Original article

Effect of clinician designation on emergency

department fast track performance
Julie Considine,1 Matthew Kropman,2 Helen E Stergiou2
1
Deakin UniversitydNorthern ABSTRACT Although 83.4% of Victorian ED roster specific
Health Clinical Partnership, Objective To examine the effect of clinician designation staff to their fast track area, there is variation in the
School of Nursing, Deakin on emergency department (ED) fast track performance. staffing profile of fast track systems across
University, Victoria, Australia
2
Emergency Department, The Design and Setting A retrospective audit of patients Victoria.7 The majority of ED used a combination
Northern Hospital, Northern managed in the fast track area of an ED in metropolitan of medical and nursing staff; however, 86.7% of ED
Health, Victoria, Australia Melbourne, Australia. with dedicated fast track staffing allocated staff
Participants Patients triaged to ED fast track from 1 using a rotating roster.7 The level of medical staff
Correspondence to
Dr Julie Considine, Deakin
January 2008 to 31 December 2008 (n¼8714). rostered to fast tracks systems was variable and
UniversitydNorthern Health Main Outcome Measures Waiting times in relation to ranged from emergency physicians to interns.7 In
Clinical Partnership, School of Australasian triage scale (ATS) recommendations and ED contrast, the majority of ED used senior nursing
Nursing, Deakin University, 221 length of stay (LOS) for non-admitted patients were staff in their fast track areas and 24.5% of nurses
Burwood Hwy, Burwood, examined for each clinician group. working in fast track areas across Victoria are
Victoria 3125, Australia;
julie.considine@deakin.edu.au Results Compliance with ATS waiting time emergency nurse practitioners/candidates. A small
recommendations was highest (82.5%) for emergency number of ED employed allied health clinicians in
Accepted 25 November 2009 nurse practitioners/candidates and lowest (48.2%) for their fast track services, including physiotherapists,
Published Online First junior medical officers. Median ED LOS was less than 3 h occupational therapists and care coordinators.7
26 June 2010
for non-admitted patients, and 85.8% of non-admitted Although there are a number of benefits associ-
fast track patients (n¼6278) left the ED within 4 h. ated with ED fast track, including decreased
Patients managed by emergency nurse practitioners/ waiting time,10 shorter ED LOS,3 5 11e16 and
candidates had the shortest ED LOS (median 1.7 h) and reduced left-before-treatment rates,10 16 little is
patients managed by junior medical officers and locum known about how clinician designation affects fast
medical officers the longest ED LOS (median 2.7 h) track performance. Despite the rapid growth of fast
(c2¼498.539, df¼6, p<0.001). track systems in Australia, the impact of various
Conclusions Clinician designation does impact on staffing profiles is poorly understood, and the
waiting times and, to a lesser extent, ED LOS for patients presumed benefits of using senior staff are based on
managed in ED fast track systems. Future research theoretical suppositions. The aim of this audit was
should focus on obtaining a better understanding of the to evaluate the effect of clinician designation on ED
relationship between clinician expertise, time-based fast track performance.
performance measures and quality of care indicators.
METHODS
Study design
A retrospective audit of all patients managed by the
Emergency department (ED) fast track systems fast track system in a metropolitan ED during 2008.
have evolved to improve the management of This audit was approved by the organisational
patients with non-urgent complaints by decreasing quality committee who deemed the audit met the
waiting time, ED length of stay (LOS) and over- National Health and Medical Research Council
crowding, and increasing patient and staff satis- criteria for a quality assurance activity.17 Submis-
faction with ED care.1e6 A statewide survey of fast sion of a full application to the Human Research
track services in Victorian ED showed most and Ethics Committee was waived.
metropolitan and major rural ED in Victoria had
a formal fast track system.7 The majority of fast Setting
track systems in Victorian ED operated during The study setting was the Northern Hospital,
hours that matched periods of peak demand and Northern Health (TNH), a 300-bed metropolitan
most ED offered a fast track service for 12e16 h teaching hospital in Melbourne, Australia. The ED
per day.7 at TNH provided care for 61 093 patients during
In order to optimise the function and capacity of 2008. Children aged less than 16 years comprised
ED fast track systems, a geographically dedicated 20% (n¼12 237) of presentations and the admission
area staffed by dedicated senior medical and nursing rate was 25% including short stay unit and medical
staff is recommended.1 4 8 It is proposed that dedi- assessment and planning unit admissions.
cated senior medical and nursing staff optimise the Fast track was implemented in ED at TNH in
performance of fast track systems as they have the November 2006 and operates from 10:00 to 02:00
ability to make timely treatment and disposition hours to manage peak presentation times. Fast
decisions with minimal consultation.1 4 8 9 In addi- track at TNH is currently focused on the manage-
tion, dedicated fast track staffing is thought to ment of patients with specific non-urgent
promote faster patient throughput by reducing complaints who are expected to be discharged from
handovers and fragmentation of ED care.1 4 8 the ED and do not require trolley care, intravenous

