Should we scrap the target of a maximum 4-hour wait in emergency departments?

October 25, 2017, British Medical Journal

As waiting times increase, should we scrap the target of a maximum four hour wait in emergency departments? Experts debate the issue in The BMJ today.

Consultants Adrian Boyle, from Cambridge University Hospitals Foundation Trust, and Ian Higginson, from Plymouth Hospitals NHS Trust, say that the target should remain as there is no realistic alternative that exists to keep departments running smoothly.

The four hour target for NHS emergency departments in England to see, treat and admit or discharge a patient was introduced in 2004 as a way to combat crowding. Crowding in emergency departments is consistently associated with increased death rates and long hospital stays. Boyle and Higginson comment that the target is a simple, well understood measure that drives flow throughout the whole urgent care system.

"Before the target was introduced, being a sick patient in an was pretty awful, emergency departments were often full, waiting times were long, and care was poor" stress Boyle and Higginson.

"There is no doubt that the target has reduced waiting times in emergency departments," they say. However, the NHS as a whole has not achieved it since 2015, and this reflects the increasing demand and our full hospitals.

They argue that, on balance, time based targets are probably associated with reductions in mortality - and say, although the target applies only to emergency departments, "it has stimulated and driven greater understanding of the whole urgent care pathway."

"The NHS is likely to be facing its most challenging winter, with widespread financial and performance problems, staff shortages, and low morale. Eliminating the four hour target would only make this worse," they conclude.

But Peter Campbell, an independent public health consultant and guest lecturer at the University of Heidelberg, disagrees, cautioning that the pressure to achieve targets is not an improvement strategy and leads to perverse incentives and use of resources.

He says that when targets inspire fear they may be met by diverting resources to emergency departments and away from departments with no targets, where patients can wait for hours on understaffed wards. Indeed, he argues that such target-driven behaviour "was a cause of the Mid-Staffordshire scandal."

He highlights how processes have been introduced where departments favour younger patients at the expense of older patients, whose problems may take longer to treat.

"Targets are ultimately the result of negotiation and best guesses. So while a missed target could be due to departmental failure, it could equally be due to poor guesswork. If so, then rewards or penalties for performance cannot be awarded automatically. Why are unrealistic guess makers never held to account?" he asks.

In contrast to Boyle and Higginson, Campbell argues an alternative approach exists that interprets and responds to the data differently, using a two-step approach that he believes has been ignored for too long.

Explore further: Flu season adds stress to hospital emergency departments

More information: BMJ (2017). www.bmj.com/content/359/bmj.j4857

Related Stories

Flu season adds stress to hospital emergency departments

June 27, 2017
The annual flu season adds up to 17,000 more patients a year to NSW emergency departments, an increased demand for services that is pushing hospitals close to the edge, a new study reveals.

Co-located GP clinics can ease the load in ERs

March 6, 2013
(Medical Xpress)—The addition of a GP clinic at hospitals should reduce waiting times in emergency departments, according to new research.

New study: Nearly half of US medical care comes from emergency rooms

October 17, 2017
Nearly half of all US medical care is delivered by emergency departments, according to a new study by researchers at the University of Maryland School of Medicine (UMSOM). And in recent years, the percentage of care delivered ...

Study identifies methods for preventing overcrowding in emergency rooms

August 28, 2017
No single solution exists for alleviating crowding in emergency rooms, but a new study identifies four key strategies that have reduced the problem.

Long emergency waiting times linked to increased risk of adverse events

June 2, 2011
Long emergency department waiting times are associated with an increased risk of hospital admission or death within seven days among non-admitted patients, finds a study published in the British Medical Journal today.

Study finds most crowded US hospitals did not adopt proven interventions

December 7, 2015
The most crowded emergency departments in the U.S. have not adopted proven interventions to address crowding, a major public health concern.

Recommended for you

How to survive on 'Game of Thrones': Switch allegiances

December 9, 2018
Characters in the Game of Thrones TV series are more likely to die if they do not switch allegiance, and are male, according to an article published in the open access journal Injury Epidemiology.

Expert calls for strong, sustainable action to make world roadways safer

December 7, 2018
According to the latest World Health Organization (WHO) report on road safety, more than 1.3 million people die on the world's roadways each year—and millions more are injured or disabled. Yet despite the huge cost to families ...

Hazelnuts improve older adults' micronutrient levels

December 6, 2018
Older adults who added hazelnuts to their diet for a few months significantly improved their levels of two key micronutrients, new research at Oregon State University indicates.

Regular bedtimes and sufficient sleep for children may lead to healthier teens

December 6, 2018
Having a regular, age-appropriate bedtime and getting sufficient sleep from early childhood may be important for healthy body weight in adolescence, according to researchers at Penn State.

Stress from using electronic health records is linked to physician burnout

December 5, 2018
While electronic health records (EHRs) improve communication and access to patient data, researchers found that stress from using EHRs is associated with burnout, particularly for primary care doctors such as pediatricians, ...

Chemicals in personal care and household products linked to earlier puberty in girls

December 4, 2018
Chemicals that are widely used in personal care and household products are linked to girls entering puberty at earlier ages, according to findings from a long-running study of mothers and children published today.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.