The medical fast‐track
Published Oct 1, 1994 · S. M. Lyons
Anaesthesia
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Abstract
The term ‘fast-track’ has been applied in a variety of areas and processes in the general workplace, and has now found its way, as part of ‘managementspeak’, into the medical field [I]. Fast-track, which came to the fore as a term descriptive of rapid career advancement, has been adopted as a synonym for speed and efficiency and its use now embraces many aspects of medical care. Methods of expediting admission of the most seriously ill patients into hospital, and the early availability of emergency treatment for those in greatest need, are illustrations [2]. Schemes of rapid throughput in operating theatres, recovery wards, intensive care and high dependency units, and in wards themselves have been described. Fast-track has been applied to training and retraining when rapidly changing circumstances, such as the introduction of day surgery, have suddenly produced the need for different expertise. The term has been adopted to illustrate nursing organisation in the accident and emergency departments [3,4] and finally Fast-track has been utilised, especially by critics of present government health policy, in the emotive context of possible waiting list queue jumping especially by patients from fund holding General Practices [5]. Speed of action and reaction, the quick riposte, and the total solution encompassed in the ‘sound bite’ answer, have increasingly been interpreted as signs of someone on top of their profession, the successful person and the role model. These attributes certainly measure strands of ability and in medicine can at times be vital in patient care. There have always been situations in which speed was of the essence. The dramatic side of practice has not only attracted potential doctors but has been a great, if not always accurate, source of fictional writing. In the treatment of acute myocardial ischaemic episodes, the acute emergency in the accident and emergency department, and in resuscitation of all kinds, an eventual favourable outcome may be totally dependent on the speed of treatment. However, it is also accepted that, while the considered, well reasoned overview may not finish first in multiple choice examinations or indeed win Mastermind, it may be paramount in good medical practitioners. Is it not preferable to be cared for by someone capable of rational and logical thought, with a breadth of vision enabling them to arrive at the correct decision, even at the expense of speed? Terms are often applicable to their time. Why has the term come to the fore at this time and what has been the impetus for change in medical practice? Over the past decade the pressure has grown to decrease the number of hospital beds. Strained resources have dictated a hard overall look at patient management and have challenged many traditional methods of care. The effect is that the average hospital stay is now shortened and would have been totally unrecognisable to previous generations. Though many of the changes have turned out to be beneficial, their introduction has often been in an attempt to make a virtue out of necessity. Lack of sufficient intensive care beds or high dependency beds, has dictated shorter stays in these facilities to maximise the use of scarce resources. Medical staff are on the whole a conservative group and yet they have initiated real revolutions in treatment, not least in the area of surgical care and have introduced more efficient preoperative investigations, shorter terms of bed rest, and shorter hospital stay in all types of surgical practice. In learning to manage with fewer beds, they have introduced policies of later and later admissions, and earlier and earlier discharge with eventually many more patients for surgical operations being treated as day patients. This has decreased costs per patient, and so allowed more patients to be treated, as part of the medical fast-track. What are the advantages in the fast-track approach? In surgery the obvious advantages are the saving of ‘hotel’ charges, the concentration of nurses where most needed, and the early discharge of patients back to their own home and family and familiar environment. The present patterns of patient care in our practice which are obviously expensive are under the microscope. All hospital care is labour intensive and is especially so in areas where concentrated expert care is necessary. It is obvious that savings may be made by decreasing the length of time which the patients stay in any expensive facility. If this is accepted, it makes the assumption that patients were, and still are, retained for excessive times in the postoperative recovery wards, high dependency units, intensive care units, day surgery units and outpatient investigatory facilities of every kind. If patients can be moved more speedily and safely through these areas, then this must be the accepted policy. A shortened time from diagnosis to treatment and treatment to discharge is appreciated by the patients, and current protocols have removed many of the more irritating delays in inpatient management. This sensitivity towards efficient care combined with the ability to deal with real emergencies as they arise must be an advantage to all concerned. The rapid diagnosis and initiation of treatment in the accident and emergency unit, the rapid access to expert hospital care, with a staff of highly trained doctors and nurses should give the best chance of a good outcome. In this way the fast-track sounds right, breathes efficiency and is the policy goal. There can be no argument that the better use of resources allows more patients to be treated with the same money and we all