Fast Track in the emergency department: a one-year experience with nurse practitioners.

The use of a Fast Track system in the emergency department is becoming increasingly popular in order to provide fast and efficient service to patients with minor emergencies. In this paper we describe the one-year results of our system staffed by nurse practitioners. During the first year of operation, a total of 4468 patients were seen in Fast Track. Approximately 28% of patients are triaged to Fast Track during its hours of operation. The average patient seen in Fast Track was ready for discharge 94.4 minutes after presentation. Fewer than 1% of patients required admission to the hospital. Overall, patients and medical staff were highly satisfied with the Fast Track system. Our experience demonstrates that nurse practitioners can effectively and efficiently staff a Fast Track in an academic emergency department.     

Streaming by case complexity: Evaluation of a model for emergency department Fast Track

Objectives: To evaluate a patient flow streaming system within a teaching hospital's ED, using functional principles to separate patients into two streams on the basis of complexity rather than acuity, severity or disposition. Methods: The project used conceptual principles, such as patient complexity and ‘lean thinking’ theory, to create a new Fast Track patient stream, which was separately resourced. Data collected before and after implementation of the Fast Track system were analysed to evaluate the system. Results: Following implementation of the system, significant improvements were observed in several key ED performance indicators. Mean waiting time was reduced from 55 to 32 min, mean treatment time was reduced from 209 to 191 min, compliance with New South Wales Department of Health waiting‐time benchmarks increased from 59% to 77% and the percentage of patients who did not wait to complete their treatment halved from 6.2% to 3.1%. Conclusions: Key features in the success of the system included use of dedicated senior staff for Fast Track patients, and quarantining of clinical resources. The ED aiming to improve their waiting times and throughput should consider using complexity as a key criterion for triaging patients into separate streams. A low‐complexity patient stream in the ED provides an ideal focus for advanced nursing practice.     

Fast Track: one hospital's journey

This paper is the first of two articles discussing the implementation and evaluation of an innovative Fast Track process. This current paper explains how one metropolitan hospital identified the need to establish Fast Track in their Emergency Department and the journey that was taken to implement the initiative. The other paper presents the findings of the evaluation of the Fast Track process over a twelve month time frame. Fast Track is the treatment of minor injuries and illnesses by designated clinicians within the Emergency Department. The model was based upon the available literature from studies on Fast Track and "See and Treat" conducted in the United Kingdom, North America and Australia, and was adapted to address the type of presentations arriving at the hospital's Emergency Department. The initial change management process lasted twelve months and as a result Fast Track has revolutionised the way many patients are treated in the Emergency Department. Furthermore, Fast Track has provided nurses with the opportunity to achieve advanced skills in the areas of suturing and plastering.     

Evaluation of Fast Track

This paper is the second of two articles discussing the execution and evaluation of implementing a Fast Track program in a West Australian outer metropolitan hospital Emergency Department. The first paper in the series outlined the implementation process over a 12-month period. This current paper presents the findings of the 12-month evaluation utilising Statistical Process Charts. The object of this evaluation was to undertake analysis of data throughout the change process and demonstrate the effectiveness of implementing Fast Track into the Department. Following the implementation of Fast Track, the Department's "Did not wait" rate decreased over a 12-month period from 10% to 5.4%, without a detrimental impact on treatment times for the patients with serious illnesses and injuries. Furthermore, Fast Track resulted in patients with minor injuries or illnesses being seen, treated and discharged within 2 hours of presentation. Indeed the journey time decreased for all Emergency Department patients. As a result of Fast Track, the Emergency Department waiting area is less congested and staff moral has increased. A further consequence of Fast Track is that nurses are providing more advanced clinical services to patients.     

The media exchange

TERMINAL CARE: FRIENDSHIP CONTRACTS WITH DYING CANCER PATIENTS Lomp Feigenberg (Translated from the Swedish by Patrick Hort) New York: Brunner/Mazel, 1980, 282 pages, hardbound, S19.50, ISBN 0-87630-224-X.

NEW DIRECTIONS IN DEATH EDUCATION AND COUNSELING: Enhancing the Quality of Life in the Nuclear Age edited by Richard A. Pacholski and Charles A. Corr (with an introduction by Herman Feifel) Arlington, VA: The Forum for Death Education and Counseling, 1981, 346 pages paperbound, ISBN 0-96077394-0-8, $12.95, postage paid from the Forum for Death Education and Counseling, PO Box 1226, Arlington, VA 22210.

