Reflections on the UK’s “4-Hour Rule”

Published on July 11, 2013
Sure, the hallways are clear, but are time-based performance indicators improving care in British emergency departments? Only time will tell.

Following a couple of months in the UK as an observer, where emergency physicians have been “suffering under the yoke” of The 4-Hour Rule, it is interesting to reflect on the effect of this controversial solution to the ubiquitous international problem of overcrowding in emergency departments (EDs).

It is important to emphasise, for those people outside the UK, that the introduction of a 4-hour standard across England has basically eliminated corridor patients in the ED. I have visited many EDs across England and looked at local and national data and there is no doubt that the EDs in England are the emptiest of any that I have seen in the developed world. More than 98% of patients are out of the ED within four hours of arrival. There are obviously examples of fudging of figures and data manipulation, but overall the figures are fairly accurate. It is also important to note that prior to the introduction of the new standard, overcrowding and access block for emergency patients was as bad in the UK as it was elsewhere – so the dramatic improvement was from a poor base.

To achieve this, a large amount of money was invested in the NH S and a lot of initiatives were undertaken over a short period of time. Innovations such as fast track, clinical decision units, walk-in clinics, acute medical/surgical admissions units, nurse practitioners and complete re-engineering of hospital processes were commenced to facilitate compliance with the new rule. There was also an investment in community and social services to enable more rapid discharge of patients. Importantly, all hospital and Trust executives were held accountable for performance against the standard. The average appointment duration of Trust CEOs was quite short during the introduction.

So was the introduction of the four-hour rule good for patients? Did it result in better care? Were all emergency physicians happy? The answers to these questions are necessarily complex. The first point to make is that we have no idea whether patient outcomes are better or worse following the introduction of the new processes. There is no systematic measurement of properly risk-adjusted outcomes in key risk areas. There is little data regarding the outcomes of those patients diverted from EDs or admitted precipitously to the ward to meet the target. There are many anecdotes and a few isolated pieces of data that are enough to raise concerns regarding patient safety and quality of care. A much quoted example is the MidStaffordshire Trust, where an inquiry found that a focus by management on time-based KPIs, to the exclusion of quality of patient care, had resulted in poor patient outcomes.

In general, patients themselves are happy that they have some guarantee about process time – they are blissfully unaware of our concerns regarding quality of care. The doctors in the ED are happy to have empty corridors – especially the senior doctors, who had to shuffle patients in corridors previously. However, many junior doctors feel that their role has been reduced to a triage officer and they have little time to undertake procedures or focus on clinical medicine. As a purely subjective impression, the general mood of ED doctors (especially junior doctors) in the UK appeared less upbeat than the mood in Australian EDs. Of course, this might just be lack of sunshine!

Will the improvement in overcrowding be sustainable? Unfortunately, the UK is in the throes of an economic disaster, which is likely to result in public spending cuts of up to 25%. It is highly unlikely that the NH S will be spared – despite government assurances. This, combined with the continuing 5% growth in ED attendances, is inevitably going to result in a major test of the present system. At the same time the new coalition government has promised to move away from a “target culture” to improvement in patient care quality and outcomes. Although the four-hour target will not be scrapped, it will not be the main focus of concern for the new government. Balancing the reduced focus on time with achievement of new quality benchmarks, will result in a major challenge for the NH S in general and EDs specifically.

What is the message for other regions? Should they adopt this standard? The main message is that it is possible to empty the EDs of corridor patients if the whole health system focuses on a major expansion in services. Second, patients generally like the idea of a guaranteed service within a short time period. But it is not known whether the huge investment and process improvements actually resulted in better patient outcomes. The effect on work practice for emergency physicians is considerable and may not be desirable for many clinicians. It is not known what time frame is most appropriate for safe and efficient care in the ED (e.g. 4 hours, 6 hours or 8 hours). It clearly depends on the model of care and patient mix. It also depends on the level of care within the rest of the hospital and support services available. However, a simple one-size-fits-all approach is most likely to work politically.

Personally, I found the ability of a health system to actually deliver an outcome that it promised very inspiring. However, I was concerned that it may have done this, in some instances, at the cost of ensuring good patient care. Some would argue that anything is better than treating patients in corridors, but I am not sure! The challenges in front of the NH S are considerable as it looks to maintain the time-centred standard, whilst changing focus to ensure that quality of care is improved. Dr. Peter Cameron is the president of the International Federation of Emergency Medicine (IFEM)

This article originally appeared in issue 2 of Emergency Physicians International

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