Emergency Medicine—Quality Indicators: the
United Kingdom Perspective
John Heyworth, FRCS, FCEM, FIFEM
During the 1990s, relentlessly increasing emergency department (ED) attendances in the United King-
dom led to major dysfunction and ED overcrowding. The situation was exacerbated by outdated ED
design, inadequate ED capacity, traditional ED processes, a predominantly junior doctor–based work-
force, and insufficient in-hospital beds for patients requiring admission.
The crisis led to high-profile lobbying by the U.K. emergency medicine body (British Association for
Emergency Medicine) and in the populist media. This led to the Reforming Emergency Care initiative
and the 4-hour target.
This article describes the benefits and disadvantages associated with a single time-related measure of
ED performance. The article also describes the subsequent development of a raft of quality indicators
designed to provide a greater breadth of ED measurement, reflecting timeliness, quality, and safety. The
intention is for these indicators to act as levers for change and to generate a program of continuing
improvement in emergency care.
The indicators were introduced in England in April 2011, and currently there is a period of bedding-in
and collective learning. The quality indicators will be reviewed and refined as required, with any amend-
ments introduced in April 2012.
ACADEMIC EMERGENCY MEDICINE 2011;
18:1239–1241 ª 2011 by the Society for Academic
improvements in the ED workforce, development of
hospital-wide processes, and in-hospital bed capacity.
As a result, EDs became the pinch point in the system,
and overcrowding became a major issue with waits for
uring the later years of the last millennium,
emergency departments (EDs) in the United
Kingdom saw a steady increase in patient
hospital admission of up to 72 hours. Photographs of
elderly patients ‘‘warehoused’’ in EDs appeared in the
media, and there was a political recognition that action
was required. As a result, the Reforming Emergency
Care initiative occurred in the early 2000s, which gener-
ated a major focus on system-wide emergency care, ED
workforce, and physical plant and recognized the need
for a time-related incentive—the 4-hour target.
This stipulated that all patients attending the ED
should be admitted, transferred, or discharged within
4 hours. A 2% buffer of ‘‘clinical exceptions’’ allowed
those patients who might deteriorate unexpectedly, or
other legitimate clinical factors, to be accommodated
within the overall measures. During the initial few -
years, the target appeared to be highly successful and
many benefits accrued, including improvements in the
ED workforce, recognition of the need for better pro-
cesses, and some improvement in hospital capacity.
Unfortunately, these changes were not universally ade-
quate to address an ever-increasing emergency care
demand, and from 2006 many EDs were struggling to
meet the target on a sustained basis. There was
immense pressure on hospital managers to comply with
the target, often it seemed at almost any cost. This led
to pressures on managers and clinicians to achieve the
target. In turn, this led to distortion of clinical care,
gaming, and manipulation of data, all products of an
unhealthy target culture.
ª 2011 by the Society for Academic Emergency Medicine
PII ISSN 1069-6563583
From The College of Emergency Medicine, London, England.
Received August 15, 2011; accepted August 16, 2011.
This manuscript is a component of the 2011 Academic Emer-
gency Medicine Consensus Conference entitled ‘‘Interventions
to Assure Quality in the Crowded Emergency Department (ED)’’
held in Boston, MA.
Funding for this conference was made possible (in part) by
1R13HS020139-01 from the Agency for Healthcare Research
and Quality (AHRQ). The views expressed in written conference
materials or publications and by speakers and moderators do
not necessarily reflect the official policies of the Department of
Health and Human Services, nor does mention of trade names,
commercial practices, or organizations imply endorsement by
the U.S. Government. This issue of Academic Emergency
Medicine is funded by the Robert Wood Johnson Foundation.
The authors have no potential conflicts of interest to disclose.
Supervising Editor: James Miner, MD.
Address for correspondence and reprints: John Heyworth,
FRCS, FCEM, FIFEM; e-mail: firstname.lastname@example.org.
During 2010, a new administration was elected in the
United Kingdom and the new Secretary of State for
Health was receptive to the concerns expressed by the
College of Emergency Medicine and others regarding
the dysfunctional state resulting from the use of a sin-
gle time measure, particularly as this was an inadequate
way of recognizing issues of quality and safety. There
were some high-profile examples in the United King-
dom of major safety compromise resulting from the tar-
get culture. The initial response from the coalition
government was to abandon the target. There were
great concerns, however, that the abolition of the target
would result in immediate dilution of focus on emer-
gency care, which would compromise the entire system
and patient care.
As a result of these concerns, the College of Emer-
gency Medicine, Royal College of Nursing, and the
Department of Health worked closely together to
develop a new set of quality indicators designed to
reflect timeliness, quality, and safety. These measures
were designed as a group of 8, in theory of equal
importance, designed to ensure focus across the range
of ED activity. Details of the indicators and the rationale
behind them are available from the Department of
Health website (http://www.dh.gov.uk/publications) and
a guide to implementation at the College of Emergency
Medicine website (http://www.collemergencymed.ac.uk).
