CLINICAL
EVALUATING CARE IN ED FAST TRACKS
Authors: Veronica Quattrini, MSN, CRNP, and Beth Ann Swan, PhD, CRNP, FAAN, Philadelphia, PA
ospital emergency departments play a variety of
H
roles in the American health care system. Once
considered a source of care for major injuries and
life-threatening medical conditions, the emergency depart-
ment has become part primary care and part social work to
many Americans.1 From 1992 to 2002, the number of ED
visits in the United States increased by 23%, with an esti-
mated 110.2 million visits per year.2 Because of this phe-
nomenon and in conjunction with other variables,
emergency departments across the United States are in crisis,
with more people than ever seeking their services.3 Because
of this, emergency departments usually place the highest
demands on hospital services. Personnel in the emergency
department have no control over the type of patients who
present for care, the pace of their arrival, or the acuity level.
No one is refused care, even when the hospital is at capacity,
which results in long waiting times, overworked staff, over-
crowded departments, and patient dissatisfaction.4 The
number of patients in need of non-emergent services over-
whelms many of the emergency departments in America.
Sixty-two percent of the nation’s emergency departments
report that they are “at” or “over” operating capacity.5 Suc-
cessful resolution of the vast number of problems facing staff
and patients in the emergency department is a monumental
task. To address this critical problem, emergency depart-
ments are developing and implementing new models of care.
One model that has been shown to decrease overcrowding
and facilitate patient flow is through implementation of a
fast-track (FT) area within an emergency department. As
FTs evolve, it is essential to examine the relationship of
structure, process, and outcome. The purpose of this eviden-
tiary review is to examine the structure, process, and out-
comes and role of nurse practitioners (NPs) in ED FTs.
Veronica Quattrini is Doctor of Nursing Practice Student, Jefferson School of
Nursing, Thomas Jefferson University, Philadelphia, PA.
Beth Ann Swan is Professor and Associate Dean of Graduate Programs and
Robert Wood Johnson Foundation Executive Nurse Fellow, Jefferson School
of Nursing, Thomas Jefferson University, Philadelphia, PA.
For correspondence, write: Beth Ann Swan, PhD, CRNP, FAAN, 1419
Amity Rd, Rydal, PA 19046; E-mail: beth.swan@jefferson.edu.
J Emerg Nurs 2011;37:40-46.
Available online 25 November 2009.
0099-1767/$36.00
Copyright © 2011 by the Emergency Nurses Association. Published by
Elsevier Inc. All rights reserved.
doi: 10.1016/j.jen.2009.10.016
40 JOURNAL OF EMERGENCY NURSING
Background and Significance
ED overcrowding has been blamed on the closing of hospi-
tals, decreasing hospital stays, and the outpatient manage-
ment of complex medical problems. 6 This trend of
decreased hospital stays, the aging of America, and
the increase in the working uninsured continues to place
stress on an already stressed system.7 Along with these vari-
ables, analysts attribute overcrowding, in part, to the predo-
minance of hospital-based subspecialists and the dwindling
foundation of community-based general practitioners in the
United States.8 The pattern of utilization of the emergency
department is especially prominent among patients who are
poor, nonwhite, and without a regular source of primary
care.9 This pattern has not changed in the last 3 decades.10
Overcrowding
Overcrowding by patients with low-acuity problems is not
a recent development. It has been a recognized problem in
the United States and worldwide.11 There is little informa-
tion in the literature on why patients with minor problems
and an established primary care physician present to the
emergency department.12 One study reported that the pri-
mary reasons for these patients presenting to the emer-
gency department were the inability to schedule an office
appointment in a timely manner, advice from the primary
care physician to use the emergency department, and high
self-perceived severity of illness.12
Overcrowding in the emergency department is one of
the most serious issues confronting hospitals nationwide.3
As a consequence, many patients have significant waiting
times before accessing medical care. ED overcrowding has
a multifactorial origin, encompassing several internal and
external factors, including the use of the emergency depart-
ment by nonurgent cases.13 Consequences of overcrowding
in the emergency department include (1) increased risk of
poor patient and organizational outcomes; (2) prolonged
waiting times, as well as boarding times; (3) increased ambu-
lance diversion; (4) increased frustration among health care
providers; and (5) dissatisfied patients.3,14
Patient Dissatisfaction
Patient dissatisfaction with ED care often centers on long
waiting times.15 The patients most dissatisfied are often
those who present with non-emergent or minor complaints
and thus are triaged at the lowest severity category. 16
VOLUME 37 • ISSUE 1 January 2011

National ED census data from the United States show that
60% to 80% of ED patients present with nonurgent or
minor medical problems.17 These patients, often requiring
a brief evaluation, traditionally have had to wait to be
assessed until the more seriously ill patients have been seen.
