Diversity for diversity: A “fast track” nursing service model to complement conventional emergency medicine service in a busy urban area emergency department

Team building and training

A dedicated “Fast Track” team was built from scratch, and all team members were selected from experienced registered nurses of our department. They were trained in a structured manner specifically for this new service, making the transition from a nursing role into a semi-independent clinical role, with adequate skills and confidence to provide quality service to patients.

In 2013, the first batch of four nurses was recruited as trainees. Lectures and practical workshops were organized for all the clinical topics that were planned to be made into Fast Track Protocols. The first batch of protocols included the following topics: needlestick injury, nasogastric tube management, acute retention of urine, minor wounds management, incision and drainage for uncomplicated abscesses, foreign body ingestion, and minor scald injury. The focus of these lectures and workshops was on the clinical aspects of diagnosis and treatment. Emphasis was also put on clinical documentation, communication, and pitfalls. During the workshops, trainees had ample opportunities to gain hands-on experience in clinical procedures and equipment, for example, direct laryngoscopy.

To encourage in-depth learning and understanding, after the introductory lectures and workshops, each nurse was entrusted with the task of fashioning the drafts of one of the protocols that would be used for the Fast Track Service. Recommendations of reference books, local and overseas clinical guidelines as well as guidance on protocol writing were provided by doctors of the team, who subsequently edited the drafts, added appendices containing important clinical knowledge and illustrations, and finalized the protocols using a uniform structured template. These completed protocols were then sent to the Chief of Service of the department for his endorsement to activate these protocols in actual clinical service.

After the protocols were activated, an “internship” period was initiated. During this training period, selected patients would be interviewed and examined by Fast Track nurses under the supervision and guidance of the team doctors. The nurses’ documentations were also carefully checked for the quality of documentation. Constructive comments would be given, and any difficulties faced by the team nurses could be discussed and explored.

After the training period, team nurses could now operate independently, and the service was introduced to doctors of the department. The quality of service and documentation were closely monitored at any point of time. Quality assurance measures will be discussed in other sections.

In 2014, two nurses were further recruited into the Fast Track team as trainees for a 1-year period, and a logbook was designed to monitor training of team members. Each trainee was required to study a set number of previous cases and to see a number of cases under supervision. Existing team members were also given logbooks and were encouraged to study cases as revision themselves, while they coach new trainees with real patient cases.

After the training period of the second batch of trainees, a written test and an Objective Structured Clinical Examination (OSCE)-style assessment were organized with the expert assistance of an Associate Consultant experienced in simulation training, who kindly prepared clinical scenarios and advised on simulation-based assessment setup. Both existing team members and fresh trainees took part in the assessment. Both trainees passed the assessment while existing members also performed well in the assessment, which was regarded as a refresher exercise for them. A high level of adherence to protocols and good diagnostic accuracy were noted in our nursing team. Similar results were demonstrated in a study ² involving the enhanced nursing service teams in several hospitals in Australia.

With a larger team of Fast Track nurses, new protocols could be developed to expand the scope of service, including the topics of ankle sprain, minor head injury, and back sprain. Again, lecture-workshops were arranged to familiarize members with clinical knowledge and physical examination skills. To enhance the accuracy of documentation and communication, reliable clinical decision tools and checklists such as the Ottawa Ankle Rules were incorporated into the Nursing Documentation Sheet, so that the whole doctor–nurse team would have an objective and identical idea of the patient’s condition.

Due to the shortage of nursing staff after 2016, the frequency of Fast Track service sessions was reduced to address manpower needs. However, Fast Track nurses remained active whenever there are suitable cases according to the protocol.

Operation of the fast track service

Potentially suitable patients for Fast Track Service according to the protocol are identified with a mark on their case files by the triage nurse which can be identified by Fast Track Nurses; however, these “marked” patients remain in the same queue as other patients of the same triage category before they are invited to be treated by our Fast Track service. A preset and uniform introduction of the Fast Track Service is given to the patient, and verbal consent is sought from the patient and recorded in the case notes. The patient is guaranteed that a doctor is ultimately responsible for all investigations, diagnosis, and treatment; therefore, this service is not a “lesser service for lesser patients” compared to the regular queue.