838 Emerg Med J 2010;27:838e842. doi:10.1136/emj.2009.083113

 Original article

analgesia or intravenous fluids. Patients suitable for management RESULTS

under the fast track model of care are identified by the triage Patient characteristics
nurse using specific inclusion criteria based on presenting prob- A total of 8714 patients was triaged to ED fast track from 1
lems irrespective of triage category. Presenting problems that January 2008 to 31 December 2008: patients managed in fast
may be managed in fast track include: localised cellulitis, track therefore comprised 14.3% of total ED presentations. The
wounds and lacerations, epistaxis, foreign bodies, insect bites, median number of patients treated by fast track per day was 24
minor burns, minor eye complaints, body fluid exposures, single (IQR 19e28). The median patient age was 30 years (IQR 17e46)
distal limb injuries. Patients are allocated directly to fast track by and 21% of patients (n¼1825) were children aged less than
the triage nurse and are not managed by any of the other 16 years. The distribution of triage categories was as follows:
ED systems aimed at expediting the care of patients in the 0.5% ATS 2 (n¼45), 7.5% ATS 3 (n¼655), 78.3% ATS 4
waiting room. (n¼6819) and 13.7% ATS 5 (n¼1195). The median waiting time
Fast track has dedicated staffing and fast track staff should for all fast track patients was 50 min (IQR 23e96) and overall
not be responsible for patient care or the supervision of less 54.4% of patients (n¼4744) were seen within the maximum
experienced medical and nursing staff in other areas of the ED. time frame recommended by the ATS. The majority of fast track
Ideal staffing is at an ED registrar, emergency physician or patients were discharged from the ED (n¼7316, 84%). Admis-
emergency nurse practitioner/candidate supported by a senior sion (including short stay unit and medical assessment and
emergency nurse. In Victoria, emergency nurse practitioners are planning unit) occurred in 647 patients, 26 patients were
authorised to manage specific patient groups independently transferred to other hospitals, 191 patients left after clinical
including assessment, ordering and interpreting diagnostics, advice, 489 patients left before treatment commenced and 45
prescribing medication, discharge and referral to specialists. patients left against advice after treatment had commenced.
Emergency nurse practitioner candidate refers to nurses who are
working towards endorsement as an emergency nurse practi- Clinician characteristics
tioner. In the context of managing patients in fast track, the There was variability in the designation of treating clinicians
scope of practice of emergency nurse practitioners/candidates is working in fast track (table 1). In total, there were 34 interns, 45
interchangeable with that of ED medical staff and emergency junior medical officers, 38 senior medical officers, 19 registrars,
nurse practitioners/candidates are part of the medical roster. The 16 emergency physicians, one emergency nurse practitioner and
emergency nurses rostered to fast track are competent in the one emergency nurse practitioner candidate. The number of
triage role indicating capacity for advanced clinical decision- locum medical officers was unknown as they all use the same
making. They also have specific educational preparation in the code in the ED information system. The median number of
following advanced clinical skills: management of distal limb clinicians working in fast track per day was four (IQR 3e5)
injuries (including initiating diagnostic imaging and simple (table 1). There were no clinically significant differences in the
plaster of Paris application); management of lacerations and triage categories of patients managed by each clinician group
wounds (including use of wound adhesives); and management (table 2).
of plaster of Paris complications.
Waiting time
Participants Overall, 54.4% of patients were seen within the time recom-
A de-identified dataset of all patients triaged to ED fast track mended by their ATS category. The percentage of patients seen
from 1 January 2008 to 31 December 2008 was provided by the within ATS recommendations by clinician group is shown in
health information service. The dataset comprised the following table 3. Compliance with ATS waiting time recommendations
fields: patient age; time and date of ED presentation; triage was highest for emergency nurse practitioners/candidates
category; ED LOS; treating clinician and discharge destination. (82.5%) and lowest for junior medical officers (48.2%).

