Published 17 July 2008, doi:10.1136/bmj.a195
Cite this as: BMJ 2008;337:a195

Views & Reviews

The good, the bad, and the four hour target

The NHS’s four hour target for being treated in accident and emergency departments has dramatically changed the way unscheduled care services are run. It aims to improve the "patient journey" by emphasising the length of time it takes for a patient to be seen, assessed, treated, and "disposed of" by the emergency department. However, the effects of this target driven system have wide reaching implications throughout the hospital. I believe that ascribing too much importance to the four hour rule may, instead of benefiting patients, as is intended, actually harm them and thus contradicts the first ethical principle of medicine.

Hippocrates described the four ethical principles of medical practice in about 400 bc, a sort of "moral compass" for doctors even today. The first and most important of these is non-maleficence: "above all else, do no harm." One would be hard pushed to find a clinician, even in 2008, who would disagree with such noble logic. Unfortunately, we are in danger of unwittingly failing our patients and the profession if we allow the four hour rule to become the sole determining rule in running acute care services.

Consider the critically ill patient. Every day there are cases where the quality of care is being adversely affected by the over-emphasis on the importance to the "patient experience" of treatment time. The septic, hypotensive patient with obtunded consciousness needs resuscitation. This includes fast and accurate assessment of their clinical condition, oxygen, venous access, fluid resuscitation, and antibiotic treatment. Although all this can, in many cases, be achieved within four hours, this does not mean that there are no exceptions.

Assessments are often far from clear cut, and appropriate investigations need to be carried out to confirm or refute diagnoses. Patients can be peripherally shut down, and gaining venous access can be a challenge. Furthermore, there is little point in initiating treatment if you cannot assess the response; the shocked patient who fails to respond to a fluid challenge may not be in septic shock; the breathless patient who does not improve with an intravenous diuretic may not be have acute pulmonary oedema, and the decreased level of consciousness in the drunk person whose score on the Glasgow coma scale doesn’t rise as he sobers up may have an alternative cause.

The response to treatment is crucial to making informed decisions about the longer term treatment plan for the patient. Patients with sepsis who quickly stabilise with initial resuscitation measures can probably be managed in a general ward environment, provided that the unit has enough available staff to continue their care. Patients who do not stabilise are often better managed in an environment such as a high dependency unit or intensive care unit.

The important point we seem to be missing is that it can take a considerable amount of time to carry out all of the necessary measures safely. Although patients with a sprained ankle will, understandably, become irate if it takes more than four hours for their treatment to be completed, the critically ill patient tends not to be the clock watching type. Patients who are undeniably sick need to be attended to promptly, often as soon as they arrive in hospital, but we should be less concerned when they "breach."

Targets can improve the quality of care of most patients attending hospital, but it is essential that we recognise the exceptions to the rule. Setting achievable and realistic targets provides scope for those patients who need to be in the emergency department for longer than four hours. However, it is irresponsible to decrease the size of this buffer zone further when the previous target is met successfully. Fining emergency departments for not meeting these dynamic targets depletes their resources, and thus care of patients suffers.

Furthermore, medical and surgical receiving units must be able to cope with the additional strains placed on them as a direct result of the four hour target. Some trusts have implemented changes that do improve care—for example, improving "downstream services" (such as medical and surgical receiving units). Unfortunately this is not the situation in other hospitals.

Computer screens in emergency departments that display patients’ waiting times should empower staff. However, if the data from these systems are used to pressure staff into working faster, quality of care and staff morale can suffer. By undermining colleagues we create an unpleasant working environment and make it more likely that systems of hazard prevention will fail.

The four hour target may therefore be incongruent with the philosophy behind the recent patient safety movement. Patients who are transferred out of the emergency department too early or who are admitted to an inappropriate area are at risk of experiencing severe adverse events. Put simply, they may die from eminently treatable conditions.

In 2008 we have bags of broad spectrum antibiotics, copious volumes of colloids and crystalloids, and various vasoactive drugs. Yet we must remember what Hippocrates told us more than 2000 years ago: above all else, do no harm. By paying a little more attention to our moral compasses and less to our watches we might actually get close to achieving the second ethical principle: beneficence.

Cite this as: BMJ 2008;337:a195

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