One recommendation to address these alarming concerns
that threaten patient safety is the creation of FT services
in emergency departments.3
Fast Track
An FT is a separate process and location within an emer-
gency department to care for patients with urgent but less
serious conditions. Studies have examined waiting time in
relation to presenting complaint and have found that many
of the ED patients had minor, non-emergent, or self-limit-
ing problems that ideally would be suited for an FT set-
ting.4 The idea of an FT is to attend more quickly to
those patients who previously had to wait to be treated
for minor illnesses or injuries, such as sprains/fractures,
lacerations, sore throats, rashes, and insect bites. Ulti-
mately, the goal is streamlining and expeditiously mana-
ging low-acuity patients. ED FT systems triage patients
with nonurgent complaints to treatment in a dedicated area
aimed at decreasing waiting times and ED length of stay,
reducing ED overcrowding, and increasing patient and staff
satisfaction.18 One study defined nonurgent patients as
those who could be evaluated in 1 hour or less.19 As part
of the study, the work group developed triage guidelines
designed to identify patients who could be seen and dis-
charged within 1 hour and to redirect staffing responsibi-
lities to address these goals. It is crucial to have triage
delineating the course of each patient to maximize the flow
process and not waste precious minutes in redirecting
patients to the main emergency department.
An FT can be viewed as a parallel system (within an
emergency department) for prompt care of non-emergent
patients. Consequently, the care costs less and is reimbursed
at a lower rate. For reimbursement purposes, FT services
must be part of a hospital’s emergency department but
may have a designated space for the separate stream of
patients. Providers in FT settings may include physicians,
NPs, registered nurses, and/or physician assistants. Although
staffing in ED FTs varies in hospitals across the country, NPs
are ideally positioned to provide the majority of care to
patients presenting for urgent (not emergent) evaluation
and management. Most adult tertiary ED patients with
minor problems indicate a willingness to be treated by an
NP, often even if this involves treatment and discharge with-
out direct emergency physician assessment.20 The cost-effec-
tiveness and quality of treatment by NPs in primary care are
January 2011 VOLUME 37 • ISSUE 1
Quattrini and Swan/CLINICAL
well documented.21 Less studied is the role of NPs and the
characteristics associated in FTs, the processes of care, and
the outcomes in ED FTs.
SEARCH STRATEGY
An electronic search was conducted of the following data-
bases: PubMed, CINAHL (Cumulative Index to Nursing
and Allied Health Literature), Scopus, and Cochrane Data-
base of Systematic Review. Each database was searched for
the following key words:
• Structure key words: nurse practitioner(s), staffing,
provider characteristics, organizational characteristics
• Intervention (process) key words: fast track, nurse prac-
titioner(s), patient flow, triage
• Outcome key words: length of stay, financial analysis,
cost, economics, quality, patient satisfaction, evaluation,
satisfaction, wait times, waiting times, provider satisfaction
• Target population key words: emergency department,
emergency medicine
To supplement the electronic searches, hand searches
were conducted. For this evidentiary review, journal issues
were examined for relevant studies. More than 50 relevant
reports were identified in the search. The articles were pub-
lished between 1978 and 2008. All of the studies included
were published in academic journals. Studies included
descriptive, retrospective cohort, prospective descriptive,
pair matched case control, data collection through inter-
views, exploratory descriptive, pre- and post-intervention
data, and a systematic review. Studies were included if they
addressed structural, intervention, and outcome characteris-
tics of ED FTs. The reasons for exclusion of studies ranged
from not reporting about ED FTs or an ED FT that only
reported physician-level information.