Data analysis ED LENGTH OF STAY

The main outcome measures for this audit were: waiting times Median ED LOS stay was 2.35 h (IQR 1.53e3.35) for discharged
per triage category with a focus on meeting Australasian triage patients and 5.05 h (IQR 3.63e6.80) for patients requiring
scale (ATS) recommendations18 19 and ED LOS for non-admitted admission. Patients managed by emergency nurse practitioners/
patients with a specific focus on compliance with the Victorian candidates and emergency physicians had a significantly shorter
Department of Human Services target of 4 h ED LOS for at least
80% of non-admitted patients.20 ED waiting time was defined as Table 1 Treating clinicians in ED fast track
the difference between the arrival time and the time seen by Total patients managed
a medical officer or emergency nurse practitioner. ED LOS was during study period
defined as the difference between arrival time and departure Clinician group n %
time.21
Senior medical officer (n¼38) 25.0
Treating clinicians were coded as intern, junior medical officer,
Junior medical officer (n¼45) 1781 20.4
senior medical officer, registrar, emergency physician, emergency
Registrar (n¼19) 1586 18.2
nurse practitioner and locum medical officer according to their
Nurse practitioner/nurse practitioner 1190 13.7
designation on the ED roster. Difference in waiting times and candidate (n¼2)
ED LOS were examined for each clinician group. Descriptive Emergency physician (n¼16) 740 8.5
statistics were used to summarise the audit data and when data N/A* 696 8.0
were not normally distributed, medians and interquartile ranges Intern (n¼34) 492 5.6
(IQR) are presented. Relationships between non-parametric Locum medical officer 48 0.6
variables were examined using c2 and the KruskaleWallis test 8714 100.0
was used to compare median values. Data were analysed using *Left before treatment (n¼482); left after advice (n¼191); clinician not recorded (n¼14);
SPSS version 15. seen by medical staff from outside emergency department (ED) (n¼9).

Emerg Med J 2010;27:838e842. doi:10.1136/emj.2009.083113 839

 Original article

Table 2 ATS categories of ED fast track patients by treating clinician

ATS 2 ATS 3 ATS 4 ATS 5
Clinician group n % n % n % n %
Registrar 14 0.9 124 7.8 1258 79.3 190 12.0
Nurse practitioner/nurse practitioner 7 0.6 62 5.2 949 79.7 172 14.5
candidate
Junior medical officer 9 0.5 155 8.7 1452 81.5 165 9.3
Senior medical officer 11 0.5 188 8.6 1700 77.9 282 12.9
Emergency physician 3 0.4 69 9.3 554 74.9 114 15.4
Intern 1 0.2 42 8.5 376 76.4 73 14.8
Locum medical officer 0 0.0 2 4.2 45 93.8 1 2.2
N/A* 0 0.0 13 1.9 485 69.7 198 28.4
*Left before treatment (n¼482); left after advice (n¼191); clinician not recorded (n¼14); seen by medical staff from outside emergency department (ED) (n¼9).
ATS, Australasian triage scale.

