The Institute of Medicine released a report in the spring of 2006 to address the challenges facing overcrowded Emergency Departments (ED). To complement the Institute of Medicine report, the Institute of Healthcare Improvement created a Learning and Innovation Community as part of its IMPACT network on “Operational and clinical improvement in the emergency department.” Unnecessary delays in emergency departments have contributed to dissatisfied patients and caregivers, inefficient work processes, and higher production costs.

Emergency departments have been primarily designed to provide care for patients with life-threatening medical conditions. Emergency departments now serve diversified roles by providing service to patients with less serious conditions as well who now comprise between 10% and 66% of all ED visits. These less serious medical conditions are also described as “low- acuity”, “ambulatory”, or “inappropriate” visits.

The Centers for Disease Control estimated a 20% increase in the number of ED visits between 1992 and 2001 while the ED departments declined by 15% during the same period. This means that not only our emergency departments have been servicing more patients than our but also servicing them with few resources than before. There were 114 million visits to emergency departments in 2001, 10% of which were non-urgent according to Centers for Disease Control and Prevention.

The General Accounting Office confirmed the general suspicions in 1993 that non-urgent visits have indeed contributed towards further burdening the already declining numbers of emergency departments in the country. Some factors that have contributed toward a greater use of emergency departments by patients with non-urgent medical conditions are limited access to primary care providers (PCP), lack of insurance, lack of patient education. Even though 83% of our low-acuity patients have a PCP, 83% have insurance, and 67% understand that their complaint is not emergent, the convenience of emergency departments have made them more attractive to patients with non-urgent medical conditions.

The 350-bed Dartmouth-Hitchcock Medical Center attracts annual emergency department visits of approximately 30,000 of which 25% to 30% are non-urgent. Instead of turning the patients away, the Medical Center’s emergency department found an innovative solution to the problem by creating a separate stream of care for low-acuity patients. These separate streams of care areas have also been referred to as “fast track,” “urgent care,” “walk in,” or “ambulatory care” units.

This study is aimed at evaluating the implementation of a fast track unit in an academic emergency department.  A fast track unit was set up in the fall of 2004 to meet the needs of low-acuity patients. The unit was staffed by a Personal Assistant (PA) who was already a staff member and a newly hired emergency department technician. To access the performance of the fast track unit, questionnaires were sent to the patients and staff. Staff members chosen for the paper questionnaires included physicians, nurses, and technicians while the rest of the staff members were encouraged to fill an online survey. Pre-intervention data were collected by two research assistants and the post-intervention data were collected by the emergency department technicians.

Pre-intervention data were obtained in September 2004 and the fast track unit opened the following month in October 2004. Post-intervention data were obtained in June 2005. The results indicated that only 36% of the customers were willing to wait to see MD instead of a PA and of this group, only 5% were willing to wait more than an hour. The outcome of the staff survey also showed a general trend towards increased satisfaction after the initiation of the fast track unit.