Implications of England's Four-Hour Target for Quality of Care and Resource Use in the Emergency Department

Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA. Electronic address: .
Annals of emergency medicine (Impact Factor: 4.33). 10/2012; 60(6). DOI: 10.1016/j.annemergmed.2012.08.009
Source: PubMed

ABSTRACT STUDY OBJECTIVE: In 2005, England implemented a controversial target limiting patient stays in the emergency department (ED) to 4 hours. We determine the effect of the "4-hour target" on quality of care and resource use. METHODS: This was a retrospective study of 15 purposively sampled EDs in England, representing a range of performance on the target. The EDs provided administrative data on all visits for May and June, 2003 to 2006. These years spanned the period before the target until more than a year after full implementation. We assessed changes in admission rate, investigations, deaths in the ED, and return visits within 1 week for all patients and separately for those aged 65 years or older. Regression analyses adjusted for clustering at the hospital level and changes in acuity reflected by ambulance arrivals. Results are expressed as the estimated annual change in the percentage of patients experiencing the outcome, with 95% confidence intervals (CIs). RESULTS: A total of 772,525 ED visits were analyzed; visits increased 19% during the 4-year period. Between 2003 and 2006, the percentage of patients arriving by ambulance decreased from 27.8% to 25.8% (annual change from 2003 -0.80%; 95% CI for change: -1.48% to -0.12%). Visits by individuals aged 65 years or older were stable (19.9% to 19.1%; annual change -0.19%; 95% CI for change -0.44% to 0.06%). Between 2003 and 2006, admissions from the ED were unchanged, at 23% (95% CI for change -0.43% to 1.11%). The percentage of patients receiving blood tests increased from 13.8% to 19.8% (annual change 1.00%; 95% CI for change -0.09% to 2.08%). Frequency of radiologic studies decreased slightly, from 38.0% to 35.7% (annual change -0.60%; 95% CI -1.58% to 0.37%). Deaths in the ED and return ED visits within 1 week were unchanged. Return visits resulting in hospital admission increased initially and then returned to 2003 levels (annual change -3.10%; 95% CI -7.32% to 1.11%). CONCLUSION: England's 4-hour target did not appear to have a negative effect on quality or safety of ED care and had little effect on test use.

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    Journal of the Royal Society of Medicine 11/2014; 107(11):432-8. DOI:10.1177/0141076814542669 · 2.02 Impact Factor
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    ABSTRACT: Study objective In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. Methods We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. Results In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (–14 minutes [95% confidence interval {CI} –47 to 20]) but decreased after wave 2 (–87 [95% CI –108 to –66]) and wave 3 (–33 [95% CI –50 to –17]); median ED length of stay decreased after wave 1 (–18 [95% CI –24 to –12]), wave 2 (–23 [95% CI –27 to –19]), and wave 3 (–15 [95% CI –18 to –12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI –0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. Conclusion Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.
    BMC Health Services Research 11/2014; 64(5). DOI:10.1016/j.annemergmed.2014.06.007 · 1.66 Impact Factor
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    ABSTRACT: Emergency Department demand continues to rise in almost all high-income countries, including those with universal coverage and a strong primary care network. Many of these countries have been experimenting with innovative methods to stem demand for acute care, while at the same time providing much needed services that can prevent Emergency Department attendance and later hospital admissions. A large proportion of patients comprise of those with minor illnesses that could potentially be seen by a health care provider in a primary care setting. The increasing number of visits to Emergency Departments not only causes delay in urgent care provision but also increases the overall cost. In the UK, the National Health Service (NHS) has made a number of efforts to strengthen primary healthcare services to increase accessibility to healthcare as well as address patients¿ needs by introducing new urgent care services.In this review, we describe efforts that have been ongoing in the UK and France for over a decade as well as specific programs to target the rising needs of emergency care in both England and France. Like many such programs, there have been successes, failures and unintended consequences. Thus, the urgent care system of other high-income countries can learn from these experiments.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2014; 22(1):55. DOI:10.1186/s13049-014-0055-1 · 1.93 Impact Factor


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