ED LOS, whereas patients managed by junior medical officers Emergency physicians may be interrupted more than other
and interns had significantly longer ED LOS (table 4) clinician groups given the seniority of their role and expectations
(c2¼498.539, df¼6, p<0.001). that they will supervise less experienced medical staff and assist
Overall, 85.8% of non-admitted fast track patients (n¼6278) in the management of complicated patients. Furthermore,
left the ED within 4 h. The percentage of non-admitted patients emergency nurse practitioners/candidates may have lower levels
with an ED LOS less than 4 h by clinician group is shown in of interruptions as their scope of practice guidelines and patient
table 5. The 80% LOS target was met by all levels of clinician types managed in fast track have a natural synergy. Although
except junior medical officers and interns who were very close to medical officers and emergency nurse practitioners/candidates
achieving this key performance indicator. Over 90% of patients are rostered exclusively to fast track, the degree to which they
managed by emergency nurse practitioners/candidates, emer- are called on to engage in the care of other patients warrants
gency physicians and locum medical officers left the ED in less further investigation.
than 4 h. Compliance with ATS waiting time recommendations was
highest for emergency nurse practitioners/candidates and lowest
DISCUSSION for junior medical officers. The median ED LOS for non-
Research literature to date suggests that dedicated senior staff admitted patients was less than 3 h for all clinician groups. This
and patient selection are key factors in the success of ED fast finding adds to the results of other studies that show ED fast
track systems.1 4 8 9 The results of this study show variability in track has a positive effect on ED LOS.3 5 11e16 The overall
compliance with ATS waiting time recommendations, ED LOS proportion of non-admitted patients discharged in less than 4 h
for non-dmitted patients and compliance with 4 h ED LOS was 78%, just below the 80% target set by the Victorian
target for non-dmitted patients. Department of Human Services.20 Compliance with this
The variability in results presented in this paper may have performance indicator was highest for emergency nurse practi-
a number of possible explanations. First, variability in practice tioners/candidates who met this target 95.9% of the time and
may be related to skills, knowledge and decision-aking of indi- lowest for interns who met this target 78.9% of the time. There
viduals or clinician groups. Less experienced clinicians or clini- were no clinically significant differences in ATS categories of
cians unfamiliar with the ED environment may take longer to patients managed by different clinician groups, so it is unlikely
assess and treat patients or require advice from more senior that patient characteristics influenced this finding. Given that
clinicians. It may be proposed that junior clinicians are more emergency nurse practitioners/candidates are experienced
likely to interrupt the care of fast track patients to seek clarifi- emergency nurses, their many years of triage experience and
cation or advice from more senior colleagues; however, further intimate understanding of triage and waiting room management
research incorporating clinical practice observation is warranted may be one possible explanation for these results. Further
to confirm or refute this assumption. Second, the level of research into the timing and types of decisions by each clinician
involvement that different clinician groups have with other ED group in terms of assessment, ordering diagnostics and patient
patients is unclear and diversion of staff from fast track to other disposition may further explain these results.
activities may be a confounding factor in the study results. Although the ED in this study had clear inclusion criteria for
patients managed in fast track, there is variation between ED in
the fast track patient selection criteria. Some ED target patients
Table 3 Proportion of patients seen within ATS recommendations by
clinician group
n % p Value*
Table 4 Median ED LOS for non-admitted patients by clinician group (h)
n Median IQR
Nurse practitioner/nurse practitioner 982/1190 82.5 <0.001
candidate Nurse practitioner/nurse practitioner 1115 1.7 1.2e2.4
Locum medical officer 31/48 64.6 0.430 candidate
Emergency physician 444/740 60.0 0.564 Emergency physician 660 2.1 1.3e3.1
Intern 287/492 58.5 0.797 Registrar 1448 2.4 1.5e3.3
Senior medical officer 1258/2181 57.7 0.141 Senior medical officer 2001 2.4 1.6e3.4
Registrar 868/1586 54.7 <0.001 Intern 437 2.5 1.6e3.8
Junior medical officer 858/1781 48.2 <0.001 Locum medical officer 40 2.7 1.6e3.3
Junior medical officer 1592 2.7 2.0e3.8
*c2.
ATS, Australasian triage scale. ED, emergency department; IQR, interquartile range; LOS, length of stay.