Designed to guarantee shortening of waiting time

In certain existing nurse-led service models, suitable patients are identified at triage and separated into a nurse-led queue to wait to be managed by nurse practitioners. However, there is no such division of queue in our Fast Track Nursing Service. Fast Track nurses only proceed to invite one potentially suitable patient still waiting to be seen by a doctor in the regular queue each time when he or she is ready to see a case. Once that patient agrees to go into Fast Track, he or she will be treated immediately. Hence, by design, the waiting times of each Fast Track treated patient is always reduced compared to the waiting time if they refuse Fast Track service and continue to wait for doctor consultation in the regular queue.

At the same time, the Fast Track nurse is always additional manpower not included in the general nursing duty roster; thus, the service to non-Fast-Track patients is never adversely affected. On the contrary, when a patient is taken up by the Fast Track Service, the queue behind that Fast Track patient is reduced immediately by one patient, creating a win–win situation.

Flexible staff

Contrasting with some other enhanced nursing service clinics, our Fast Track team nurses, apart from having undergone additional training, are no different in ranking or job position as any other registered nurse or advanced practice nurse in the department. Therefore, Fast Track nurses can perform both Fast Track service and general nursing service or resuscitation duties in the department at any time according to manpower needs. In fact, in our department, whenever one Fast Track team nurse is on Fast Track duty on a certain shift, the other Fast Track nurses who happen to be on duty on the same shift will be assigned as a member of the general and/or senior nursing staff. Nevertheless, the principle is that the Fast Track duty nurse of any shift is always an additional manpower.

On ordinary days with Fast Track nursing service, the assigned Fast Track nurse will dedicate her/his efforts in Fast Track cases and works independently from and is not counted as part of the general nursing staff.

In cases of overwhelming and extraordinary manpower needs, such as during disaster alerts, the Fast Track team nurse on duty could immediately take up roles in the general nursing team when resuscitation needs override those of non-life-threatening Fast Track cases. In these situations, nursing manpower is increased.

A doctor is responsible at all stages of consultation

The training of our Fast Track Team focuses on the initial assessment of the patient, that is, history taking and physical examination, as well as simple treatments such as wound, Foley, and Ryle’s tube management. However, Fast Track nurses are not officially empowered to document X-ray findings, order investigations such as X-rays or wound swabs, make diagnoses, or to prescribe medications. This approach allows the Fast Track nurse to facilitate the assessment of patients to shorten their waiting time, but also ensure a doctor actively takes responsibility and communicates with the nurse in every step of the case, instead of simply signing off the case. In this way, Fast Track patients actually enjoy “dual channel care,” that is, firsthand knowledge of the case from the beginning to the end by both the nurse and the doctor, compared to the usual case where nursing involvement only begins after a doctor has seen the case single-handedly and focuses mainly on following treatment orders.

Enhancement of clinical knowledge of nurses

Fast Track nurses are trained in more clinical aspects than other nurses and have a more global picture of the clinical logic of diagnosis and treatment, since a Fast Track nurse is required to manage each patient from the initial assessment phase to the investigation phase, and then to the diagnosis, management, and discharge phase. They are also vigorously trained to identify “red flags” during patient assessment. Many of our Fast Track nurses are advanced practice nurses (senior nurses), and their enhanced knowledge of clinical logic and sensitivity toward “red flags” would also help them make decisions with a more holistic view as a nurse-in-charge when they are not on Fast Track duty, thereby benefitting patients as a whole and not limited to Fast Track cases. Fast-track nurses also became more interested in reading X-rays and wound outcome etc., as they have a greater sense of involvement and achievement under this service. This led to better first-hand knowledge, for example in the patterns of ankle injuries and complications of foreign body ingestion, which could in turn be applied onto future patients they encounter.