Volume 194 - Issue 11
Lessons from the 4-hour standard in England for Australia
Author: Shyan L Goh
Med J Aust 2011; 194 (11): 615. || doi: 10.5694/j.1326-5377.2011.tb03125.x
Published online: 6 June 2011
Published online: 6 June 2011
To the Editor: I refer to the article by Cameron and Cooke,1 and the letter from Forero and colleagues.2
Cameron and Cooke correctly identified key problems associated with using a time-based process standard as a solution to poor patient outcome linked to overcrowding in emergency departments (EDs). They highlighted the need for monitoring to ensure “patient safety and quality of care are not compromised at any stage of the emergency pathway”. Forero et al challenged their assertion that the United Kingdom has replaced the 4-hour rule, and suggested there are three new time-based measures used as indicators of performance.
Unfortunately, Forero et al have not noted the critical difference in new UK policies, in which no specific time cut-off is used as the benchmark for good performance.3 While acknowledging the importance of timeliness of care, “clinical outcomes and the experience of the patient” will be the focus of emergency care in the UK under the new Department of Health initiative effective April 2011.4 Surely Andrew Lansley’s (UK Secretary of State for Health) statement that “the four hour standard should be abolished”5 must mean nothing else but complete abandonment of this standard!.
Concerns regarding a time-based performance indicator (and funding) were previously illustrated by Nocera in this Journal, who showed that numerical key performance has been a primary motivation for data fraud in Victoria and New South Wales, relating to ED waiting time.5 Furthermore, there is a possibility of admitting an unprepared patient to a ward at 4 hours,6 without acceptance of care by specialist team. A patient not properly worked up and sent to ward will not have the same automatic privileged access to critical care staff ratios or fast-tracked requests for pathology or radiology investigation provided in the ED. This can contribute to the excessive length of stay and, indirectly, hospital bed block.
I caution against overly enthusiastic support for the 4-hour rule being instituted in Australian hospitals as a panacea to access block in the ED, and stress the need for better discharge planning, experienced patient flow and bed management, and improved hospital staff rostering for after hours. The latter include rethinking of ED doctors’ 24-hour staffing, with ED specialists attending to patients primarily,7 and junior doctors as assistants (if a 4-hour standard is to be attained), especially when facing an imminent glut of junior doctors, who will require close supervision, rotating through the ED.8
References
- Cameron PA, Cooke MW. Lessons from the 4-hour standard in England for Australia [editorial]. Med J Aust 2011; 194: 4-5. 0_CBBHIHGJ
- Forero R, McDonnell GD, McCarthry SM et al. Lessons from the 4-hour standard in England for Australia [letter]. Med J Aust 2011; 194: 268. 0_CBBDJFIE
- United Kingdom Department of Health Urgent and Emergency Care. A&E clinical quality indicators. Data definitions. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122892.pdf (accessed Feb 2011).
- Lansley A, Secretary of State for Health, United Kingdom. [Letter to John Heyworth, President of the College of Emergency Medicine.] 2010; 21 Jun. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116917.pdf (accessed Nov 2010).
- Nocera A. Performance-based hospital funding: a reform tool or an incentive for fraud? Med J Aust 2010; 192: 222-224. 0_i1095862
- Hughes G. Four hour target for EDs: the UK experience. Emerg Med Australas 2010; 22: 368-373. 0_i1095864
- FitzGerald G, Ashby R. National health and hospital network for Australia’s future: implications for emergency medicine. Emerg Med Australas 2010; 22: 384-390. 0_CBBBFDCA
- Weiland TJ, Mackinlay C, Jelinek GA. The Emergency Medicine Capacity Assessment Study: anticipated impact of a major increase in intern numbers in Australian ED. Emerg Med Australas 2010; 22: 136-144. 0_CBBGFECG