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A&E quality indicators
  1. Geoffrey Hughes
  1. Correspondence to Professor Geoffrey Hughes, Emergency Department, Royal Adelaide Hospital, North Terrace, Adelaide 5000, South Australia, Australia; cchdhb{at}

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International readers may need reminding that in April 2011 a new set of clinical quality (A&E) indicators was introduced in the NHS in England to replace the previous 4 h waiting time standard, the new indicators providing a platform with which to measure the quality of care delivered in A&E departments in England. The indicators were developed by the national clinical director for urgent and emergency care, working with the College of Emergency Medicine, the Royal College of Nursing and informed patient representatives.

At the beginning of October last year the government released data for May 2011, related to A&E attendances for that month and drawing on just over 1.4 million detailed records of attendances at major A&E departments, single specialty A&E departments (eg, dental), minor injury units and walk-in centres in England.1

Five indicators are reported:

  • left department before being seen for treatment rate;

  • re-attendance rate;

  • time to initial assessment;

  • time to treatment;

  • total time in A&E.

As the press release makes clear, these A&E Hospital Episode Statistics (HES) data are experimental statistics and are trying to identify the shortfalls in the quality and coverage of records submitted via the A&E commissioning dataset.

If you are an enthusiast for this sort of thing and continue to explore the links accompanying the press release there is a real risk that you will become entangled in an endless, esoteric stream of jargon and become as confused and disorientated as Alice was when she first entered her own Wonderland. For example:

  • “The data used in these reports are sourced from Provisional A&E HES data, and as such these data may differ to information extracted directly from Secondary Uses Service data, or data extracted directly from local patient administration systems. Provisional HES data may be revised throughout the year (eg, activity data for April 2011 may differ depending on whether they are extracted in August 2011, or later in the year). Indicator data published for earlier months have not been revised using updated HES data extracted in subsequent months.

  • The data presented here represent the output of the existing A&E Commissioning Dataset (CDS V6 Type 010). It must be recognised that these data will not exactly match the data definitions for the A&E clinical quality indicators set out in the guidance document A&E clinical quality indicators: Implementation guidance and data definitions (external link).

  • The Department of Health is currently working with Information Standards Board to amend the existing CDS Type 10 Accident and Emergency to collect the data required to monitor the A&E indicators.

  • A&E HES data are collected and published by the NHS Information Centre for Health and Social Care. The data in this report are secondary analyses of HES data produced by the Urgent & Emergency Care team, Department of Health.

  • The published information sets out where data quality for the indicators may be improved by, for example, reducing the number of unknown values (eg, unknown times to initial assessment) and default values (eg, the number of attendances that are automatically given a time to initial assessment of midnight 00:00).”

If we ignore all this complex stuff and accept that the ‘quality and coverage of A&E HES data have considerably improved over the years, and the Department of Health and the NHS Information Centre are working with NHS Performance and Information directors to further improve the data’ then here are some important points:

  • The data contain over 1.4 million A&E attendances for May 2011 at all types of A&E. However, these data are incomplete as over 1.7 million A&E attendances were reported in the Department of Health Situation Report data collection and 137 organisations that report data to Situation Reports did not report data to A&E HES; these organisations are mostly lower acuity services such as minor injury units and walk-in centres.

  • Several organisations reported data that did not meet the data quality checks required by the A&E indicators. The 95th centile and longest single-wait information are particularly sensitive to poor data quality, outliers and data definitional issues, which contributes to the reason that some unusually high values may be seen for these measures.

  • 3% of people attending A&E left before being seen.

  • 7.3% of people attending A&E re-attended within 7 days.

  • The median average time to initial assessment for ambulance patients was 5 min, 95% being assessed within 1 h 11 min. For all patients the median average time to treatment was 57 min, with 95% receiving treatment within 3 h 15 min.

  • The median average total time in A&E for all patients was 2 h 9 min, 95% leaving within 4 h 20 min of arrival.

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  • Provenance and peer review Commissioned; internally peer reviewed.

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