DIMENSIONS OF LOSS AND DEATH EDUCATION by Patricia Weller Zalaznik Minneapolis: EDU-PAC Publishing Company, 1979, 208 pages, loose-leaf binder, $29.95, ISBN 0-931152-03-8. Student Activities Workbook, 76 pages, perforated sheets, $4.25 per copy, ISBN 0-931152-11-9.

THE CONSTRUCTION OF LIFE AND DEATH by Dorothy Rowe Chichester, England: Wiley, 1982, 214 pages, ISBN 0-471-10064-1.

SUICIDE AT 17 Film and VC, 18 min, color (rental $4O/sale film $300, VC $240).

A DIFFERENT KIND OF LIFE VC, 29 min, color (rental $55/sale $200).

BEGINNING AGAIN WIDOWERS VC, 30 min, color (preview $90; 2 week rental $60; 4 week rental $9O/sale non-profit $90, for-profit $175). Rental charges applicable to purchase price within 30 days of preview.     

INACTIVATING A TOTAL ARTIFICIAL HEART: SPECIAL MORAL PROBLEMS

The Two-Track Model of Bereavement Questionnaire (TTBQ) was designed to assess response to loss over time. Respondents were 354 persons who completed the 70-item self-report questionnaire constructed in accordance with the Two-Track Model of Bereavement. Track I focuses on the bereaved's biopsychosocial functioning and Track II concerns the bereaved's ongoing relationship to the range of memories, images, thoughts, and feeling states associated with the deceased. Factor analysis identified 5 factors that accounted for 51% of the variance explained. In accord with the theoretical and clinical model, 3 factors were primarily associated with the relationship to the deceased (Track II): Active Relational Grieving, Close and Positive Relationship, and Conflictual Relationship; and 2 factors with aspects of functioning (Track I): General Biopsychosocial Functioning and Traumatic Perception of the Loss. Construct and concurrent validity were examined and were found satisfactory. Differences by kinship, cause of death, gender, and time elapsed were examined across the 5 factors, the total TTBQ, and the ITG. The new measure is shown to have both construct and concurrent validity. Discussions of the results and implications for the measurement of response to loss conclude the article.     

The media exchange

UNTIL TOMORROW COMES Orville E. Kelly New York: Everest House, 1979, published simultaneously in Canada by Beaverbooks, 348 pages hardbound, $9.95, ISBN 0-89696-031-5.

LIFE AT DEATH: A SCIENTIFIC INVESTIGATION OF THE NEAR DEATH EXPERIENCE Kenneth Ring New York: Coward, McCann & Geoghegan, 1980, 310 pages, hardbound, $11.95, ISBN 0-698-11032-3.

THE LAST DAYS OF LIVING Film, 58 min, color, (rental $60/sale $630, VC $420).

THE LAST DAYS OF LIVING Reviewed by Linda H. Kilburn, M.S.W., Exeuctive Director, Hospice of the Good Shepherd, Inc., Newton, Mass. President, Hospice Federation of Mass., Inc.

TIME TO COME HOME Film, 24 min, color, (rental $35/sale $275).     

The media exchange

DEATH IN LITERATURE edited by Robert F. Weir New York: Columbia University Press, 1980, 451 pages, hard cover, $25.00, ISBN 0-231-0493-6; soft cover, $10.00, ISBN 0-231-04937-4.

CHILDREN'S CONCEPTIONS OF DEATH by Richard Lonetto New York: Springer, 1980, 219 pages, hardbound, $19.75, ISBN 0-8261-2550-6, paperback, ISBN 0-8261-2551-4.

A FAMILY'S RESPONSE TO DEATH VC, 50 min, color, (rental $40/sale $1 50).

CANCER: A FAMILY JOURNAL Film and VC, 57 min, color, (rental $50/sale $250), study guide with purchase. SWOG, Sidney Farber Cancer Institute, 35 Binney St., Boston, MA 021 15. Reviewed by Philip F. Roy, LICSW, Social Worker, Palliative Care Service, University of Massachusetts Medical Center.     

