Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, CanadaBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2983 (Published 01 June 2011) Cite this as: BMJ 2011;342:d2983
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Re: Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada
The 4 hour target and 24 hour, 365 day access to emergency departments (EDs) in the UK remains the most accessible medical service for patients. Until primary care target standards mirror the ED's immediate access, face to face contact with a medical or nurse practitioner, diagnosis and treatment within 4 hours, 24 hours /day, ED attendances will continue to rise. Inability to access medical /nursing care within these time frames leads worried and frustrated patients to continue attending EDs in ever increasing numbers.
Competing interests: No competing interests
Association between waiting times and short term mortality and hospital admission after departure from emergency department
I was interested to read Guttman et al's paper concerning the
association between prolonged lengths of stay (LOS) and poor outcomes in
the emergency department but feel that applying these findings to current
NHS working practices may be difficult. Emergency Department LOS greater
than six hours has tended to become less common in England following the
implementation of the previous 98% Government Standard and is likely to
reflect clinical acuity and access to specialist beds. Our experience does
not correlate with Goodman et al's relatively low number of attendances of
elderly patients and those with mental health problems or chest pain or
with the apparent inverse relationship between patients, who left without
being seen and the numbers of their previous attendances. Emergency
Departments caring for high numbers of patients in heavily populated urban
areas in England may not see a significant reduction in weekend
Our local experience suggests that prolonged LOS reflects hourly
attendances, patients presenting with high acuity illness and adequate
medical and nursing staffing and skill mix. Efficient coordination of the
clinical workload and access to senior decision-making promotes prompt
assessment and improved outcomes and our efficiency has improved
significantly with electronic access to pathology and radiology results
with a concomitant reduction in length of stay. Effective care pathways
facilitate timely and efficient transfer of patients to tertiary centres
or referral to on-site specialist teams. Finally, Emergency Departments
need to ensure efficient and effective use of Clinical Decision Unit beds
to facilitate expedient but safe discharge of patients requiring short-
Competing interests: No competing interests
We agree with Stephen Black that the 4 hour target was and is
achievable and this is supported by England National (Figure 1) and local
data sets. The assumption that the target of itself drove short length of
stays is misleading as this has been part of the drive to support improved
patient care for many years. It must be noted that delivering shorter
waiting times within the Emergency Department (ED) was initially driven by
public opinion, and reflected systems that regularly delivered waiting
times of longer that 12 hours and on occasion's days in the UK. Is Jones
suggesting this is acceptable? Further there is an increasing literature
showing longer ED waits are associated with increased mortality. Further,
it is well recognised that delays in medical diagnosis and treatment lead
to poorer patient outcomes.
Although the 98% target was due to be down-regulated to 95% in April 2011
it is clear from Figure 1 (which uses Statistical Process Control to
establish limits for expected variation in time series data) that this has
happened 6 months in advance of the change. This means that of the 6.8
million people attending Major ED in England over the 6 months from
October 2010 to March 2011, 220,000 are waiting longer than if the 98%
target had been achieved, compared to the actually achieved average in
The question is what impact this has had on the quality of care given the
evidence around long waits being related to mortality and patient
experience of acute care. An inevitable modelling consequence of down-regulation of the target with no change in systems will be increased
overcrowding within the ED. Unfortunately, clinical outcomes and
overcrowding have not been measured as part of the changes. There is an
urgency to review the 4 hour target and assess the impact of down-
regulation of the waiting times for patients in England.
McCarthy, M (2011) Overcrowding in emergency departments and adverse
outcomes. BMJ 342:d2830 doi:10.1136/bmj.com.d2830 (Published 1 June 2011)
Sprivulis PC, DaSilva JA, Jacobs, IG, Frazer, AR, Jelenik, GA. (2006)
the association between hospital overcrowding and mortality among patients
admitted via western Autralia emergency departments. Med J Aust 2006;
Wheeler, DJ (2003) Making Sense of Data: SPC for the Service Sector.
Knoxville, SPC Press Inc. ISBN 978-0-945320-61-6
Department of Health Performance Statistics for A&E
[accessed 13 June 2011]
Figure 1. Patients in England waiting less than 4 hours in Major A&E, with SPC limits, showing two points that lie outside of expected variation if the process had remained unchanged.
Competing interests: No competing interests
Rodney Jones makes several interesting but flawed observations in his
response. Two in particular sound plausible, are widely held but are
misleading and wrong. The first is that the 4hr target was never
achievable; and the second is that we build hospitals that are too small
(which he blames on PFI).
Both errors derive from a common flaw often made by analysts and
statisticians when looking at health systems: the assumption that
persistent problems must be caused by factors outside the control of the
highly motivated and dedicated workforce.
So we assume that beds are highly occupied because the
(uncontrollable) demand for their use exceeds the design capacity of the
ward or hospital. Several sources of evidence suggest that this is a
naive, incorrect and dangerous error.
