Woodcock et al highlight that changing the four hour standard from
98% to 95% resulted in processes adjusting accordingly. But they fail to
address the key issue of whether it benefits patients. Their conclusion
that this shows that more patients are waiting for care is imprecise and
possibly wrong. The four hour standard relates to the total time spent in
the emergency department until discharge or admission to a ward. Care
starts much earlier, figures for January 2012 show that the median wait
for ambulance cases to be assessed by a health care professional (triage)
was 3 minutes (95% seen in 47 minutes) and the median time for all cases
to be seen by a decision making clinician is 49 minutes (95% in 85
minutes) [1]. This has only been collected nationally since April 2011 and
so we cannot assess change over the last few years.
The 240 minute total time in England stills compares favourably to
other countries. The four hour rule in Western Australia requires 90 per
cent of patients leave the ED within four hours [2]. New Zealand has a 95%
admitted, discharges or transferred within six hours target[3]. In Alberta
it is 75% of discharge patients in four hours and 60 per cent of admitted
patients leaving in eight hours[4].
The change to 95% was introduced following requests from professional
bodies and was openly welcomed by the RCN [5] . It was reduced because
clinicians believed that the change in clinical emergency medicine
practice meant more people would benefit clinically from spending longer
in the emergency department. Over the last ten years more investigation
and more treatment has been undertaken in the emergency department before
admission. More patients are now discharged home after more complex
investigations. This takes longer but benefits patients.
This study looks at the total time standard in isolation. Use of the
single target was subject to much criticism and so it is unfortunate that
this article persists in analysing one measure in isolation. The reason
for establishing the clinical quality indicators was to "provide a broader
picture" [6] and encourage a "more sophisticated debate". To achieve this
requires the whole set of indicators to be viewed together. Using three
measures of time allows the flow of patients through the emergency
department to be seen. Measuring experience as well as re-attendance rate
and left without being seen rate helps to ensure that care is of high
quality as well as timely. Later this year I will be publishing the first
annual report of the clinical quality indicators for Accident and
Emergency Departments in England and will illustrate why we need the
balance approach of analysing all the indicators as one set.
Professor Matthew Cooke
National Clinical Director Urgent and Emergency Care, Dept of Health
1. Accident and Emergency Hospital Episode Statistics (HES). NHS
Information Centre. London (accessed 6 June 2012)
http://www.ic.nhs.uk/statistics-and-data-collections/hospital-
care/accident-and-emergency-hospital-episode-statistics-hes
2. Emergency Access Reform. Government of Western Australia. Perth
(accessed 6 June 2012)
http://www.health.wa.gov.au/emergencyaccessreform/home/
3. Shorter Stays in Emergency Departments health target. Minsitry of
Health. Aukland. (accessed 6 June 2012) http://www.health.govt.nz/our-
work/hospitals-and-specialist-care/emergency-departments/shorter-stays-
emergency-departments-health-target
4. Action on Emergency Department Lengths of Stay. Alberta Health
Services. Alberta . (accessed 6 June 2012)
http://www.albertahealthservices.ca/3166.asp
5. Reducing four-hour target a welcome move. Royal College of Nuring.
London. (accessed 6 June 2012)
http://www.rcn.org.uk/newsevents/press_releases/uk/reducing_four-
hour_target_a_welcome_move,_rcn_says
6. A&E Clinical Quality Indicators. Department of Health. London
2010.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123055.pdf
Conflict of Interest:
None declared
Woodcock et al highlight that changing the four hour standard from 98% to 95% resulted in processes adjusting accordingly. But they fail to address the key issue of whether it benefits patients. Their conclusion that this shows that more patients are waiting for care is imprecise and possibly wrong. The four hour standard relates to the total time spent in the emergency department until discharge or admission to a ward. Care starts much earlier, figures for January 2012 show that the median wait for ambulance cases to be assessed by a health care professional (triage) was 3 minutes (95% seen in 47 minutes) and the median time for all cases to be seen by a decision making clinician is 49 minutes (95% in 85 minutes) [1]. This has only been collected nationally since April 2011 and so we cannot assess change over the last few years.
The 240 minute total time in England stills compares favourably to other countries. The four hour rule in Western Australia requires 90 per cent of patients leave the ED within four hours [2]. New Zealand has a 95% admitted, discharges or transferred within six hours target[3]. In Alberta it is 75% of discharge patients in four hours and 60 per cent of admitted patients leaving in eight hours[4].
The change to 95% was introduced following requests from professional bodies and was openly welcomed by the RCN [5] . It was reduced because clinicians believed that the change in clinical emergency medicine practice meant more people would benefit clinically from spending longer in the emergency department. Over the last ten years more investigation and more treatment has been undertaken in the emergency department before admission. More patients are now discharged home after more complex investigations. This takes longer but benefits patients.
This study looks at the total time standard in isolation. Use of the single target was subject to much criticism and so it is unfortunate that this article persists in analysing one measure in isolation. The reason for establishing the clinical quality indicators was to "provide a broader picture" [6] and encourage a "more sophisticated debate". To achieve this requires the whole set of indicators to be viewed together. Using three measures of time allows the flow of patients through the emergency department to be seen. Measuring experience as well as re-attendance rate and left without being seen rate helps to ensure that care is of high quality as well as timely. Later this year I will be publishing the first annual report of the clinical quality indicators for Accident and Emergency Departments in England and will illustrate why we need the balance approach of analysing all the indicators as one set.
Professor Matthew Cooke National Clinical Director Urgent and Emergency Care, Dept of Health
1. Accident and Emergency Hospital Episode Statistics (HES). NHS Information Centre. London (accessed 6 June 2012) http://www.ic.nhs.uk/statistics-and-data-collections/hospital- care/accident-and-emergency-hospital-episode-statistics-hes
2. Emergency Access Reform. Government of Western Australia. Perth (accessed 6 June 2012) http://www.health.wa.gov.au/emergencyaccessreform/home/
3. Shorter Stays in Emergency Departments health target. Minsitry of Health. Aukland. (accessed 6 June 2012) http://www.health.govt.nz/our- work/hospitals-and-specialist-care/emergency-departments/shorter-stays- emergency-departments-health-target
4. Action on Emergency Department Lengths of Stay. Alberta Health Services. Alberta . (accessed 6 June 2012) http://www.albertahealthservices.ca/3166.asp
5. Reducing four-hour target a welcome move. Royal College of Nuring. London. (accessed 6 June 2012) http://www.rcn.org.uk/newsevents/press_releases/uk/reducing_four- hour_target_a_welcome_move,_rcn_says
6. A&E Clinical Quality Indicators. Department of Health. London 2010. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123055.pdf
Conflict of Interest:
None declared