FAST unit reduces use of ED as regular admit route
Admissions in 40 minutes, first meds in 30
Employees at Wadley Regional Medical Center knew the emergency department (ED) was fertile ground for quality improvement.
But they figured their 400-bed hospital in Texarkana, TX, didn’t have enough emergencies for a full-scale QI initiative until one "really bad" night in 1996. An unusually large number of patients came in with orders for initiation of treatment plans, highlighting what ED staff knew all along — the ED was being used to bypass regular admissions.
The two ED nurses used the momentum from that crisis to organize an improvement effort. Baseline data gathered by the ED director "showed us a tremendous opportunity for improvement," notes Fiona Adams, RN, MS, vice president of administrative services.
"But you don’t know these things until you actually look at the data," she explains. Beyond long door-to-drug times for heparin and antibiotics, data revealed that the regular admissions process was just a minute shy of five hours.
The improvement effort, launched in late 1996, worked under the moniker FAST (Focused Admission Service Team). In less than a year, the team cut the admissions routine by three hours and pared door-to-drug times to less than 30 minutes.
FAST soon learned that a better admissions process was critical to speeding up door-to-drug times and to easing the ED’s growing workload. "Everybody’s time is divided," Adams concedes. "And the nurses on floor have different priorities than the emergency department. They think the current patients are sicker so the new admits don’t get immediate attention."
Nor did the fragmented admissions process make it easy for unit nurses to initiate care for the new admits. Despite the hours-long admissions routine, new patients often arrived on the floor with incomplete orders or incomplete intake information on their charts.
While sending non-emergent patients through the ED is an obvious misuse of resources, the logic is obvious — the maneuver produced faster turnarounds on lab, X-ray, and EKG reports as well as first dosing of meds. For patients and their families, admission through either route was long, confusing, and anxiety-producing due to the parade of different caregivers giving multiple tests.
Teamwork and benchmarks
From a nucleus of the ED’s two nurses and director, FAST grew to embrace these staff whose jobs would change and who could streamline or stonewall the project:
director of process design, a specialist in planning and implementation of organizational processes;director of business support to manage the financial ramifications;
care coordinator to preserve continuity of care from the inpatient unit to the community;
ad hoc members from nursing, medical staff, and the ED medical director.
The group augmented internal data analysis with a literature search of best practices and a site visit, in May 1996, to Muhlenberg (NJ) Medical Center to study the center’s state-of-the art admissions processes.
FAST’s goals were as follows:
Design an efficient, seamless admissions process for all patients.Initiate admission orders within 30 minutes.
Divert the load of non-emergent patients from the ED to regular admissions.
Increase utilization of care protocols.
Initiate care plans and patient/family education at the point of admission.
Improve care outcomes.
Test site hijacked’ from oncology
In early 1997, FAST opened a month-long pilot. The two-bed "FAST unit" consisted of "two beds hijacked from the oncology outpatient unit," quips Adams. It would serve as the admissions channel for all Wadley patients except those headed to intensive care, labor and delivery, pediatrics, or chemotherapy. Hours of operation were 8:00 a.m. to 5:00 p.m.
Both the ED and admissions staffs were cross-trained to complete the admissions paperwork as well as draw blood samples and do EKGs. "We learned how important it is to choose the right people for the job," explains Adams. "People who succeed in the FAST unit are those who can focus on a set of procedures. They have to be caring and efficient at the same time and move the patients on to the next step of treatment.
"This is not everyone’s cup of tea," she adds. "Some nurses like more excitement. They belong in the emergency room. Others like to spend a lot of time at the bedside learning the patient’s background and explaining treatment plans."
The FAST unit staff sends patients to inpatient beds with the following in place:
initial assessment with complete patient admission profile;care plan;
diagnostic tests/studies ordered, including lab, EKG, basic radiological studies, referrals, specimen collection, first dose of medications, IV insertion and therapy, urinary catheterization, and respiratory treatments;
completion of physicians’ initial set of orders to include order entry;
initiation of patient education;
initiation of discharge planning.
At the end of the pilot, the team knew they had a winner. "The floor nurses loved it. They thought it reduced their workload," Adams says. Physicians readily use the FAST unit instead of slipping non-emergent patients in through the ED. Patient satisfaction runs close to 100%. Admission times dropped by 83%, compared to the baseline data. (To track the improvement progression, see graph, p. 58.)
FAST unit here to stay
The permanent FAST unit opened with six treatment beds in April 1997. It has a workstation, cardiac monitoring system, and supply storage area. Hours of operation are 7:30 a.m. to 11:00 p.m. Adams explains nighttime volumes are too low to make 24-hour operations worthwhile.
Forty-minute admissions are now the norm. "When you’ve got a focused unit," Adams says, "they get the job done."
Wadley’s before and after figures on length of stay (LOS) for patients who could be admitted through the FAST unit show shorter stays. While Adams points out that many factors affect LOS, she believes that the FAST unit deserves much of the credit. (For pre- and post-FAST numbers, see graph, p. 59.)
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