The media exchange

TRACKS OF A FELLOW STRUGGLER: HOW TO HANDLE GRIEF by John Claypool Waco, TX: Word Books, 1974, 96 pages, hardbound, $3.95, ISBN 0-87680-348-6; paperbound, $1.25, ISBN 0-87680-863-1.

CHILDHOOD MALIGNANCY: THE PSYCHOSOCIAL CARE OF THE CHILD AND HIS FAMILY by David W. Adams Springfield, IL: Thomas, 1979. 197 pages, hardbound, $14.50, ISBN 0-398-03928-3.

THE PSYCHOSOCIAL CARE OF THE CHILD AND HIS FAMILY IN CHILDHOOD CANCER: AN ANNOTATED BIBLIOGRAPHY by David W. Adams Hamilton, Ontario: McMaster University Medical Centre, 1979. 112 pages, paperbound, $4.50, ISBN 0-969-0051-0-5.

THEY NEED TO KNOW: HOW TO TEACH CHILDREN ABOUT DEATH by Audrey K. Gordon and Dennis Klass Englewood Cliffs, NJ: Prentice-Hall, 1979. 274 pages, paperbound, $4.95, ISBN 0-13-917104-5.

TEENAGE SUICIDE Film, 16 min, color (rental $40/sale $250).

JOCELYN Film, 28 min, color (rental $45/sale $425, VC $375).     

The media exchange

DEATH: A BIBLIOGRAPHICAL GUIDE by Albert J. Miller and Michael J. Acri Metuchen, NJ: Scarecrow Press, 1977, 420 pages, hardbound, $16.00, ISBN 0-8108-1025-5.

HOME CARE: Living with Dying by Elizabeth Prichard, et al. (eds.) New York: Columbia University Press, 1979. hard cover, ISBN 0-231-04258-2.

PHILLIP: In Search of Meaning by Hadley Read Champaign, IL: Charles Nathan & Associates, 1972. 138 pages, paperbound, $3.95.

Joe & Maxi Film or VC*, 80 min, color (rental $1 15/sale (negotiable) $1325).

Griffin and Phoenix Film, or VC, 96 min, color (rental $160/sale $1595, VC $550).

Griffin and Phoenix Reviewed by J. Andrew Billangs, M.D., Department of Medicine, Massachusetts General Hospital, Chelsea Health Center and Harvard Medical School, Chelsea, MA., and president, Hospice of Massachusetts.     

The media exchange

WHEN BAD THINGS HAPPEN TO GOOD PEOPLE by Harold S. Kushner New York Schocken, 1981, 149 pages, hardbound, ISBN 0-8052-3773-9. Reviewed by John S. Stephenson, San Diego University

MOTHERHOOD AND MOURNING: PERINATAL DEATH by Larry G. Peppers and Ronald J. Knapp New York: Praeger, 1980, 165 pages hardbound, ISBN 0-03-055901-4. Reviewed by Margaret S. Miles, School of Nursing, University of Kansas

CAN'T IT BE ANYONE ELSE? Film and VC, 54 min, color (Rental $60/Sale 16 mm $695/VC $395). Pyramid Films, Box 1048, Santa Monica, CA 90406.

TEACHING CHILDREN ABOUT CANCER THE HEALTH PROFESSIONAL'S ROLE Slides and audio cassette or VC, 33 min, color (Rental $45/Sale $225) Medical Media Consultants, 2644 Potter St., Eugene, OR.     

The Chronological Track of Contemporary Development of Rehabilitation Medicine in China

While the 2013 ISPRM World Congress Chooses Beijing China as its venue,Chinese colleagues in rehabilitation medicine(RM) feel especially honoured and happy,looking back at the past three decades of hard working in advancing the new specialty in China.In this article I would like to outline the step by step progress of rehabilitation medicine in chronological order,with a hope that the readers might find the impetus of this progress and some characterists of medical rehabilitation in this rising oriental developing country.     

The media exchange

OVER THEIR DEAD BODIES, by Thomas Mann and Janet Creme, Brattleboro, Vermont: The Stephen Crecne Press, 1962, hardbound, $5.95. ISBN 0-8289-001 7-5. Reviewed by Sandra L Bertman, University of Massachusetts Medical School.

