If I were minister for health,I would … review the four-hour waiting time in the emergency department

Waiting times in the emergency department have long been a point of complaint. The 4-h waiting time in emergency departments was a target introduced by the Labour government in 2004 to try to reduce waiting times in the emergency department, ¹ stating that no patient should wait longer than 4 h from arrival to discharge or admission. ¹

This target was reduced from 100% to 98%, allowing clinical exceptions such as critically unwell patients, and was reduced further to 95% in 2010. There has been much discussion as to whether the 4-h target is appropriate, or even achievable – since 2015, the 4-h target has not been achieved in England. ² Much of the debate is around whether appropriate care can be delivered in 4 h and the impact of the target on staff morale. There is the concern that emergency medicine trainees may be deskilled by the time pressure, losing out on practical skills or managing complex unwell patients due to time pressure. Further, there are ways for the emergency department to ‘game these targets’; for example, moving the patient to another area in the emergency department which is not technically part of the main emergency department to complete their treatment may ‘beat the clock’ on the patient’s 4-h target time, but clearly is not in the correct spirit. I am not advocating for a removal of target times entirely, as studies have shown that waiting time targets can reduce mortality. ³ Rather, I will explore the why the target may have been justified, the current effect it is having on emergency department staff and patients in the UK, and why I feel we should consider reviewing it, with suggestions as to how this may be done.

Why might the target be justified? Crowding in the emergency department is a problem worldwide, and there have been multiple studies on how to manage this issue. Unsurprisingly, many of these studies arrive at a similar conclusion; there is a surplus of patients compared to physicians and beds.

The 4-h target has been adopted by the UK to try to reduce waiting times, but in other countries this is not the case. In the USA, for example, a multicentre retrospective study showed that across 364 US hospitals, less than 50% of hospitals admitted their emergency department patients within 6 h, ⁴ despite strong evidence that prolonged wait time in the emergency department leads to poorer patient outcomes. ⁵ Australian research shows that among other factors, time-based targets for emergency care are associated with improved patient mortality outcomes and reduced emergency department crowding (a factor for mortality), though it is noted that the time-based target is only one of the factors to improve service. ⁶ We also know that as resources are stretched, the patients that are likely to suffer the most are the elderly, the most infirm and the most vulnerable. ⁷

Further, a crowded emergency department leads to patients kept in the back of ambulances (which are then unable to attend other emergencies). This has been clearly shown in recent years with the news showing video footage of patients being triaged and, in some cases, treated in the back of an ambulance due to crowding.

The Royal College of Emergency Medicine reports that the 4-h target is a powerful tool allowing the formation of short stay and ambulatory care units, as well as employment of more staff and improved hospital bed management. ¹ However, these benefits only work if the 4-h target is being achieved. The 4-h target has been consistently missed since 2015, and the reasons are multifactorial but not limited to increasingly complex and elderly patients, poorer provision of social care services and insufficient levels of staffing and beds. ⁸ Bed occupancy rates continue to rise, and the overall number of available beds has been reduced, ⁹ which is known to correlate inversely with the achievement of the 4-h target. ¹⁰

Emergency department attendances are continuing to rise, and the elderly patient constitutes approximately 20% of all emergency department attendances, with higher rates of reattendance. ¹¹ In short, the emergency department is becoming more crowded, there are fewer available beds to admit patients and targets are consistently not being met.

Morale in emergency medicine is poor. In 2013, 62% of the emergency medicine consultant cohort reported that their current job plans were unsustainable, and 94% worked in excess of their rostered hours. ¹² In 2018, 80% of emergency medicine doctors surveyed by the Royal College of Emergency Medicine reported that ‘things are getting worse’ and that the current level of work is unsustainable. ¹³ Bed shortages and poor access to social care were also noted as significant drivers for pressure and crowding in the emergency department. Multiple respondents in the survey were concerned about the risk of burnout.

Emergency medicine as a specialty has been in crisis for a number of years, with vacant training slots available for the last 13 years. ¹⁴ Research shows that burnout, low job satisfaction, high vacancy rates and decreased performance measures are all contributing to this crisis among emergency medicine staff.