Clinical audits of patients in NHS beds often suggest that as many as
half of them don't need to be in a bed (either they are fit to go or only
need a level of care that would be easy to provide elsewhere). So we waste
bed capacity through a failure to coordinate discharges and follow up
Analysis of the timing of arrivals and discharges from beds
(information which remarkably few NHS hospitals collect,use or analyse)
suggests another perspective: hospitals perversely waste bed capacity by
failures of coordination. Controllable arrivals of elective patients take
place early in the morning, most discharges late in the afternoon. The
peak of emergency arrivals often occurs in the morning, leading to peak
need for beds around lunchtime when a large number of beds are still
occupied by fit-to-go-home patients whose discharge round isn't due until
the late afternoon. This pattern minimizes the number of free beds at the
time of day when the need for them is highest. This can easily lead to bed
occupancy being 20% higher than it needs to be just when free beds are
most required. It is not even that hard to change (the same consultants
doing afternoon discharges in the NHS have often done an early morning
discharge in their private practice where there is a significant financial
penalty for wasting capacity).
The bottom line is that hospitals waste large parts of their capacity
through a failure to design or impose management practices that would use
it well. Inpatient capacity is high because of operational and management
failures, not because we don't build enough capacity.
This implies that the cost of PFI schemes is irrelevant. In any case
it isn't the cost that is their worst feature but their inflexibility.
A similar observation applies to the 4hr target in A&E. Modellers and
analysts who look at the aggregate behaviour and performance tend to
assume that the randomness and uncontrollability of demand drives
performance. But even a group of highly skilled and motivated staff won't
do a good job if they are poorly coordinated. The best seem able to treat
most patients in times much less than 2hr never mind 4. Patients who need
a bed can and should be admitted quickly (of course this means the
hospital has to be well enough organised to have free beds at the right
time). Observations of real departments show that the reasons for slow
treatment are mostly organisational not external (and many of these habits
derive from the belief that speed is unimportant for all but the most
Before we start building bigger hospitals we should make sure we have
fixed the failures of coordination and organisation in our existing units.
Competing interests: Has worked as consultant to several health organisations on the performance of A&E departments and the 4hr target.
Too much fine tuning has been attempted in ER design and trying to
handle increased patient flow through emergency rooms. This study points
out clearly that if hospitals are built with emergency room capability
then the health care system has to build in the capacity to handle
multicasualty numbers whether they be from an actual disaster or routine
injury and illness patient flow.
Having said this, the best spent dollar in health care is a dollar spent
on prevention. This study suggests that without a dedicated prevention arm
built into a health care system the study numbers will persist and
possibly worsen based on the the health trajectory of North American
society. This study serves as an alert to administrators and providers
that society has to be retooled to be more physically active and eat a
healthier diet or emergency rooms will be overwhelmed.
Competing interests: No competing interests
The excellent editorial (1) and article on the adverse effects of a
long stay in the emergency department (2) point to more fundamental
problems within health care policy and the planning methodologies
supporting such policies.
The suggestion that abandoning the 4 hour target may not be desirable
(2) requires a deeper understanding of how this particular policy was
implemented in the UK. In hindsight, for patients who required an
admission via A&E, it is now almost certain that the 4 hour A&E target was
never achievable given the very high inpatient occupancy in UK hospitals
(3,4). For this group of patients the target was 'achieved' by creating
over one million zero (or same) day stay emergency 'admissions' (5-8),
which was probably an abuse of the NHS Data Definitions (9) and led to
serious flaws in the tariff for A&E and short stay emergency 'admissions'
(8,10-12). This consequently distorted the financial flows across the
Due to the prohibitively high cost of the private finance initiative
(PFI) the unacceptably high inpatient occupancy in UK hospitals partly
arose from a policy to build smaller hospitals which cannot be supported
by the trends in occupied bed days (13). It has been argued that the
existing models for sizing hospitals are deeply flawed (14-16) and open to
manipulation to give whatever answer is deemed to be 'acceptable'. To
correct this deficiency an alternative model based on bed days per death
has been proposed. This is based on the fact that use of acute beds is
highest in the last year of life, irrespective of the age at death (17-
In terms of planning for the size of the emergency department and the
inpatient bed pool it has also been noted that the very long term trends
in emergency medical admissions and A&E attendance follow a cyclic pattern
which repeats at a three to eight year interval, around 6 years being the
most common (19-24). This pattern has many similarities to one which would
arise from a repeating infectious outbreak (25) and appears to co-incide
with a cycle in the costs associated with healthcare (26-29). This cycle
is international in nature, effects both admissions, length of stay and
total occupied bed days and is gender and diagnosis specific. Irrespective
of the cause of such an international phenomena our models of the way in
which health care demand is 'supposed' to work are seriously flawed and
this in turn will lead to a further cycle of flawed policy.