THE JEWISH WAY IN DEATH AND MOURNING, by Maurice Lamm, New York: Jonathan David Publishers, 1969 (rev. ed., 1972), + 285 pages, hardbound, $6.95; paperbound, $3.95, ISBN 0-8246-0041-X hardbound; 0-8246-01 26-2 softbound. Reviewed by Paul K. Chafetz, Department of Clinical Psychology, University of Florida.

DYING AND DEATH: A Clinical Guide for Caregivers, edited by David Barton, M.D. Baltimore: Williams & Wilkins, 1977, 256 pages, soft cover, $14.95, ISBN 0-683-00440-9. Reviewed by Ruth Reko. Continuing Care Unit, Lutheran Medical Center, St. Louis.

YOU CANNOT DIE, by Ian Currie, Toronto: Methuen, 1978,288 pages, $9.95. hardbound, ISBN 0458-95750-0. Reviewed by Richard Lonetto. University of Guelph

Audiovisual Reviews: COMING TO TERMS WITH LOSS A SERIES OF INTERVIEWS

DEATH NOTIFICATION, Film, 23 min, color (rental $65/dc $395). Harper & Row Publishing Company. 2350 Via Avenue, Hagerstown, MD 21740. Reviewed by J. Eugene Knotr, Ph.D., Department of Human Development, Counseling, and Family Studies, University of Rhode Island

AFTER OUR BABY DIED, Film, 20 min, color (rental-free loan by Modem Talking Pictures Service, Inc., 2323 New Hyde Park Road, New Hyde Park, N.Y. 11042/sale $116 from National Audio Visual Center, Order Department, Washington, D.C. 20409). Reviewed by Andrea Parkus Patenuude, Ph.D., Staff Psychologist, Children's Hospital Medical Center, Boston, MA 021 15.

THE SYNDROME OF ORDINARY GRIEF, VC. 32 min, color (rental $50/sale $150). Videotape Library of Clinical Psychiatric Syndromes. University of Texas Medical Branch, Galveston, TX 77550. Reviewed by Joanne T. Jozefowski, R.N., Ph.D., Director, Thanatology Resource Center of Massachusetts, Worcester.

THE LIFE THAT'S LEFT, Film and VC, 29 min, color (rental $25/sale: film $S75, VC $225). Great Plains National Insauctional Television Library, Box 80669, Lincoln, NE 68501. Reviewed by Michael A. Simpson, M.D., B.S., M.R.C., Psychiatry, D.P.M. Associate Professor of Psychiatry, Temple University, Philadelphia; Convener, International Task Force on Death and Dying.     

Comparison of Three Cardioverter Defibrillator Implantation Techniques: Initial Results with Transvenous Pectoral Implantation

A total of 121 patients underwent epicardial (n = 32), transvenous abdominal (n = 30), and transvenous pectoral (n = 59) ICD implants. Perioperative complications were defined as those occurring within 30 days after surgery. Hospital costs were calculated with $750 per day as a fixed charge. Duration of surgery was the time between the first skin incision and the last skin suture. Severe perioperative complications that were life-threatening or required surgical intervention occurred in the epicardial (6%) and transvenous (10%) abdominal groups, but not in the pectoral group. Perioperative mortality occurred only in the epicardial abdominal group, predominantly in patients with concomitant surgery (18%), and in 5% of patients without concomitant surgery. The duration of surgery was significantly shorter for transvenous pectoral implantation (58 ± 15 rain, P < 0.05) compared to transvenous abdominal implantation (115 ± 38 min). Epicardial abdominal ICD implantation had the longest procedure time (154 ± 31 min). The postimplant hospital length of stay was significantly shorter for pectoral implantation (5 ± 3 days, P < 0.05) compared to transvenous (13 ± 5) and epicardial (19 ± 5) abdominal implantation. Total hospitalization costs significantly decreased in the pectoral implantation group ($4,068 ±$2,099 for the pectoral group vs $14,887 ±$4,415 and $9,975 ±$3,657 for the epicardial and the transvenous abdominal group, respectively, P < 0.05). These initial results demonstrate the advantage of transvenous pectoral ICD implantation in terms of perioperative complications, procedure time, hospital length of stay, and hospitalization costs.     

