The impact of the 4 h target on patient care and outcomes in the Emergency Department: an analysis of hospital incidence data

Freeman, Jenny; Croft, Susan; Cross, Susan; Yap, Chris; Mason, Suzanne

doi:10.1136/emj.2009.085431

Cited by 29 publications

(41 citation statements)

References 23 publications

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“…Concerns have been expressed about the potential adverse effects of this target but research evidence does not support the potential for it to increase short-stay emergency admissions; in fact it decreased short-stay admissions. 55 Improving access to primary care?…”

Section: Four-hour Targetmentioning

confidence: 99%

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

O’Cathain

Knowles

Turner

et al. 2014

Health Services and Delivery Research

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BackgroundRecent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.ObjectiveWe aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.MethodsThe design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.ResultsThe 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.ConclusionsDeprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.FundingThe National Institute for Health Research Health Service and Research Delivery programme.

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Section: Four-hour Targetmentioning

confidence: 99%

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

O’Cathain

Knowles

Turner

et al. 2014

Health Services and Delivery Research

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“…Although there is evidence of some reduction of the time to first being seen by a treating clinician, the proportion of hospital where the median time to review was \1 h, remained unchanged at 57 % between 2000 and 2007 (interquartile range 43-70 %) [21]. Two studies report minor falls in ED presentations within 7 days [22,23]. Studies exploring attitudes and beliefs about the 4 h rule find that while many staff and patients were positive about the resulting service reconfigurations, concerns were expressed about the pressure that the rule placed on doctors and nursing staff, and that quality was compromised by time considerations taking priority over other aspects of care and fragmentation of care for certain subgroups of patients [21,24,25].…”

Section: Introductionmentioning

confidence: 99%

Overcrowding in emergency department: an international issue

Somma

Paladino

Vaughan³

et al. 2014

Intern Emerg Med

334

235

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Overcrowding in the emergency department (ED) has become an increasingly significant worldwide public health problem in the last decade. It is a consequence of simultaneous increasing demand for health care and a deficit in available hospital beds and ED beds, as for example it occurs in mass casualty incidents, but also in other conditions causing a shortage of hospital beds. In Italy in the last 12-15 years, there has been a huge increase in the activity of the ED, and several possible interventions, with specific organizational procedures, have been proposed. In 2004 in the United Kingdom, the rule that 98 % of ED patients should be seen and then admitted or discharged within 4 h of presentation to the ED ('4 h rule') was introduced, and it has been shown to be very effective in decreasing ED crowding, and has led to the development of further acute care clinical indicators. This manuscript represents a synopsis of the lectures on overcrowding problems in the ED of the Third Italian GREAT Network Congress, held in Rome, 15-19 October 2012, and hopefully, they may provide valuable contributions in the understanding of ED crowding solutions.

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“…3 Although the initiative would seem to have clear benefits for patient care, the picture is not quite as straightforward as first imagined, and some of the effects of the implementation have been controversial. 4 Concerns included the possibility that clinicians may be making hurried decisions without complete information to attain the target. 5 One of the consequences of adhering to a 4-hour waiting time is that nurses have reported to be under increased stress to comply with target attainment, with subsequent threats of disciplinary action.…”

Section: Background/contextmentioning

confidence: 99%

“…6 Although targets may well improve patient care, some authorities have raised concerns regarding unintended consequences for patients and staff resulting from the pressure to achieve targets. 4,7 There have been suggestions that figures have been manipulated to fit in with management goals. Locker and Mason 8 suggest that it is likely that the true performance of some emergency departments in relation to the 4-hour target is considerably lower than reported.…”

Section: Background/contextmentioning

confidence: 99%

Attempting to Reduce the Maximum Emergency Waiting Time to 4 Hours in England: Was the Initiative Successful?

Day

Oldroyd

2012

Journal of Emergency Nursing

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The impact of the 4 h target on patient care and outcomes in the Emergency Department: an analysis of hospital incidence data

Abstract: Although time target introduction is associated with changes in patient care, the introduction of a co-located MIU had greater impact.

Cited by 29 publications

References 23 publications

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

Overcrowding in emergency department: an international issue

Attempting to Reduce the Maximum Emergency Waiting Time to 4 Hours in England: Was the Initiative Successful?

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