Lessons from the 4-hour standard in England for Australia

Increasing demand for emergency care has worsened access to acute hospital services across the developed world. Australia’s response has been a mixture of time-based emergency department (ED) targets to drive process improvements, efforts to divert patients from EDs into community-based services and changes to accelerate hospital-wide processes and patient discharges. There has also been increased investment in bed capacity, although not commensurate with rising demand. Seasonal planning has been undertaken for both acute and sub-acute sectors. Despite these initiatives, access to acute hospital care has become measurably worse.1

The Australian Government has announced the introduction of a 4-hour rule that guarantees all emergency patients access to a hospital bed within 4 hours of arrival if clinically appropriate; the target will apply to critically ill patients (triage category 1) by January 2011, and to all patients by January 2015.2 Almost simultaneously, the United Kingdom Government has announced that it will replace England’s 4-hour standard with measures of patient outcome and safety,3 designed to deliver continuous improvements in standards in EDs. A look at the experience in England and why the decision has now been taken to move away from a time-based standard may reveal lessons for Australia about how to implement its new rule.

The 4-hour emergency access standard in England is different from the guarantee announced in Australia because it allows for fewer exceptions, requiring that all ED patients be admitted, transferred or discharged within 4 hours of arrival in the ED. It has been in place for nearly 10 years, with a 98% operational threshold since 2003 to allow for the small number of patients who need more than 4 hours of ED care. Despite some obvious attempts at gaming and data manipulation,4 it has genuinely reduced length of stay overall in EDs and won patients’ approval.5 Before the introduction of the standard, there was evidence of patients having long waits in EDs before being seen by a doctor and before being transferred to a ward. The causes of delays were variable between hospitals.6 Also as a direct consequence of the 4-hour standard, innovations7 to manage patient care more efficiently have been introduced, including new models of care (eg, clinical decision units to fast-track care of patients with minor injuries). However, initiatives to reduce ED attendances have had little success. In fact, they may have led to poor practice in some hospitals, such as premature discharge and transfer of patients from the ED, resulting in preventable deterioration and mortality.8

Investment in the UK National Health Service (NHS) has doubled in recent years,9 with increased hospital staffing and capacity, increased resourcing of EDs and increased investment in community social care.

The 4-hour standard has been the single major performance measure of the processes of the UK’s emergency care system. NHS organisations were strongly performance managed against this standard, with penalties for not achieving it. Hence, a lot of effort was expended to meet the target.

In most EDs, accurate data collection systems are now in place to track patients, but are not necessarily available throughout the rest of the patient journey. Research has shown a link between length of stay in the ED and various outcomes, but it is not known whether overall patient outcomes have improved or deteriorated as a result of the 4-hour target. The Mid Staffordshire Trust review10 found that an excessive focus on time-based targets caused a significant increase in patient mortality and a major outbreak of hospital-acquired infection. But an independent report from Harvard University found “no evidence for any of the dysfunctional effects”.11 A recent Nuffield Trust report5 suggested that the emphasis on time in EDs had resulted in increased referral of patients between agencies, but no real improvement in efficiency and possible decline in efficiency. The over-focus on time-based medicine may result in work dissatisfaction for staff and decreased training opportunities. Additionally, the patient contact time may be reduced or hurried, potentially decreasing both patient and doctor satisfaction.

The evolving approach in England aligns to the incoming UK coalition government’s commitment to freeing the NHS from what it sees as unnecessary micro-management through the imposition of process targets. Its more holistic approach is to hold the NHS to account for clinical outcomes and the quality of patients’ experiences, and to allow local decisions on processes and structure; results of a dashboard of clinical quality indicators will be published to encourage continuous improvement. Nevertheless, the UK Government recognises the clinical importance of timeliness of care and has said that it will include it in the dashboard of indicators.

The lesson for Australia is that although introduction of a rigid time-based target to empty EDs is seductively simple and potentially effective in solving a single problem, there are significant dangers. Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway. This requires a significant investment in information technology and highly developed monitoring of patient care processes and outcomes, including national registries for high-risk, high-cost patients and national audits of important standards of care.

Clinicians in both countries agree that best care combines optimal outcome, patient experience and timeliness, and involves looking at the whole emergency care pathway from the first call for help until return home.