With regard to future policy, while the above may seem to be an
argument to build bigger acute facilities, it would seem that the only
places in the UK where the number of bed days per death is vastly lower
than the norm (up to 33% lower) occurs in Torbay (an integrated health and
social care Trust) and the Isle of Wight (an integrated acute and primary
care Trust). Hence it has been argued that integration rather than
competition is the way to avert the cost pressures arising from the higher
numbers of deaths which are due to occur from 2012 onward as the World War
II baby boomers near the end of their life (30).
Flawed health care policy only leads to flawed implementation, flawed
targets and often deflects attention away from the real causes of the
problem and its necessary solutions.
1. McCarthy M (2011) Overcrowding in emergency departments and
adverse outcomes. BMJ 342:d2830 doi: 10.1136/bmj.d2830 (Published 1 June
2. Guttmann A, Schull M, Vermeulen M, Stukel T (2011) Association
between waiting times and short term mortality and hospital admission
after departure from emergency department: population based cohort study
from Ontario, Canada. BMJ 342:d2983 doi: 10.1136/bmj.d2983 (Published 1
3. Jones R (2011) A&E performance and inpatient bed occupancy.
British Journal of Healthcare Management 17(6): 256-257.
4. Jones R. (2011) Hospital bed occupancy demystified and why
hospitals of different size and complexity must operate at different
average occupancy. British Journal of Healthcare Management 17(6): 242-
5. Jones R (2006) Zero day stay emergency admissions in Thames
Valley. Healthcare Analysis & Forecasting, Camberley.
6. Jones R (2009) Trends in emergency admissions. British Journal of
Healthcare Management 15(4): 188-196.
7. Jones R (2009) Length of stay efficiency. British Journal of
Healthcare Management 15(11): 563-564.
8. Jones R (2011) Impact of the A&E targets in England. British
Journal of Healthcare Management 17(1): 16-22.
9. Jones R (2007) Equilibrium. Healthcare Analysis & Forecasting,
10. Jones R (2010) Emergency assessment tariff: lessons learned.
British Journal of Healthcare Management 16(12): 574-583.
11. Jones R (2010) High efficiency or unfair financial gain? British
Journal of Healthcare Management 16(12): 585-586.
12. Jones R (2011) Costs of paediatric assessment British Journal of
Healthcare Management 17(2): 57-63.
13. Jones R (2009) Building smaller hospitals. British Journal of
Healthcare Management 15(10): 511-512.
14. Jones R (2001) New approaches to bed utilisation - making queuing
theory practical. Presented at 'New Techniques for Health and Social
Care'. Harrogate Management Centre Conference 27th Sep, 2001.
15. Jones R (2003) Bed management - Tools to aid the correct
allocation of hospital beds. Presented at ' Re-thinking bed management -
opportunities and challenges'. Harrogate Management Centre Conference,
27th January, 2003.
16. Jones R (2010) Myths of ideal hospital size. Medical Journal of
Australia 193(5): 298-300.
17. Jones R (2011) Does hospital bed demand depend more on death than
demography? British Journal of Healthcare Management 17(5): 190-197.
18. Jones R (2011) Bed days per death: a new performance measure.
British Journal of Healthcare Management 17(5): 213
19. Jones R (2009) Cycles in emergency admissions. British Journal of
Healthcare Management 15(5): 239-246.
20. Jones R (2009) Emergency admissions and hospital beds. British
Journal of Healthcare Management 15(6): 289-296.
21. Jones R (2010) Emergency preparedness. British Journal of
Healthcare Management 16 (2): 94-95.
22. Jones R (2010) Forecasting demand. British Journal of Healthcare
Management 16(8): 392-393.
23. Jones R (2010) Forecasting emergency department attendances.
British Journal of Healthcare Management 16(10): 495-496.
24. Jones R (2011) Unanswered questions from the trends in
international bed occupancy. British Journal of Healthcare Management
17(7): in press
25. Jones R (2010) The case for recurring outbreaks of a new type of
infectious disease across all parts of the United Kingdom. Medical
Hypotheses 75(5): 452-457.
26. Jones R (2010) Nature of health care costs and financial risk in
commissioning. British Journal of Healthcare Management 16(9): 424-430.
27. Jones R (2010) Nature of health care costs and the HRG tariff.
British Journal of Healthcare Management 16(9): 451-452.
28. Jones R (2011) Cycles in inpatient waiting time. British Journal
of Healthcare Management 17(2): 80-81.
29. Jones R (2010) Trends in programme budget expenditure. BJHCM
30. Jones R (2011) Factors influencing demand for hospital beds in
English Primary Care Organisations. Journal of Integrated Care (submitted)
Competing interests: The author provides consultancy services to health care organisations.