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: 4.68). 10/2012; 60(6). DOI: 10.1016/j.annemergmed.2012.08.009
Source: PubMed


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.

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).

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%).

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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Available from: Ellen J Weber, Jan 01, 2015
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    • "To address these chronic problems in EDs, wait targets have been applied as a means to monitor, assess and, therefore, improve the overall experience and quality of care. The focus on targets has triggered controversy about their effectiveness [13-20]. Findings from a recent systematic review [21], suggest that the 4 hour ED wait target in the English NHS has failed to consistently improve clinical outcomes and cautions countries which have embarked upon similar schemes [22,23] to learn these lessons. "
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    ABSTRACT: Background In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues. Methods A qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes. Results The wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients. Conclusions The imposition of a wait-target in response to a perceived “crisis” of patients’ dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians’ experience and satisfaction.
    Full-text · Article · Jun 2014 · BMC Emergency Medicine
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    • "Patient related factors shown to be potential contributors include serum urea, creatinine, sodium, osmolarity, albumin, troponin and acute illness severity [1] [2] [3] [4] [5] [6] [7]. The establishment of an Acute Medical Admissions Unit (AMAU) is an example of a potential system factor contributing to outcomes, as is the setting of health care targets [8] [9]. We have previously shown that an increasing volume of patients cared for by a physician is associated with improved outcomes [10]. "
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    ABSTRACT: There are little data on the experiential learning of certified consultant specialists and outcomes in acute medicine. We have examined the 30-day in-hospital mortality and hospital length of stay (LOS) in relation to practice duration, using a database of emergency admissions. All emergency admissions (60,864 episodes in 35,168 patients) over eleven years (January 2002 to December 2012) were evaluated. Consultant staff were categorised by duration of clinical practice as <15years, 15-20years, >20≤25years and >25years. We used a stepwise logistic regression model to predict 30-day in-hospital death, adjusting risk estimates for major predictor variables. Marginal analysis used adjusted predictions to test for interactions of key predictors, while controlling for other variables. Thirty-day in-hospital mortality correlated with time in clinical practice; decreasing from 8.9% and 9.1% with <15 and 15-20years to 7.7% for each of the categories of >20≤25years and >25years. There was a progressive shortening of LOS with extent of clinical practice - from a median 5.0days (IQR 1.8, 10.3) for consultants within 15 years of registration to 4.6 (IQR 1.7-8.9; p<0.05) at >20≤25years and 4.4 (IQR 1.7-9.0; p<0.01) with >25years. Duration of clinical practice predicted mortality in the univariable analysis - odds ratio (OR) 0.85 (95% CI: 0.78, 0.91; p<0.001); when adjusted in a multivariable model, it remained independently predictive - OR 0.87 (95% CI: 0.79, 0.96; p<0.001) for 30-day in-hospital mortality. Certified specialists appear to continue with experiential learning with evidence of improved outcome after 20years in clinical practice.
    Full-text · Article · Jan 2014 · European Journal of Internal Medicine

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