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The 4 Hour Target - from a doctor's perspective

Dr Michael Brooks

Although my main job is as the Chief Medical Officer of PatientSource Limited, I still practise for one week a month in Emergency Medicine in the NHS.

As an Emergency Medicine (A&E) doctor, I get rather irritated by the way journalists report on the “4 hour target”. Very frequently, I see statements such as “only X% of patients were seen within 4 hours”. This is a complete misinterpretation of how the target works. The target has distorted priorities, and I believe that blindly chasing this target has increased costs.

The “95% 4 hour target” says that 95% of patients must be discharged, admitted, or transferred within 4 hours of arriving in A&E. The clock starts when the patient sets foot (or ambulance trolley wheel) in the department, and stops when the patient leaves the department. The clock categorically does not stop when the doctor first sees the patient, yet journalists imply this all the time. Within those 4 hours, we are expected to stabilise, assess, run tests, diagnose, treat and refer or discharge the patient.

The “95% 4 hour target” was introduced to try to lubricate the movement of patients from A&E on to the wards, and also probably as a political vote winner to cap the amount of time people would spend sitting in the A&E waiting room. The target has definitely made A&E a top focus of most hospitals and has helped us get patients referred for admission onto wards faster. However it is a blunt tool and the effect of this limit though has been perverse and far-reaching: Emergency Medicine is now struggling to attract doctors to the area of medicine, a large part due to the pressure of the work, with more than 50% of middle-grade training posts left vacant in the last 3 years of recruitment. Hospitals are being fined for missing the target, which has led to all sorts of figure fiddling. Patients who would otherwise be suitable for discharge are being referred purely to avoid exceeding 4 hours, a phenomenon evidenced by the rate of admissions being highest in the twenty minutes before the 4 hour limit.

As a Middle Grade doctor in A&E I am fortunate to work in a very good NHS Trust which has a management board full of former front-line nurses and doctors, and an Emergency Department which has very enthusiastic and experienced Consultant doctors who are present on the A&E shop floor 16 hours a day, every day. So, I probably have the best of the UK situation.

On my shifts, which tend to be night shifts, I am frequently faced with a situation where a patient is probably going to be well enough to go home, but will end up exceeding the 4 hour limit while we wait for final test results, or while their treatment finishes. I am faced with one of two choices:

  1. Admit them into hospital, or,

  2. Keep them a little bit longer in A&E, breach the 4 hour limit, then discharge them from A&E

The “4 hour target” pressurises me to pick the first option. Let’s see what happens to the patient if I dutifully follow the target, avoid a breach and admit them:

 

Option 1:  Admit them into hospital

  • The patient is moved from A&E into a ward, thus is “saved” from “breaching” the 4 hour limit

  • Another team of doctors, let’s say from General Medicine, take over the patient’s care

  • The patient takes up a bed on a hospital ward

  • A junior General Medicine doctor sees the patient on the ward, they:

    • takes the patient’s history all over again,

    • re-examine the patient,

    • review existing test results,

    • review my diagnosis

    • complete several pieces of paperwork such as a clerking proforma and a drugs chart

  • A more senior General Medicine doctor then sees the patient, they:

    • Check the patient’s history again (the third time the patient is asked to tell their story)

    • May re-examine the patient

    • Review the test results

    • Review the diagnosis

    • Review the treatment

  • The patient remains on the ward, taking up a bed overnight, until the Consultant ward round next day

  • The Consultant (most senior doctor) reviews the patient in the morning, they:

    • Check the history

    • Check the diagnosis

    • Check the treatment

    • Make a decision to discharge them

  • The patient sits on the bed, taking it up despite being well, until their discharge paperwork is completed

  • A junior doctor from the day team sits down after the ward round and writes a discharge letter

  • This may include “To Take Out” medication for the patient to go home with, so they have to sit on the bed for another 2 hours after the discharge letter is written in order for the hospital pharmacy to dispense the medicine

Pros: The patient does not breach the 4 hour limit

Cons: The patient uses up a whole bed-day on a hospital ward, 2 junior doctors’ time, 1 middle-grade doctor’s time, 1 Consultant doctor’s time, 1 day of the patient’s time, and possibly some pharmacist’s time

 

Option 2: Keep them a little bit longer in A&E, breach the 4 hour limit, then discharge them from A&E

  • The patient “breaches” the 4 hour limit

  • A manager rings the A&E desk phone constantly to enquire why the patient has not been admitted or discharged yet

  • The patient stays in an A&E cubicle for another half hour

  • Their treatment finishes or test results come back

  • I discharge the patient myself from A&E (which doesn’t require a separate letter) and issue them an outside prescription slip for their medications

Pros: A bed on a ward is kept free, the four General Medical doctors’ time is saved, the patient doesn’t have to retell their story over and over again, the patient hangs around for 30 more minutes rather than for a whole day.

Cons: The hospital takes a hit on its 4 hour target figures, I get criticism from the managers for not admitting the patient.

 

In reality, 4 out of every 5 patients I hold on to in the A&E department in these circumstances end up being well enough to go home the same night. One in every five ends up having to be admitted. Given the high costs of admission, I think this is a net money and resource saving approach. However the 4 hour target is pressuring me not to do this.

If you were the patient, which scenario would you prefer?