Impact of target led care in UK emergency departments
The UK four-hour standard for the processing of all patients
attending type I emergency departments has been in place since 2004.
Initially the target was set at 90% of all patients being seen and treated
within the four-hour window and over a period of 2 years this increased to
98%. Performance across all acute trusts in England has improved such that
the majority report hitting the target each quarter, with those that fail
doing so by a few percentage points. We have previously shown that the
effect of the target is not uniform and those who are admitted to hospital
from the ED are being affected the most by a ‘spike’ in activity during
the last 20 minutes before four hours which affected 12.3% of admitted
patients and 3.6% of discharged patients in 2004 1.
We sought to find out whether this ‘spike’ was still occurring nationally.
We analysed 12.2 million new patient episodes at English emergency
departments from HES data for 2008/9. The figure shows that the ‘spike’ in
activity is still present and much larger than in 2004, with 30.7% of
patients who are admitted to hospital leaving the ED in the 20 minutes
before the four hour target is breached, and 10.5% of those patient who
are discharged (see figure 1).
Whilst many in the specialty of Emergency Medicine support the benefits
that the four hour target has produced, it is clear that they are not
being experienced by all patients, and that processes throughout the
hospital and wider healthcare system may not have improved to accommodate
it. If acute trusts are experiencing such apparently severe difficulties
in achieving this target, then perhaps a different approach such as the
one announced by the new government of a reduction to 95% combined with
phasing this out altogether and introducing other factors which measure
quality are more appropriate. However, good evidence based indicators of
quality in emergency medicine need development2. To date, we have no
evidence that the 98% four-hour target benefits patient care, and indeed
our findings would suggest that it has encouraged target-led care rather
than needs-led care.
Figure 1: Distribution of patient time in the emergency department by
admitted and discharged in 2008/9
1. Locker T, Mason S. Analysis of the distribution of time that
patients spend in Emergency Departments. British Medical Journal,
2005;330:1188 – 1189
Competing interests: No competing interests