840 Emerg Med J 2010;27:838e842. doi:10.1136/emj.2009.083113

 Original article

Table 5 Proportion of non-admitted patients with ED LOS of 4 h or less on time-based performance indicators. Although previous small
by clinician group studies have shown that ED fast track can improve elements of
n % p Value* care such as analgesia administration and time to x-ray,24 this
Nurse practitioner/nurse practitioner 1069/1115 95.9 <0.001
study did not consider quality of care indicators. Finally, this
candidate study was set in one ED thus limiting the generalisability of the
Emergency physician 594/660 90.0 0.001 study findings.
Locum medical officer 36/40 90.0 0.447
Registrar 1262/1448 87.2 0.102
CONCLUSION
Senior medical officer 1690/2001 84.5 0.042
Clinician designation does impact waiting times and, to a lesser
Junior medical officer 1262/1592 79.3 <0.001
extent, ED LOS for patients managed in ED fast track systems
Intern 345/437 78.9 <0.001
function. Patients managed by senior clinicians (emergency nurse
*c2. practitioners/candidates and emergency physicians) had the
ED, emergency department; LOS, length of stay.
shortest ED LOS and greatest compliance with the 4 h ED LOS
target for non-admitted patients. The challenge for the future of
likely to go home5 22 and other ED use case complexity rather fast track systems is to balance increasing demand for emergency
than probable disposition as a basis for fast track inclusion care with the provision of safe and high quality emergency care
criteria9 Nevertheless, the intent is the same: fast track is aimed and the training of less experienced medical and nursing staff in
at the management of patients with apparent diagnoses who the rapid management of a spectrum of illnesses and injuries.
can be managed rapidly and do not require concentrated emer- Future prospective research should therefore focus on better
gency nursing care.9 understanding the relationship between clinician expertise, time-
Recommendations that senior staff should be used in fast based performance measures and quality of care indicators.
track are based on assumptions that increased experience and
Competing interests None declared.
knowledge will result in logistical advantages such as increased
procedural competence and speed, improved communication Ethics approval The Northern Health Quality Committee deemed the audit met the
and rapid identification of the seriously ill patient. In this study, National Health and Medical Research Council criteria for a quality assurance activity.
Submission of a full application to the Human Research and Ethics Committee was
5.6% of fast track patients were managed by interns and 20.4% waived.
were managed by junior medical officers. The allocation of
interns and junior medical officers to fast track does not allow Contributors JC conceptualised the study, obtained and analysed the study data. JC,
MK and HES interpreted the study data. JC drafted the manuscript and MK and HES
for the most efficient processing of large number of patients. provided critical revision. JC, MK and HES approved the final manuscript. JC takes
However, it may also be argued that rostering junior medical overall responsibility for the paper.
officers and interns to fast track provides valuable training and Provenance and peer review Not commissioned; externally peer reviewed.
education opportunities.
Although junior medical staff are encouraged to consult
with more senior colleagues for clinical advice to ensure a high REFERENCES
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Images in emergency medicine

needs immediate action. The condition is usually more common

Unusual cause of suffocation in an in older people or those who are very young.1 However, healthy
asthmatic adult patient adults either underestimate aspiration of foreign bodies or fail to
recognise it, and may tolerate it for a long time without acute
life-threatening consequences.
A 43-year-old man with a known history of asthma, and is on In this asthmatic patient, persistent respiratory complaints
daily inhalers, presented to the emergency room (ER) because of following forced inspiratory effort led to suspicion of foreign
a persistent sudden onset of difficulty of swallowing associated body aspiration, which was confirmed and managed in the ER
with throat discomfort and a feeling of “suffocation” after setting by endoscopy.
choking while eating soup. The patient’s acute coughing and
suffocation sensation improved after a few hours, but he M A El-Tarchichi, M F Yafi, A H Debek
reported persistent throat discomfort and breathlessness when
Internal Medicine Department, Kingdom Hospital, Riyadh, Saudi Arabia
he inhales forcefully, induces cough or performs any activity. He
took some puffs of his inhalers but did not acquire complete Correspondence to Ali Hassan Debek, Internal Medicine Department, Kingdom
relief; he decided to visit the ER for evaluation. After history Hospital, PO Box 84400, Riyadh 11671, Saudi Arabia; alidebek@yahoo.com
taking and physical exam, which was normal, a chest x ray was Competing interests Authors have no competing interests to declare.
taken, which did not reveal abnormalities; thus, an urgent Ethics approval This study was conducted with the approval of the educational
flexible endoscopic evaluation was carried out. It revealed the committee of the hospital.
presence of a plant leaf, “Laurel” (figure 1A,B), which was used Patient consent Obtained.
to add flavour to the soup, lodged behind the arytenoid processes
Accepted 26 September 2008
opposing the epiglottis. It possibly acted like a valve, causing Published Online First 8 April 2010
closure of the upper airways during deep inspiration effort. The
patient does not recall ingestion of the leaf while sipping the Emerg Med J 2010;27:842. doi:10.1136/emj.2008.067157
soup. The leaf was removed by forceps and the patient’s
symptoms resolved immediately. The patient was discharged on
his usual inhaler medications.
REFERENCE
Foreign body aspiration and/or retained hypopharyngeal 1. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies:
foreign body can be a serious medical condition and sometimes presentation and management in children and adults. Chest 1999;115:1357e62.

Figure 1

842 Emerg Med J November 2010 Vol 27 No 11