minutes) 42.00 (5 - 355) 80.00 (5 - 390) <0.001
Patient cost (USD‡) 13.89 (10.33 - 118.49) 14.87 (10.33 - 250.00) 0.113
LWBS† (N, %) 98 (31.8) 210 (68.2) 0.008
Ambulance diversions (N, %) 7 (26.9) 19 (73.1) 0.204
§FT: Fast track
*WT: Wait time
†LOS: Length of stay
‡USD: US Dollar
†LWBS: Left without being seen.

transferred to another medical facility (Figure). A total of was detected in terms of total costs between the two
249 patients were seen during the FT week, and 239 groups (p<0.113).
during the non-FT week at the ED. Demographic data for
Moreover, possible effects of FT on WTs of the patients
all CTAS 4/5 patients was recorded (Table-1).
with CTAS 1-3 were also studied. No statistically
The most common presenting complaints were ear-nose- significant difference was found between WTs of the
throat (ENT) diseases 103(21.1%), minor trauma 98(20.1%) patients with CTAS 1-3 during the two weeks (p<0.128).
and orthopaedic problems 86(17.6%) (Table-2). We endeavoured to determine the most frequent hours
Further, 17(6.8%) of the 249 patients in Group 1 were during which patients presented while FT area was open
referred to relevant departments and 11(4.6%) of 239 in round the clock. The number of patient presentation
Group 2 were referred to relevant departments. In terms times was statistically higher between 12:00-16:00 and
20:00-00:00 (p<0.001, p<0.001).
of consultation, no statistical significant difference was
found between the groups (p=0.389). With regard to responses to questions in the survey,
patient satisfaction in Group 1 was found significantly
A statistical significant difference was observed between
higher than the patients in Group 2 (p<0.001).
Group 1 and Group 2 in terms of WTs and LOS (p<0.001,
p<0.001, respectively) (Table-3). No statistical difference The number of LWBS in Group 2 was statistically higher

Vol. 64, No. 7, July 2014

794 G. Aksel, F. Bildik, A. Demircan, et al

Table-4: Comparison of the NEDOCS§ scores and parameters that are used in the NEDOCS score.

Group 1 (*FT week) Group 2 (non-FT week) P value

mean ± SD or median (min-max) mean ± SD or median (min-max)

NEDOCS Score 141.50 (60-200) 200.00 (165-200) <0.001‡

Patient index - Total patients in the ED† 26.50 (15-33) 27.50 (18-33) 0.502‡
Admit index - Total admits in the ED 14.60 ± 4.40 17.41 ± 4.48 0.002¤
Admit time - Longest admit times 74.52 ± 28.11 175.52 ± 47.42 <0.001¤
Registration time - Wait time for the last patient called (from triage) 10.00 (0-60) 18.50 (1-120) 0.008‡
Number of mechanical ventilators in use in the ED 0.50 (0-3) 3.00 (2-4) <0.001‡
*FT: Fast-track
†ED: Emergency department
§NEDOCS: National Emergency Department Overcrowding Study
‡Mann Whitney U test
¤Student T-test.

Figure: Patient flow during the study periods.

J Pak Med Assoc

Effects of fast-track in a university emergency department through the national emergency department... 795
(p=0.008). Even though the number of ambulance evaluation of patients with regard to their symptoms, not
diversions was higher in Group 2, no statistically their final diagnoses.1 In our study, 27% of the patients
significant difference was observed between the groups presenting to the ED was in the group with CTAS 4/5. This
(p=0.204). percentage was indicated as 30% in a study and as <%10
in another.3,7 Three patients were hospitalised in Group 1
The NEDOCS scores which were measured during the
and 1 patient in Group 2. Even though these patients were
non-FT week were found higher compared to the FT week
classified as CTAS 4/5 based on their initial symptoms on
(p<0.001) (Table-4).
presentation, with regard to their final diagnoses they
Of the NEDOCS scale parameters, there was a statistically were shown to have significant pathologic conditions.
significant difference in terms of admit index, number of Besides, patients with triage score 4 and 5 also included
mechanical ventilators in use in the ED, admit time and those who needed urgent intervention in ED, even
registration time, and all the components in Group 2 were though they did not display life-threatening conditions.
found higher compared to the ones in Group 1 (p<0.003, Renal colic patients present a good example of this
p<0.001, p<0.001, p=0.008, respectively). In terms of category of patient. Yet the pain must quickly be
patient index, no statistically significant difference was alleviated. As ACEP suggests, the decision whether a
detected between the groups (p<0.502). patient does not require urgent healthcare cannot be
made without examining a patient, it is therefore
It was also indicated that having been discharged from concluded that patients with CTAS 4/5 definitely have to
ED, 2(0.80%) of the 249 patients presented to ED again be examined in the ED.1
within the first 72 hours of their discharge during the FT
week and 2(0.83%) of 239 patients also presented in the In the study patients occupying EDs were among the
same manner to ED during the non-FT week. Both important reasons of EDO since these patients failed to
patients' complaints who presented the second time receive necessary primary healthcare in an unorganised
during the first week were different than their initial health system. Particularly, family physicians cannot
complaints. However, both patients presenting again schedule timely appointments for their patients, thus they
during the second week were renal colic patients and are referred to EDs.8 In our study, when complaints of FT
their complaints were the same as their initial complaints. patients were analysed, it was observed that ENT diseases,
minor trauma and orthopaedic problems accounted for
Three (1.20%) patients (2 acute appendicitis patients, 1 the most frequent patient complaints. Patients unable to
angioedema) required hospitalisation during the FT week access polyclinics in a timely manner, prolonged periods
and 1 (0.41%) patient who had humerus fracture needed of examination and treatment result in larger numbers of
hospitalisation during the non-FT week. During the presentations of these patients to EDs. In order for the
studyperiod, no FT patients were exitus. effective and fast treatment of the majority of these
groups of diseases to be provided, particularly in primary
Discussion
healthcare system, and relevant polyclinics, sufficient
In a study conducted in the ED of our hospital in 2008 by
administrative and structural solutions should be offered.
using the NEDOCS, it was revealed that we had
In this way, we will greatly contribute to reducing EDO.
Emergency Department Overcrowding (EDO) of a critical
level.2 However, that study did not offer any solutions for Various studies have shown that EDO increases LWBS
EDO. With our study, we aimed at finding whether or not rates.4,6-8 Weiss et al. indicated that LWBS rate was directly
FT practice could be a high-impact solution in EDO. proportionate to EDO when it was studied by the NEDOCS
scale.5 In the study including 30 hospitals, Stock et al.
There exist several reasons for EDO that have serious
found that patients leaving without being seen were 4.2%
negative effects on the quality of healthcare of
on average.9 In our study, patients leaving the ED without
emergency patients. Patients presenting to EDs, even
being seen during two weeks were found quite high with
though they do not require urgent care, are also
a rate of 15.6%.
considered one of the reasons for EDO. Especially in the
1980s and early 1990s, these patients were assumed to be Sanchez et al. indicated that FT practice decreased the
the most important cause of EDO.6 Despite the fact that number of patients leaving unexamined by a rate of
these patients require no urgent healthcare, it is hard to 52.18%.3 Darrab et al. also found that while the number of
determine the urgency or otherwise of their situation patients LWBS was 5% prior to FT, the number reduced to
until the final diagnosis. EDs are responsible for taking 2% by opening FT area.4 In our study, we observed that FT
care of this patient group as well. Today, ACEP suggests lessened LWBS from 21% to 10%. Baker et al. reported that

