An extensive study led by Professor Suzanne Mason of the University of Sheffield found that the Government´s controversial rule that no emergency patient should wait more than four hours from arrival to admission, transfer or discharge, has improved waiting times but may not be the best way to manage ED crowding or deliver high quality patient care.
The research entitled England´s Four Hour Rule – A Case of Hitting the Target but Missing the Point, examined waiting times from 2003 to 2006 when the target was fully introduced. The research showed that total length of patient stay actually increased and activity in the last 20 minutes of the four-hour window grew every year since the rule was introduced.
Professor Mason said: “The law of unintended consequences seems to be at work, even though the rule came out of a strong intention to improve patient care. We hoped that the target would have led to improved processes leading to shorter wait times in the ED without diminishing time for physician-patient interactions. But we did not observe this pattern.”
“Our results suggest that an absolute cut-off may not be the best way to manage ED crowding. However there was a marked improvement in the proportion of patients being seen and leaving within four hours in the EDs we looked at.”
Researchers analysed 735,588 visits in 15 EDs over a four year period. The proportion of patients leaving the ED within four hours increased from 83.9 per cent in 2003 to 96.3 per cent in 2006.
“Patients destined for hospital admission are the most challenging to manage within a stringent time frame,” said Professor Mason.
“The four hour rule seems to have shown less benefit for the elderly than for younger patients. The elderly are more vulnerable and would be likely to benefit more from early transfer to a hospital bed.”
Although the total average time in the ED fell initially from 119 minutes in 2003 to 107 minutes in 2004, by 2006 that number had risen again to 114 minutes. The percentage of patients leaving the ED in the last 20 minutes of the four hour window increased from 4.7 per cent to 8.4 per cent.
Compared to 2003, the elderly spent around 40 minutes less in the ED in 2004 and 2005, and 47 minutes less in 2006. However, the proportion of elderly patients who exceeded the four-hour window was 7.6 per cent which is much greater than the proportion of younger patients which was recorded at 2.9 per cent.
Set by the Department of Health in 2005, the target stated that 98 per cent of all ED patients must be seen, treated and leave the department (for home or an inpatient bed) within four hours. The target was set in response to lengthy waiting times, crowded waiting rooms and consequent compromised standards of care. However, after nearly six years in place, the Government abolished the target in April 2011 and it was replaced by quality measures.
Notes for Editors: This research was carried out by Professor Suzanne Mason, Joanne Coster and Dr Jennifer Freeman from the University of Sheffield´s School of Health and Related Research with Ellen Weber at the University of California, San Francisco and Dr Thomas Locker at the A&E Department at Barnsley Hospital Foundation NHS Trust.
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