REVIEW OF LITERATURE
Now more than ever, the challenges associated with the
emergency department delivering safe, effective, timely,
efficient, and patient-focused health care are more complex.
ED overcrowding is a serious issue affecting hospitals across
the nation.
Conceptual Framework
Donabedian’s structure-process-outcome quality framework
will guide this review.22 The fundamental characteristics of
the paradigm are that structure, process, and outcome infor-
mation can be used to assess quality only when and to the
extent that they are causally related. Donabedian in 1966
stressed that the triad is not attributes of quality but that
structure is the physical and organizational properties of
WWW.JENONLINE.ORG 41
CLINICAL/Quattrini and Swan
TABLE
Characteristics of ED FTs
Structure Process
Patient characteristics Technical process of care
• Demographics • Triage criteria
• Chief complaint • NP care-delivering protocols and guidelines
• Comorbidities
• Acuity index
Provider characteristics Interpersonal process of care
• Staffing • Patient perception/attitude about NP care
• Staff mix • NP role
Organizational characteristics Process of care
• Admission rate • Overcrowding
• Quality improvement initiatives • Daily census
the setting in which care is provided, process is what is done
for the patient, and outcome is what is accomplished for
the patient. The structure-process-outcome characteristics
of ED FTs are listed in the Table.
According to Donabedian,23 the basic characteristics of
structure are that it is relatively stable, that it functions to
produce care or is the feature of the environment of care,
and that it influences the kind of care that is being pro-
vided. Donabedian believed strongly in the importance of
health care structure, seeing it as a driving force for later
care processes and, ultimately, for health outcomes. Struc-
ture may comprise the characteristics that patients bring to
the experience, the characteristics of the provider, and
organizational characteristics. Structure related to the pro-
vider may refer to the staffing model, provider assessment
and diagnosis, education, and staff mix. Structure of the
organization is the hospital-based space in which the provi-
sion of health care occurs. Included in the space are size
and cleanliness, equipment available, ease of access, and
available parking. For this review, patient characteristics
include demographics, chief complaint, and comorbidities;
provider characteristics include type of staffing and staff
mix; and outcome characteristics include admission rate
and quality improvement initiatives.
Process of care denotes what is actually done to the
patient in the giving and receiving of care. The process
of care is related to the promotion, preservation, and resto-
ration of health.24 In describing the process of care, Dona-
bedian23 differentiated between 2 mechanisms: technical
care and interpersonal care. The technical process includes
the specific skills and services used and the way the encoun-
ter is managed, including the continuity of care and its
42 JOURNAL OF EMERGENCY NURSING
Outcome
Patient outcomes
• Waiting time
• Length of stay
• Leaving without being seen
• Revisits
• Mortality
• Patient satisfaction
Provider outcomes
• Adequacy of care
• Provider satisfaction
Cost outcomes
• Hospital
• Provider
coordination.23 The interpersonal process involves the
way a health care provider relates to a patient. The inter-
personal process of care encompasses friendliness, courtesy,
respect, sensitivity, patient participation in decision making
regarding treatment, and the overall level of communica-
tion.23 For this review, technical and interpersonal pro-
cesses include the method of triage, type of protocols and
care guidelines, role of the NP in delivering care, the
patient’s perception of care, and daily census.
Health outcomes are the direct result of a patient’s
health status as a consequence of contact with the health
care system. Outcomes have the advantage of being inte-
grative. They reflect the contributions of care providers,
including the patient’s contributions to his or her own care.
