Shooting Targets (the 4 hour rule)

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Targets are useful. They give us something to aim at (“I’ll leave the office by 5pm”). They give us, and others, something to measure progress against (“I’ll have that report finished by Friday”). But, as always, there is another side to the coin. Targets, by their very nature, are simplistic. So, finishing that report by Friday might be easy to achieve, but the report might not be very good. Or you might finish the report, but leave all your other work undone. So picking the right target is very important.

In UK healthcare, targets were a buzzword of the nineties that have survived into the current more cash-strapped times of coalition. The “four hour rule” (the amount of time a patient is permitted to spend in the Emergency Department before being discharged or admitted) is familiar to every staff member in every hospital emergency unit in England.

The 4 hour rule has a beguiling directness to it. Patients must be in and out in 4 hours. Departments record this data anyway, making it simple and cheap to measure. It’s appealing to Government because it is tangible to voters. Everyone has waited in an Emergency Department, and everyone cares at least a bit about how long they might wait there. Politicians can stand up and make bold claims, and voters are likely to listen. Having a prominent Government target relating to EDs has also focused attention on this important aspect of care, encouraging trusts to employ more doctors and nurses to meet targets. It has encouraged departments to run more efficiently.

So the 4 hour rule appeals to politicians and to voters, it is easy to measure, and it encourages hospitals to focus on emergency care. So far, so good.

But rules, especially simple rules, encourage creative thinking about how to stretch them, and effectively cheat the system. The clock doesn’t start ticking until the patient is checked in on the computer system in the ED. At busy times, there may be a significant wait before this is done, and this won’t be counted. If it’s really busy, ambulances may have to queue outside the department and this waiting time is also not counted. And the 4 hour rule only applies to the ED. Every hospital has a ward next to the ED with a different name (emergency assessment unit, clinical decision unit etc) where patients who are taking too long can be moved, and the rule magically no longer applies.

And the existence of fixed rules, without flexibility, can also cause more harm than good. Let’s consider four (entirely fictional) patients presenting to the Emergency Department with four different problems, of varying severity.

Ms Apple presents at 11pm on Friday night with a painful foot. She had a few too many drinks in the pub with friends and fell down a small flight of steps, landing badly on her ankle. She is brought in by friends. She doesn’t want to stand in the queue (her ankle hurts) so she waits 20 minutes until there is no queue, and she is then seen by the administrator, who logs her on to the computerised waiting system. The clock starts ticking. She waits for half an hour for a nurse to triage hier. She is triaged to “minor injuries”, offered a pain killer, and goes back to the waiting room. Her notes are placed on a pile, and she waits for a doctor or nurse to assess her ankle.

Mr Blueberry presents at 11pm on Friday night with weak and tingly legs. There is no obvious cause, but he has had a bad back for a couple of days. He comes in with his wife, by car. He is seen by the administrator and the clock starts ticking. He waits in the waiting room for half an hour for a nurse to triage him. He doesn’t have a problem that fits easily into a category, but he is sent to “major injuries”. His notes are put on a different pile in “majors” and he waits for a doctor to see him.

Ms Cherry presents at 11pm on Friday night with an overdose of paracetamol. She was found by friends surrounded by empty pill boxes. She is rushed in by ambulance, and checked in by the administrator as she is wheeled into “majors” on a stretcher. The clock starts ticking. Her notes go on the pile after Mr Blueberry’s.

Mr Damson presents at 11pm on Friday night after being hit by a bus. He comes in by ambulance, and the crew phone ahead to put out a “trauma call”. He is met at the entrance to the emergency department by the trauma team of several doctors and nurses. He is checked in by the administrator as they start assessing him and the clock starts ticking.

By 1am, all four patients have used up half of their allocated 4 hours.

Ms Apple has fallen asleep in the waiting room waiting to be called. As it is Friday night, there are many other people with minor injuries ahead of her in the queue.

Mr Blueberry has been assessed by the Emergency Department doctor, who is not sure what to make of his symptoms. Although they are probably not serious, the doctor is worried about a back problem causing pressure on the spinal cord, so he asks for the orthopaedic team to review him. The ED doctor wants to arrange a scan of Mr Blueberry’s back, but the radiologist won’t agree to this until the orthopaedic team have given their opinion. The orthopaedic doctors are operating on Mr Damson, and not answering their pagers, so the clock ticks on.

Ms Cherry has had a blood test taken by a nurse, and an ED doctor has seen her and prescribed the antidote given to people with a paracetamol overdose, which is running through a drip. She has been referred to the medical team for review but the medical team are very busy and it is not clear when she will be seen by them.

Mr Damson was completely assessed within the first 15 minutes of arrival in the department, and taken for CT scans of his head and body. The only damage spotted is a broken leg, and he is now in theatre being operated on, keeping the orthopaedic team busy and preventing them from answering their pagers. He has officially left the emergency department under the care of the orthopaedic team and his 4 hour clock has stopped ticking. He has a bed on the orthopaedic ward once he comes out of theatre.

By 2am, the three remaining patients have just one hour left.

Ms Apple is still waiting to be seen. The duty manager notices that she has reached the 3 hour mark and flags this up to the senior doctor in the department. He moves from majors to minor injuries to help with the backlog. Ms Apple is examined and sent for an Xray.

Mr Blueberry is still waiting for the orthopaedic team to see him. They are expected to finish in theatre soon, and a message has been left.

