Health policy/original research
Time Patients Spend in the Emergency Department: England's 4-Hour Rule—A Case of Hitting the Target but Missing the Point?

https://doi.org/10.1016/j.annemergmed.2011.08.017Get rights and content

Study objective

To address concerns about prolonged emergency department (ED) stays from crowding, England mandated that the maximum length of ED stay for 98% of patients be no greater than 4 hours. We evaluate the effect of the mandated ED care intervals in England.

Methods

This was a retrospective analysis of ED patient throughput before, during, and after implementation of the target. Fifteen acute hospital trusts' ED data were purposively sampled, including all patient visits during May and June of 2003 to 2006. We compared total time in ED and time to clinician across years, segregating for admitted versus discharged patients and young versus old patients, using a random-effects regression model and adjusting for hospital clustering.

Results

We analyzed 735,588 ED visits. The proportion of patients seen and treated within 4 hours improved from 83.9% to 96.3%. Adjusted total length of ED stay from 2003 to 2006 increased by 8.6 minutes for all patients and 30 minutes for admissions; time to physician improved by 1 minute for all patients. The proportion of patients leaving the ED during the last 20 minutes before 4 hours increased from 4.7% of all patients in 2003 to 8.4% in 2006. Admitted patients were more likely than discharged ones to leave the ED in the last 20 minutes, and the relative likelihood increased each year after 2003, with incidence rate ratio 1.04 (95% confidence interval [CI] 0.78 to 1.39), 1.39 (95% CI 1.05 to 1.82), and 1.55 (95% CI 1.19 to 2.20) for 2004, 2005, and 2006, respectively. An increasing proportion of elderly patients were in the last 20-minute departure interval each year compared with younger patients (in 2003 7.4% versus 4.1%; in 2006 17.3% versus 6.3%).

Conclusion

The introduction of a time target reduced the proportion of patients staying greater than 4 hours. More patients departed within 20 minutes of the target 4-hour interval after the mandate, notably, the elderly.

Introduction

In 2000, the National Health Service in England announced its intention to improve the quality of emergency department (ED) care by instituting a maximum length of ED stay of 4 hours.1 “By 2004 no-one should be waiting more than four hours in accident and emergency from arrival to admission, transfer or discharge. Average waiting times in accident and emergency will fall as a result to 75 minutes.”1 The “4-hour target” was meant to eliminate the problem of corridors lined with ill and injured patients waiting to be treated by a physician or be admitted to a hospital bed. Starting in 2004, the target was gradually implemented for an increasing proportion of patients, with the final threshold reached in January 2005. From that point on, 98% of all ED patients were to be treated and either discharged home or admitted to a ward within 4 hours. The leadership of the trust, not the ED, was considered ultimately responsible for meeting the target, and performance on the target was publicly reported. By 2008 to 2009, approximately 97% of patients left the ED within 4 hours, although the target was met at the 98% level in less than half of acute hospital trusts.2

The use of a specific time cutoff has been controversial, given that there was no empiric evidence for fixing the period at 4 hours. Whether a patient stays 2 hours or 3 hours and 59 minutes is equally rewarded, and once the patient “breaches,” their length of stay becomes irrelevant (to the target at least). This could result in some patients staying even longer than before, despite the clinical need to move to a bed. In 2004, Locker and Mason5 showed that after the introduction of the 4-hour target, a surprising proportion of patients appeared to leave the ED within or after the last 20 minutes before the cutoff. It is unknown whether United Kingdom hospitals have improved their processes over time to smooth this last-minute surge of activity.

Targets and performance measures are increasingly being used to ensure quality (and value for money), but they run the risk of unintended negative consequences such as gaming or cheating, effort substitution, or distortion of clinical priorities.6, 7, 8, 9, 10, 11, 12, 13, 14 The United Kindom was the first to set a throughput target for ED visits, but New Zealand and parts of Australia and Canada are trialing a similar target for their ED patients.15, 16, 17 ED crowding has long been recognized as a “crisis” in the United States, with documented adverse effects on the quality of care, yet no policies to address it have been forthcoming from the Centers for Medicare and Medicaid Services or The Joint Commission.18, 19, 20, 21, 22, 23, 24 However, in 2012 US hospitals will begin having to report on time patients spend in the ED, and pay for reporting will make this essentially mandatory from 2013 on.25, 26

We conducted an analysis of the change in distribution of time patients spend in the ED during the years before and after the target implementation. We focused on the effect the target has had on the time spent by the most vulnerable patients: the elderly and those admitted. We hypothesized that the target would have a disproportionate effect among patients with different levels of acuity.

Section snippets

Materials and Methods

The SAFETIME Study is a mixed-methods study of the effect that the imposed 4-hour target has had on hospital process, patient care, and staff attitudes in England. As part of this study, we conducted a retrospective analysis of routine data from ED visits in May and June for 2003 to 2006. The methods mirror those used in 2 related studies of the 4-hour target.5, 27 The years selected span the period from the introduction of the target to more than a year after its establishment at the 98%

Results

We analyzed 735,588 visits from 15 EDs (Table 1). Half of the visitors were men and approximately one fifth arrived at the ED by ambulance (Table 2). Of all ED visits, approximately one fifth of the patients were admitted to the hospital. Patient sex, age, and proportion arriving by ambulance were similar across the 4 years of the study.

The proportion of patients leaving the ED within 4 hours increased year to year from 83.9% to 96.3% between 2003 and 2006 (Table 2). Unadjusted median total

Limitations

This study is limited to 15 EDs in the United Kingdom. These were selected from an initial list of 35 acute hospital trusts that were known to have a range of performance against the target. The reduced number of EDs participating in this study highlights the difficulty that many acute hospital trusts have in supplying the volume of data we required for this analysis. However, because the trusts in the study represented a range of performance and type of hospital, we have no reason to suspect

Discussion

The existence of a time target in England focused attention on EDs and their patients. Many departments report receiving more resources to ensure meeting the target.3, 4 Traditional ways of working have been challenged and innovative strategies implemented.3 To achieve the target, acute National Health Service trusts were expected to adopt a whole-systems approach to improving their provision of emergency care. There is broad agreement from the specialty of emergency medicine that having a

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    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This study was supported by grants from the BUPA Foundation, the Society for Academic Emergency Medicine (US), and the College of Emergency Medicine (UK). The study funders had no role in study design; collection, analysis, interpretation of the data; the writing of the article; or decision to submit the article for publication. EJW and SM are members of the 2 professional societies that provided partial support for this study. They have no other affiliations with the funders.

    Please see page 342 for the Editor's Capsule Summary of this article.

    Supervising editor: Donald M. Yealy, MD

    Author contributions: All authors participated in revision of the article, had full access to all the data (including statistical reports and tables) in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. SM and TL conceived the study. SM designed the study and supervised cleaning of data and statistical analysis. EJW was responsible for data collection. EJW, JC, JF, and TL participated in data interpretation. JC cleaned and analyzed data. JF performed statistical analysis. SM and JF participated in drafting of the article. SM takes responsibility for the paper as a whole.

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    Publication date: Available online November 15, 2011.

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