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.