Monday, October 27, 2014

4 hours in A&E

Much is made of the 4 hour waiting target for A&E departments in the UK and various hospitals' adherence to the target as well as methods hospitals use to fudge the  numbers to make it look like they adhere to the target.

The Mary Seacole Program which I have just completed exists as a direct  result of the Francis Report trying to improve education and leadership in the NHS workforce. Something mentioned in the Francis Report was the fact that Mid Staffs were placing adherence to targets  above the need for safe patient care.

I understand that fast care should result in improved patient safety and satisfaction and targeting time spent in the A&E department should bring about improvements. Unfortunately imposing arbitrary and artificial restraints on a system will mean that the system will adapt to nullify the effect of the restraint. This took the form in mid Staffs of holding wards, inappropriate discharges, boarding patients in inappropriate places and generally harassing staff who were there to see the patients. In my experience I've seen all of these in one form or another in the various places I have worked. I would like to share an example of the unwavering adherence to the 4 hour rule and how ludicrous it can make us look.

It was a Saturday night and I was on call for Urology. I was called to a very busy and rowdy A&E department to see a patient with a painful urological problem which whilst distressing was quite easy to fix and would result in complete resolution and discharge from hospital immediately after the procedure. It was uncharacteristically quiet in theatre so I proceeded to A&E without delay to be met at the entrance with a clip board wielding band 8 nurse who was "site manager" for this shift. This is hospital speak for "enforcer of 4 hour wait rule"and the extent of her first interaction with me that evening boiled down to:

"Majors 12 has been here 3 hours 55, Send him home now or he is going upstairs [to the admissions unit]"

Firstly, I was referred the patient at 3 hours 50 minutes and expected to sort them out in 10 minutes. Secondly, having reviewed the patient quickly I was confident the short procedure would send him on his way home. This would probably take about 5-10 minutes to perform, but would take him over 4 hours in the department. This obviously couldn't do.

After confirming the problem, I left the room to get a pair of gloves and the piece of equipment needed to help the patient out, having applied some local anaesthetic to the area in question and leaving the patient in a compromising position in the private room. In the 10 seconds I took to get the gloves, a porter and "site manager" had gone into the room and wheeled him out (still in a compromising position) in order to transfer him to the admissions ward.

My protests fell on deaf ears:

Me: "I'm only going to take 5 minutes, he doesn't need to go upstairs"
Manager: "He is about to breach, whatever you are doing it can wait until the admissions ward."

So it takes half an hour for patient to be transferred and admission paperwork to be completed before the patient is in a room able to do the procedure. I have a very irate, embarrassed patient who has been paraded in front a department with his pants down. It takes less than 5 minutes to do the  original procedure yet he has been admitted, had an admission nurse fill out a booklet full of paperwork and been subjected to a humiliating trip. All so he didn't breach the 4 hour target.

What should have happened is that he would have remained in the department for 4 hours and 5 minutes and he would have gone home happy. This chain of events hindered the nurse on admissions, myself, the porter and most importantly the patient. It didn't help anybody and wasted a lot of time, effort and money. Thankfully other than a complaint, it didn't actually harm the patient. I'm sure there are many other examples that have.

So that's why I don't like the 4 hour target; it makes people do silly things in order to get the numbers correct.


  1. "What should have happened is that he would have remained in the department for 4 hours and 5 minutes and he would have gone home happy."

    No, what should have happened is that you should have been contacted earlier and then you could make arrangements to see him on your ward thus freeing an ED space and saving you a trip down to ED.

  2. So you think a patient should have been transferred to a different ward and undergo a whole "admission proforma" for what could have been done in the ED? Should all head lacerations should be admitted because they are about to breach before closure?

    If the patient had been referred at 3 hour 20mins, this wouldn't have been a problem. If I was in theatre or due to be delayed then an admission would have been unavoidable, but the fact was, I was there in the department already.

    1. The patient does not need to be admitted, you have cherry picked an incident. If the patient had been identified as a urology problem and referred quickly he could have gone to the ward/clinic and had his procedure done by you in your area and then discharged.

      When surgeons, medics etc. attend A&E to see patients it is usually when they are free - this leads to delay. When they arrive in A&E they can be paged, which they have to answer - this leads to delay. They do not know where anything is (usually) and need to get nursing staff to help them, this leads to delay. They can attempt procedures in the A&E which are better carried out in other areas - theatres, procedure rooms etc. and A&E does not keep a particular bit of equipment - this leads to delay.

      The Band 8 "clip board wielding site manager" that you so casually denigrate is acting on the instructions of her managers and trying to follow hospital procedure and what to you seems a simple solution is anything but.

      The problem with the 4 hour target is that it has become an A&E problem when in fact it should be a hospital problem. I have a few battles around change over time when new doctor decide that they want to come to A&E and faff around and get very upset that I as a nurse am telling them no. I win these battles because our consultants have procedures in place to stop this.

      It is possible to have the 4 hour target and meet it consistently - we do it and have the figures to prove it. No fudging, no putting patients at risk no 'clinical decision unit' beds.

  3. Oh, and as an addendum, I seriously doubt that you were referred the patient at 3 hours 50' and arrived in the A&E at 3 hours 55'. Takes longer than that for you to answer your page, discuss what the problem is, get some details and then actually arrive in A&E.

  4. As a hospital with a single point of admission without an SAU then I regularly spend large portions of my time in A&E. In this case (a reduction of paraphimosis for clarity) only needed a pair of gloves and some lube.

    The point I am making, is that I am already in the department, so the patient doesn't need to go anywhere, and got delayed and embarrassing care because of an arbitrarily placed barrier.

    Oh and as an addendum, you weren''t there and you can "seriously doubt" whatever you like, it happened as described.

  5. I agree as you were there it would have been better (and simpler) if you had got on with it. My point however is that you should never be in A&E. See the urology patients in urology. Leave A&E to get on with its own work and you can see patients in the comfort and familiarity of your own area.

    You do not need an admissions unit, you are not admitting the patient, you are performing a procedure. This highlights my point about making the 4 hour target a purely A&E problem. If you make it a hospital problem then systems can be put in place to ensure compliance with the 4 hour target. I have written about this in the nursing press and on other blogs and no-one ever asks how we do it.

    If as stated you can go from referral to patient in 5 minutes please come and work for us, that is truly impressive. (no sarcasm implied or intended).

    For clarity, I work for NHS Tayside in Scotland and we consistently meet the 98% target for 4 hour waits.
    I remember the old days when patients with 'minor' injuries had to wait 6-10 hours to be seen and I much prefer our current system.
    We still get complaints on a busy Sunday when someone arrives and moans that they are not willing to wait 2 hours to be seen.

  6. You are right that other departments problems affects the running of yours and we should all be working on the solution. I think an SAU would be a very good idea, as we're even seeing GP admissions in A&E,

    I see the same problem with any outside constraint on a system. For example the 2 week wait for cancer referrals has the knock on effect of increasing our routine patient waiting time, leading to complaints.

    At the risk of backtracking, responding to A&E in 5 mins is the exception as opposed to the rule!

  7. Not sure if you are still following this but an example of how it can be when systems are in place; a couple of Fridays ago we had 2 patients in our department at 8:00PM on a Friday night. OK, Scotland were playing football and the Christmas lights were going on in town but still.... 2 patients at 8:00PM. 1 in resus, 1 in majors - no minors at all.

  8. I suggest you to continue posting your thoughts. It's very interesting.

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