Scholarship of Suicide

Abstract

DEATH: A BIBLIOGRAPHICAL GUIDE by Albert J. Miller and Michael J. Acri Metuchen, NJ: Scarecrow Press, 1977, 420 pages, hardbound, $16.00, ISBN 0-8108-1025-5.

HOME CARE: Living with Dying by Elizabeth Prichard, et al. (eds.) New York: Columbia University Press, 1979. hard cover, ISBN 0-231-04258-2.

PHILLIP: In Search of Meaning by Hadley Read Champaign, IL: Charles Nathan &; Associates, 1972. 138 pages, paperbound, $3.95.

Joe &; Maxi Film or VC*, 80 min, color (rental $1 15/sale (negotiable) $1325).

Griffin and Phoenix Film, or VC, 96 min, color (rental $160/sale $1595, VC $550).

Griffin and Phoenix Reviewed by J. Andrew Billangs, M.D., Department of Medicine, Massachusetts General Hospital, Chelsea Health Center and Harvard Medical School, Chelsea, MA., and president, Hospice of Massachusetts.     

Reduced door-to-balloon times in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background: Primary percutaneous coronary intervention (PCI) in patients with ST‐elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity, particularly when door‐to‐balloon (D2B) time is < 90 min. We sought to minimize preventable delays by instituting an on‐site cardiology team‐based approach in the emergency department (ED). Methods: The on‐site group comprised 146 consecutive patients with STEMI undergoing primary PCI after implementation of the on‐site strategy. This new patient care model was compared with the conventional care administered before instituting the on‐site cardiology team‐based strategy in ED, which included 90 patients (interim group) receiving primary PCI at a catheterization room in the same building as the ED, and 147 patients (pre‐on‐site group) undergoing primary PCI at a catheterization room two blocks away from the ED. Results: Median D2B time decreased from 107 min in the pre‐on‐site group to 72 min in the interim group, and to 47 min in the on‐site group, respectively (p < 0.001). The percentage of D2B times < 90 min increased from 34% to 78% and 96%, respectively among the three groups (p < 0.001). Hospitalization costs were significantly reduced in the on‐site and interim vs. pre‐on‐site groups ($5944, $5999, and $6581, respectively; p = 0.008). In‐hospital mortality did not differ significantly among the three groups (4.8%, 2.2%, and 6.1%, respectively; p = 0.387). Conclusions: Institution of an on‐site cardiology team‐based approach in the ED significantly reduces D2B time in STEMI patients eligible for primary PCI.     

A comparison of the Puritan-Bennett 7200a ventilator's flow-by mode to the T-piece mode prior to extubation in postsurgical patients

We compared flow-by ventilation (FB) via the Puritan-Bennett 7200a ventilator with T-piece ventilation (TP) during weaning from mechanical ventilation (MV). METHODS: We placed 22 consecutive postsurgical patients being weaned from MV on FB at base flows of 10 L/min and 20 L/min and then on TP. Blood pressure, pulse rate, respiratory rate, blood gases, tidal volume, and peak inspiratory flow were measured after at least 20 min in each mode. Statistical analysis of clinical status used a three-level, one-way analysis of variance with technique as a within-subjects factor. Setup costs of the three ventilatory modes were evaluated using relative value units for labor plus actual costs of added equipment and supplies. RESULTS: Although there was a statistically significant difference in PaCO2 among the ventilatory modes, this was not clinically important. No other differences were found. Each FB mode cost $2.55 to set up, whereas TP cost $11.90. CONCLUSIONS: FB and TP were clinically equivalent. However, the alarm and monitoring capabilities during FB are useful and may be worth the one-time cost ($1,000) of adding the optional flow-by software to the 7200a ventilator.     

The media exchange

HOW IT FEELS WHEN A PARENT DIES by Jill Krementz New York: Knopf, 1981. 114 pages, hardbound, $9.95, ISBN 0-394-51911-6. Reviewed by Emu Funan. Cleveland Center for Research in Child Development.

THE BROKEN CONNECTION: ON DEATH AND THE CONTINUITY OF LIFE by Robert Jay Lifton New York: Simon & Schuster, 1979.495 pages, hardbound, ISBN 0-671-22561-8. Reviewed by John S. Stephenson, San Diego State University

VALLEY OF THE SHADOW. A Journey through Grief Film and VC, 38 min, color (rental film $50, VC $4O/sale film $450, VC $315).