Vol. 64, No. 7, July 2014

796 G. Aksel, F. Bildik, A. Demircan, et al

presenting diseases of the LWBS patients worsened two satisfaction.14,16,17

times more than those in the control group.10 Similarly,
Other than the study conducted by Kim et al., no scoring
Monzon et al. stated in their study that one LWBS patient
systems such as the NEDOCS was included in any previous
presenting with psychiatric complaint committed
study while examining the effects of FT on EDO.18 Parallel
suicide.11 In our study, we did not keep a record of triage
to the finding of Kim et al., we also found a significant
scores of the LWBS patients and since follow-ups of these
decrease in the NEDOCS score owing to FT practice. Of the
patients were not possible, we did not have results
five variable parameters of the NEDOCS, only registration
concerning these scores. However, given the fact that 4
time and patient index were considered to be affected by
(0.8%) patients with CTAS 4/5, who were included in the
FT. In FT week, number of available hospital beds was
study, required hospitalisation, we assumed that LWBS
more than non-FT week and more of patients in ED could
patients were subject to serious health risk.
have admitted to hospital beds so that admit time and
In this study, FT area improved ED effectiveness, admit index is found higher in the non-FT week. These
measured by decreased WTs and LOS. FT also did not parameters are regarded not to be affected by FT. The only
cause deterioration in the quality of care provided, reason for the NEDOCS score being low during the FT-
measured by rates of mortality and revisits. We found that week compared to the other week cannot solely be
FT reduced the WTs by approximately 54.9% and a similar attributed to FT; other components which are not affected
reduction of 50% was also mentioned in the study by by FT are also considered to account for this result.
Sanchez et al.3 Again in the same study, it discussed a However, we can conclude that FT contributed to the low
shortening of total LOS by 9.79% following FT and in our NEDOCS score.
study this rate was found to be higher, which was 36,5%. FT does not seem to be directly impact ambulance
Parallel to the findings in the study by Sanchez et al., we diversions because FT patients mostly consist of stable
found no changes in the rates of mortality or revisits.3 In patients. But we think that FT may affect ambulance
various studies in the literature, it has similarly been diversions indirectly. Overcrowding has many potential
reported that FT has shortened both WTs and total LOS in detrimental effects, including diversion of ambulances.19
EDs.4,12-14 Similar results were observed in another study As FT contributed to the low NEDOCS score according to
regarding paediatric patients.15 our results, we think that less overcrowding in EDs may
In literature, it has been noticed that FT area is generally cause less ambulance diversions. In the present study,
open at certain times of the day during which patient ambulance diversions were less during the FT week, yet
presentations are high, instead of 24 hours.13-15 Only no statistical difference was observed between the two
Devkaran et al. applied FT on a 24-hours basis in their weeks. Being a single-centre study, our results may not be
study.7 In our study, by opening FT area 24 hours, we generalizable which is a limitation of the study.
endeavoured to determine the most convenient periods Fluctuation in attendance in different months of the year
is obvious and our data in September may not be
of time for FT. In our study, the number of patient
generalisable to the whole year. It also seems difficult to
presentation times was found statistically higher between
come to a precise conclusion regarding morbidity and
12:00-16:00 and 20:00-00:00 hours. In the study by
mortality rates due to the brief study period and
Devkaran et al., the most crowded times were indicated
insufficient number of total patients.
between 18:00-06:00.7 With regard to the findings, it was
assumed that the most convenient time interval for FT Conclusion
was between 12:00 and 00:00 hours. This finding may vary Owing to FT, EDO was lessened according to the NEDOCS.
according to geographic regions and hospitals. Patient satisfaction increased owing to FT. No statistical
We indicated in our study that FT increased patient difference was seen between FT and non-FT weeks in
satisfaction significantly according to the results of terms of morbidity, mortality, rates of patients being
satisfaction survey. Even though many studies show a consulted and patient costs.
similar finding like ours, most of these studies do not References
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surveys have similarly reported that FT increased patient 2011; 10: 60-4.

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