In summary, the indicator groups are:
patients, carers, and staff.1
Left ED without being seen—this reflects the satis-
faction of patients with the initial care provided in
the ED. The rate should be minimal, and best prac-
tice would be below 5%. This is a group of
patients potentially at high risk of subsequent
Unplanned reattendances—this is another known
high-risk group. Good practice is for a reattending
patient to be seen by a different and more senior
clinician. Rates above 5% are likely to reflect poor
quality, but rates below 1% may reflect excessive
Time to initial assessment—this must be meaning-
ful and therefore should include a pain score and
vital signs to derive a physiological early warning
score. The aim is for this assessment to occur
within 15 minutes of the patient’s arrival. In the
first instance, this will be in patients transported
to the ED by ambulance—a surrogate measure for
potential severity of the presentation.
Time to treatment2—expert
suggests patients should be seen by a decision
maker within 60 minutes of arrival, with more
prompt assessment for time-critical presentations,
for example, sepsis, stroke, and myocardial infarc-
tion. A median above 60 minutes from arrival to
Total time in the ED3,4—excessive total time in the
ED is linked to poor outcomes. A 95th percentile
wait above 4 hours for admitted patients and
nonadmitted patients is not good practice. The
indicator also suggests that the single longest wait
should be no more than 6 hours.
Consultant sign-off—at present much emergency
care in the United Kingdom is delivered by rela-
tively junior, although excellent, doctors who are
inevitably inexperienced, particularly with regard
to the challenging ED case mix. The aim is to
increase the number of patients who are reviewed
in person by the ED consultant. The aim of this is
twofold: to improve quality of care for high-risk
conditions and to drive the agenda for increasing
emergency medicine consultant numbers. In the
first instance, three exemplar conditions have
been selected for consultant sign-off—adults with
nontraumatic chest pain, febrile children less than
1 year old, and unplanned returns.
Ambulatory care—practice in conditions suitable
for ambulatory care varies widely. Two exemplar
conditions, cellulitis and deep vein thrombosis
(DVT), have been selected, as these are, in the
most part, better managed on an outpatient basis
workup in the ED. Evidence suggests that 60% to
90% of cellulitis cases and over 90% of DVT
patients may be managed on an ambulatory basis.
It is intended that the suite of indicators should act as
a group to provide a comprehensive set of balanced
However, to provide focus and engagement, five indica-
tors were initially identified as representing potential
triggers for intervention according to the performance
management program of the National Health Service.
1. Unplanned reattendances—greater than 5%.
2. Total time in the ED—95th percentile wait above
3. Left without being seen—a rate at or above 5%.
4. Time to initial assessment—95th percentile time to
assessment above 15 minutes.
5. Time to treatment—a median above 60 minutes
from arrival to seeing a decision-making clinician
across all patients.
The spirit and intent is that these should function as
indicators—not targets—to allow individual organiza-
tions to measure their current performance, establish
the reasons for underachieving, and identify the mea-
sures required to improve followed by implementation
of the new strategies.
Perhaps inevitably, the early experience of the new
quality indicators as they have bedded in is that a target
culture has rapidly emerged. In the worst-case scenar-
ios, this has represented a multiple of the adverse
issues surrounding the single 4-hour target, and clearly
this is distant from the intention of these new quality
Unfortunately, the political imperative resulted in the
opportunity to undertake proper piloting and evalua-
tion. We all are therefore in a collective piloting exer-
cise, and it is inevitable that this should be a somewhat
bumpy ride during the first few months.
Heyworth•QUALITY INDICATORS: THE U.K. PERSPECTIVE
There is a very definite balance that should be struck
between soft indicators, which may not generate focus
and improvement, against a target culture, which
results in distortion and dysfunction. The indicators
must have teeth to be effective as edentulous indicators
are impotent. However, a balance must be struck
between the two tensions to ensure that patient care is
optimized as intended.
The College of Emergency Medicine is confident that
these new quality indicators will result in significant
improvements in patient care and is working with the
Department of Health and other organizations respon-
sible for monitoring and regulation to ensure that the
correct balance is achieved. The current quality indica-
tors will be subject to detailed review and refinement
with amendments as required in the second iteration
due in April 2012.
In addition, it is important to note that there is a
statement within the new indicators (although not for-
mally performance managed as yet) that no patient
should be in the ED for more than 6 hours. The signifi-
cance of this applies to particular subsets of patients, in
particular those requiring admission to intensive care
and mental health patients. The College believes that
this will provide a major drive to better systemwide
processes and capacity planning, although clearly much
work is required in this area.
The quality indicators are an important step in provid-
ing focus on care in the ED and prioritizing this on the
clinical and managerial agenda. However, they must be
regarded as indicators for improvement and levers to
drive change, not sticks with which to beat clinicians.
Careful ongoing evaluation is essential to ensure the
maximum benefit from these changes.
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2. Cooke M, Fisher JD, Dale J, et al. Reducing Atten-
dances and Waits in Emergency Departments: A
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Programme. Available at: http://www.sdo.nihr.ac.
uk/files/project/29-final-report.pdf. Accessed Sep 21,
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ACADEMIC EMERGENCY MEDICINE•December 2011, Vol. 18, No. 12•www.aemj.org