Outcomes also reflect skill in execution as well as appropri-
ateness of the strategy of care. Donabedian et al25 specified
outcomes as either disease-specific outcomes or general
health outcomes. Disease-specific outcomes relate to a par-
ticular pathologic condition and indicate a change in actual
health. General health outcomes are referred to as “integra-
tive” outcomes and are categorized according to one’s abil-
ity to function and one’s sense of well-being.25 For this
review, patient outcomes include length of stay, patient
satisfaction, waiting time, and return visits. Provider
outcomes are adequacy of care and provider satisfaction,
and organizational outcomes include both hospital costs
and provider costs.
FT Outcomes
Because of the continuing pressure to see increasing
numbers of patients efficiently and safely, as well as
VOLUME 37 • ISSUE 1 January 2011

the serious issue of overcrowding in the emergency depart-
ment, hospitals have had to strategize ways to maximize
patient flow. With the understanding that prolonged wait-
ing times have implications for patient safety, as well as
patient and provider satisfaction, the concept of the FT
has evolved.
FTs staffed by NPs or a mix of NPs and other midlevel
providers have been associated with documented improve-
ments in patient waiting times, length of stay, and overall
quality in both adult and adult/pediatric emergency depart-
ments. One study explored the implementation of a desig-
nated FT area staffed by midlevel providers and found that
waiting times were decreased along with decreased length
of stay during the post-FT period in comparison to the
pre-FT period. Additional findings showed that with the
FT intervention, there was a greater attention to patient
flow with earlier decision making and improved communi-
cation and teamwork in the emergency department.26 A
second study implemented an FT care model with midlevel
practitioners and found that 30% of the 75,000 patients
visiting the emergency department annually were triaged
appropriately to the FT.27 Thus ED effectiveness and qual-
ity were improved as measured by decreased waiting time
to be seen, decreased length of stay, decreased mortality
rate, and decreased revisit rates.27 A third study evaluated
a patient flow streaming system, separating patients based
on complexity rather than acuity, severity, or disposition.28
Findings showed improved waiting time benchmark com-
pliance and that the mean treatment time during the FT per-
iod decreased in comparison to earlier periods. Of note, the
number of patients who presented to the emergency depart-
ment increased by 14.5% and the overall staff time increased
by 16.6% during the study period. In addition, the FT case
mix had relatively low complexity with a greater focus on
treatment than on diagnosis and investigation, a case mix
that is well suited to advanced practice nurses. Case com-
plexity, as a key criterion for triaging patients into separate
streams, was an important factor in the positive outcomes of
the study.28 Key principles that can be applied to patient
flow through the emergency department include elimination
of duplicate work, minimizing queuing, and focusing on
staff and processes that add value to patient care.28
Additional studies have examined the effect of imple-
menting FTs staffed by NPs on ED length of stay and
impact on length of stay on other ED patients and showed
similar positive findings as discussed previously.29 One
study showed a significant reduction in ED length of stay
by 16 minutes for non-admitted patients managed by the
FT; however, the FT model did not dramatically affect
waiting times or length of stay for other ED patients. A
second study following FT implementation showed
January 2011 VOLUME 37 • ISSUE 1
Quattrini and Swan/CLINICAL
decreased length of stay, as well as reduced length of time
patients waited for treatment, reduced ED waiting room
overcrowding, improved length of stay for all ED patients,
and improved clinical skills of the nursing staff.30 In addi-
tion, the FT was identified as the most immediate and
effective solution to some of the problems besieging the
emergency department.30 A third study showed that an
FT for less urgent patients decreased the time to assessment
for urgent patients, reduced the length of stay for less
urgent patients, and reduced the number of patients who
left without being seen.31 In addition, care of urgent
patients in the main emergency department was not
delayed.31 A fourth study evaluated whether an FT staffed
by NPs for minor injuries would decrease waiting time
without delaying the care of those with more serious inju-
ries.32 The findings showed a decrease in the number of
trauma patients waiting for more than 1 hour by 30%
