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Emergency delays need urgent attention

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6975.283 (Published 04 February 1995) Cite this as: BMJ 1995;310:283

Nearly one in five patients needing emergency treatment in British hospitals experience a delay in admission, says a report from the Clinical Standards Advisory Group published last week. In just over 40% of cases the delay was due to a lack of beds, but in one in six cases it was due to no doctors being available. In some hospitals only a third of patients seen as emergencies were admitted to a bed within four hours. The worst delays were seen in the four Thames health regions and the three regions bordering Greater London.

The Clinical Standards Advisory Group, an independent expert body set up to advise the government on standards of clinical care, found that hospitals that admitted most of their emergency patients within two hours had a lower mortality at 28 days.

The group carried out a study looking at urgent and emergency admissions to 38 hospitals picked at random from a stratified, representative sample of district health authorities. Teams of doctors and nurses spent a week in accident and emergency departments and admitting wards monitoring patients from their arrival to the start of definitive management. The group looked at nearly 8000 admissions. Nearly 60% of emergency patients were seen by a doctor within 30 minutes, but the time taken to see patients varied twofold between the slowest and fastest hospitals. Most often the delay was due to doctors seeing other patients—delays were most common for patients referred by general practitioners as opposed to those arriving as emergencies by ambulance. The report suggests that such delays may be due to poor organisation of on take teams, with doctors in theatre or outpatient clinics.

The start of initial treatment, such as the administration of nebulisers for patients with acute asthma, was delayed in nearly one in 10 patients. Delay, which was defined as a wait of over one hour, was more common in patients with orthopaedic problems (13%) than in sick children (5%). The main reason in nearly half the cases was that no doctor was available.

The group makes over 30 recommendations for improvements. It notes that many accident and emergency departments are too small and that there are shortages of consultants and senior staff in these departments.

Nearly half of all admissions to hospital are urgent. The report accuses the NHS reforms of creating inequalities of funding whereby money is spent on elective procedures at the expense of emergency admissions. It says, “A more satisfactory balance in the funding formula should be struck so that hospitals are rewarded rather than penalised for treating urgent and emergency patients.” It recommends that contracts should take into account the activity and quality of emergency services and that hospital managers must give these services the necessary priority.

The report is adamant that national guidelines for emergency services must be incorporated into local protocols and contracts. They should include time standards: more than 80% of patients should be seen by a doctor within one hour or more than 90% should be admitted within four hours. They should also incorporate issues of availability, and quality of treatment.

The Department of Health said that its new patient's charter advisespatients admitted as emergencies that they can expect a bed “as soon as possible and certainly within three to four hours.”—LUISA DILLNER, BMJ

Figure1

The time taken to see patients varies twofold

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