However, is this related to the 4-h target? Or, rather, can an association be made between the 4-h target and the current staff morale? Emergency medicine physicians are under significant pressure to formulate a rapid management plan and to ‘direct’ a patient early on in the assessment (either marking them as ‘home’ or ‘admit’). The rapid turnaround of patients has led to a reduction in the practical skills undertaken by emergency medicine physicians. There is workforce attrition as doctors leave the specialty and training is directly affected due to pressure to deal with the queue of patients. ¹⁴ Whether this is directly due to the 4-h target or whether the 4-h target highlights issues that are already present in the emergency department, the end result is the same – the relentless round-the-clock pressure to review patients, formulate rapid management plans and enact these plans before moving swiftly on to the next patient (often at the expense of training opportunities) has created a culture of burnout, unhappiness and unsustainability in the emergency medicine workforce.

It would be inappropriate to state that simply removing the 4-h target would solve these issues immediately. It is well accepted that there has been chronic under-investment and failure to prepare for an ageing population, and that we are now reaping what has been sewn, ⁸ and that the failure to meet the 4-h target may merely be a proxy for system-wide failure in performance. ¹⁵ So, what is an acceptable solution?

Many patients attend the emergency department because they feel that there is no realistic alternative, and when they have attended the emergency department for help, they deserve to be seen and cared for. However, does this need to happen within 4 h? Non-urgent attendances to emergency departments are rising, with 15% of attendances between 2011 and 2014 being ‘non-urgent’, and 20% of these arriving by ambulances. ¹⁶ Younger adults are more likely to attend the emergency department for non-urgent care, and are also more likely to do this out of hours. ¹⁶ Many of these presentations can be managed in primary care, but anecdotally patients often report being unable to access their primary care practitioner within a reasonable timeframe and therefore attend the emergency department. So, with regard to the 4-h target, do all emergency department patients need to be ‘tarred with the same brush’? Patients are triaged on admission, but for those non-urgent patients that are not able to be diverted to primary care, perhaps there should be some way of retrospectively coding these patients such that their attendance is not counted towards the 4-h target. This would certainly reduce some of the time pressure, though it increases the risk of physical crowding in the department, and the risk that the ‘non-urgent’ patients may be left to languish in the department. Further, there is the risk of ‘gaming’ the system and marking down inappropriate patients as ‘non-urgent’ to simply ensure that the overall 4-h target is being met from the rest of the department.

In the same vein, critically unwell patients that are managed in the resuscitation department will often exceed the 4-h target. Retrospective removal of these patients will remove even indolent time-based pressure on the emergency medicine physician.

Does the 4-h target need to be 4 h? There is no body of evidence for this particular number as opposed to any other, and research in New Zealand has shown improvements in patient care with a target time of 6 h. ¹⁷ It is worth noting, however, that this study aimed for 95% of patients to be managed within 6 h, as opposed to the 98% that was the UK target when the 4-h target was introduced.

Finally, we consider whether despite the advantages to the 4-h target, it needs to be in place currently. The 4-h target has not been met for half a decade. As a proxy, this failure demonstrates failure in the healthcare system as a whole in the areas noted above: poor funding; lack of beds; and inadequate primary and social care. These are not issues that can be solved overnight, and reflect ongoing issues with the health service as a whole. There is UK-based research that showed to achieve a 95% adherence to the 4-h target, medical bed occupancy must be reduced, ¹⁸ which the authors indicated would require significant system-wide change. However, if we are at a point where studies are stating that the whole system needs to be transformed to achieve an (arbitrary) 4-h target, have we reached a point where the target needs to be altered? After all, if we are suggesting changing one end of the equation to balance the other, why is it not more sensible to change the 4-h target to 5 or 6 h (to follow New Zealand’s example)? Perhaps, given the perilous state of the emergency medicine workforce and the very real risk of burnout, the most appropriate way forward would be to relax the target to less than 95%, or perhaps to remove it entirely. This would certainly remove the time pressure on emergency medicine physicians and may provide some much-needed breathing room, allowing for improvements in training and job satisfaction. Certainly, the lack of feeling as though they are fighting a ‘losing battle’ when they try to achieve a target that may not be achievable may boost morale. Removal of the target entirely, however, does have its risks, ensuring that patients are not waiting excessively to be seen has been a positive effect of the 4-h target as well ensuring that the emergency department receives adequate resources and funding.

In conclusion, the 4-h target has had positive and negative effects. However, accepting that within the limits of the current system, the target in its current form – 95% adherence – may not be achievable and may be having a negative effect on staff is important.