and that care for more urgent patients was not delayed.32
Some studies explored whether an FT intervention
would provide a more efficient decision-making environ-
ment without decreasing the quality of care for nonurgent
patients. One study examined the differences in evaluating
and managing the same presenting problem by patients seen
in an onsite ED FT versus a main emergency department.33
FT patients had fewer diagnostic studies ordered, were less
frequently admitted or given intravenous fluids, and had
briefer lengths of stay. Despite these differences, outcomes
and high levels of satisfaction among the patients and their
families were the same. Consistent with the presumed
minor nature of their illnesses, the large majority of patients
in both settings had improved by the time of follow-up.33
Likewise, there was no difference in the rate of unscheduled
follow-up visits for either group.33
Process-of-Care and FT Outcomes
ED patient satisfaction research strongly shows that ED
patients’ dissatisfaction is linked to delays.4 Evidence exists
that FT areas are a positive addition to busy emergency
departments. The previously reviewed studies showed signif-
icant decreases in waiting times with increased ED flow,
improved use of resources, and increased overall patient
satisfaction. The literature supports that FTs may improve
throughput time, thus resolving the overall ED overcrowding
problem. Furthermore, studies support the use of midlevel
providers exclusively in FT emergency departments.4
A study evaluating the effectiveness and efficiency of a
newly developed NP-staffed FT unit concluded that the
patients were highly satisfied with the care that they received
from the NPs.4 The rate of leaving without being seen was
low, and unscheduled return visits were kept to a minimum.
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CLINICAL/Quattrini and Swan
A second study compared the care and outcomes of patients
with minor injuries who were managed by NPs with patients
treated by junior doctors in the emergency department.34
The primary outcome measure was the adequacy of care,
which included history taking, examination of the patient,
interpretation of radiographs, treatment decision, advice,
and follow-up. The findings showed that well-trained, expe-
rienced NPs are as accurate in assessing and managing minor
injuries as junior doctors.34 NPs can provide a safe alterna-
tive to junior doctors for the care of patients with minor ill-
nesses or injuries. The NPs were more accurate in terms of
the medical history but slightly less accurate in the examina-
tion of the patient, thus supporting the need for focused
continuing education of NPs in FTs.34 There was no differ-
ence in patient satisfaction among the 2 types of providers;
however, the NPs were reported to be more courteous. A
third study evaluated attitudes of ED patients with minor
problems that were treated by NPs.20 Findings suggested
that most adult ED patients with minor problems indicated
a willingness to be treated by NPs, often even if this meant
being discharged without direct emergency physician assess-
ment.20 The findings support that the patient’s willingness
to be treated by NPs is critical, and there have been many
studies on the use, the care spectrum, and patient acceptance
of NP care.20 The research supports that the introduction of
NPs for nonurgent ED care improves patient flow, increases
staffing flexibility, and provides high-quality care at a lower
cost. Finally, a systematic review showed that NPs working
in emergency departments and FTs reduced waiting times,
improved patient satisfaction, provided care equivalent to a
mid-grade resident, and provided quality care with reason-
able cost-effectiveness.35
The studies reviewed previously examined process of
care in terms of NPs. Another process to consider in evalu-
ating ED FTs is the triage criteria that are used when patients
arrive at the emergency department. Triage criteria were
explored in several studies comparing patients streamed to
FT versus the main emergency department. In the study
conducted by Docimo et al19 in 2000, the goal was to reduce
total ED time from registration to discharge for nonurgent
patients to 90 minutes or less while reducing clinical
encounter time to 60 minutes or less and increasing the
number of patients being seen. The work group involved
in the project identified several factors believed to be the
major root cause for prolonged length of stay. The triage
guidelines needed to be designed to identify patients who
could be completely evaluated within 1 hour rather than
those who could safely wait. It was identified that if the triage
process was not effective, delays occurred in the FT area.
Included in the goal was to have a dedicated nursing staff
with consistent clinical processes.
44 JOURNAL OF EMERGENCY NURSING
The triage criteria established by Wright et al36 in
1992, along with a study completed by Rodi et al37 in
2006 included a written criteria sheet placed in the triage
area. The format for the criteria of Wright et al was deli-
neated by systems that included patients who could be
quickly diagnosed with treatable illnesses and injuries. In
the study of Rodi et al, the strict triage criteria were written
and posted in the triage area designed to meet the needs of
low-acuity patients. Patients with complaints that needed
prolonged observation and injuries that needed consulta-
tion were excluded from the FT. There were exceptions
made to the triage criteria, which included (1) if there
was a 1-hour or greater wait to be seen in the FT and
the main ED waiting time was less, (2) if the patient
requested to be seen in the main emergency depart-
ment, and (3) if the FT was not open.
Structure and Patient Outcomes
Few studies have examined structural characteristics of FT
services in emergency departments. One study identified
the facilitators and barriers associated with integrating NPs
into the emergency department and FTs.38 Three major
complex issues connected with implementing NPs were
organizational context, role clarity, and NP recruitment.
Organizational context referred to the environment NPs
entered and involved issues related to the ED culture, phy-
sician reimbursement system, and patient volume. Role
clarity referred to the understanding of the NPs’ role in
the emergency department, and recruitment issues referred
to attracting and retaining NPs to work in the emergency
department.38 A second study examined an organization’s
quality improvement initiatives related to identifying major
causes for delay in evaluation and treatment of ambulatory
patients in the emergency department and rational solutions
to reduce those delays; it found that formal application of
continuous quality improvement techniques in emergency
departments and FTs can result in appropriate changes in
the process of patient flow, leading to measurable and signifi-
cant reductions in length of stay for FT patients.39
IMPLICATIONS
Although much has been written about patient and
organizational outcomes of FTs in emergency departments,
less is known about structure and process for development
and implementation of an FT. For example, what are the
best practices in terms of types, characteristics, and demo-
graphics of patients best evaluated and managed in FTs
with a 90-minute benchmark? Low-acuity patients are
triaged to FTs; however, if the low-acuity patient is a child
requiring a specialty consultation or an older adult with
VOLUME 37 • ISSUE 1 January 2011

multiple comorbidities requiring special diagnostic testing,
these characteristics may be contraindications for an FT.
What is the ideal acuity index? What triage criteria
should be used? Historically, most US emergency depart-
ments have used a 3-level “comprehensive” triage system,
using some combination of vital signs, directed questioning,
and a small amount of intuition to assign a triage level.40
Although many US hospitals still use a 3- or 4-level triage
system, the trend is toward a 5-level system. Some of the
newly appointed 5-level triage tools/systems most widely
used include the Canadian Triage and Acuity Scale, Man-
chester Triage System, Australian National Triage Scale,
and Emergency Severity Index (ESI). The ESI was developed
around a new conceptual model of ED triage. The purpose
of the ESI is to also consider resources necessary for patients.
The ESI retains the traditional foundation of patient acuity/
urgency and seeks focus on patient streamlining to the right
resource. The ESI is unique because it requires the triage
nurse to anticipate expected resource needs.41
What is the best staffing and staff mix? Most emer-
gency departments have some form of FT, and many
FTs are staffed during traditional daytime hours. However,
this may not match with peak patient volume and thus is
not aligned to combat ED overcrowding. It is imperative to
match the FT delivery model and staff mix with the indi-
vidual needs of emergency departments to take full advan-
tage of the outcomes discussed previously. Ultimately, how
can these structure and process characteristics continue to
improve patient, provider, and organizational outcomes of
ED FTs?
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VOLUME 37 • ISSUE 1 January 2011