Ms Cherry is still awaitng the medical team. Her blood tests are back, and it looks like she will be admitted, and the bed manager is asked to find a female bed on a medical ward. Currently there is no bed available.

At 2-45am the three remaining patients are 15 minutes away from breaching the 4 hour rule.

Ms Apple has had her x-ray and the senior doctor in the department is interrupted while seeing a new patient so he can review it. There is no fracture, and Ms Apple is sent home with pain killers.

Mr Blueberry is still waiting to be seen by the orthopaedic team. An ED nurse has finally managed to get hold of the orthopaedic specialist who has promised to come soon. With only 15 minutes left on the clock, and no prospect of his assessment being completed in that time, the emergency department manager decides to move him to the neighbouring assessment unit. This is a small ward next to the emergency department. As he is transferred he technically moves out of the emergency department and the clock stops ticking.

Ms Cherry is being reviewed by the medical registrar who has been repeatedly paged because of the proximity to a 4 hour breach. The ED manager then interrupts to point out that there are only 15 mintues left. The medical registrar rushes to finish, knowing that otherwise she may have to follow the patient up to the ward to finish the consultation. She prescribes more of the antidote and asks for a psychiatric review which will happen the following day. There is still no bed for Ms Cherry on the female medical ward, however. The last bed in the ED assessment unit has just been occupied by Mr Blueberry, and the only female bed available is on the maternity ward. She is sent there, and the bed manager makes a note to transfer her to a medical bed when one becomes available in the morning.

At 3am, all the patients have left the department without breaching the 4 hour rule. No heads will roll on this occasion. The ED manager is focusing on the next set of patients due to breach.

Let’s consider how the 4 hour rule has helped, or not helped, these four patients.

Ms Apple benefited from the 4 hour rule. Her minor injury was not prioritised on clinical grounds and she might have waited longer than 4 hours without the target, which helped draw attention to her and ensure that she was seen more promptly. (Although in fact if you include the 20 minutes she waited before being registered on the system, she was in the department for just over 4 hours anyway!).

Mr Blueberry did not benefit. In fact, he waited longer than 4 hours to be seen by the appropriate specialist team. But because he was shifted to a bed outside the emergency department he will be counted as a 4 hour success, not a failure. And there is an “out of sight, out of mind” attitude on the assessment unit, where no-one will chase up the orthopaedic team. If they do come to see him, they will wake him up and may well send him back to the Emergency Department for xrays or scans of his back. If he does get admitted to the orthopaedic ward, he is likely to be moved again, perhaps in the middle of the night.

Ms Cherry did not benefit. She was seen by the appropriate teams within 4 hours, but waiting a bit longer for the medical team would have made no difference to her, as she was already on the correct treatment, and she wasn’t in a hurry to go anywhere. The only significant effect of the 4 hour rule on her medical care is that she has been sent to an inappropriate ward rather than being allowed to wait in the ED. She is in a bed, rather than a trolley, so perhaps she is more comfortable. But the midwives caring for her in maternity do not know how to administer the antidote she needs, and they certainly don’t have stocks of it on the ward (which will probably lead to a long delay when the bag needs changing over). She will be transferred again to a different bed in the morning, making it hard for her friends to find her, and hard for the doctors looking after her to find her too. If there is a problem overnight the midwives won’t know what to do (which is not their fault) and the medical team won’t be nearby. She would have been better cared for by remaining in the Emergency Department, even if it meant waiting until the morning.

Mr Damson was immediately prioritised on clinical grounds and didn’t need any assistance from the 4 hour rule.

Overall, then, in these cases, the 4 hour rule has helped the least unwell patient be seen and discharged within 4 hours, if you ignore the bending of the rule to ignore the first 20 minutes. However, it has potentially harmed the two intermediate patients, and had no effect on the sickest patient.

I think that the main problem with the rule is not that people bend the rules and get around it (although this does happen). I think it is more fundamental than that. I think the rule (and the people who came up with it) forgot to ask themselves an important question: What is the ED for? And the answer is not to see all comers and discharge them from the department within 4 hours. It is to see all comers and achieve the best outcomes for their health, ideally in the most efficient way.

And, as my examples hopefully demonstrate, the 4 hour rule not only misses this point, it makes it less achievable. It leads to doctors, particularly specialists, being asked to rush assessments for no good reason (particularly if the ED doctor refers a patient to a specialty late). It leads to patients being admitted unnecessarily because they have run out of time while waiting for test results, taking up beds in the hospital that could be needed by sicker individuals, and potentially waiting longer overall because they now require extra discharge paperwork. It leads to patients being transferred to unsuitable wards, sometimes without being fully assessed by the appropriate clinician. Often the patients involved, who are sick enough to require admission, couldn’t care less whether they spend an extra hour or two in the ED. Few enjoy the musical chairs of ED to assessment ward to inappropriate ward to correct ward, which may take days.

It is not only the patients who can suffer. The rule leads to increased stress in an already very stressful workplace, and this stress spreads out from the ED to involve all the staff involved in admitting patients into the hospital from nurses to doctors to porters.

In exchange for all this, the benefit achieved is to see the least sick patients a little quicker, and to give the politicians some statistics to taunt each other with.

Targets can’t cover everything, and this is increasingly true as budgets get more and more stretched in the current economic climate. So if we are going to use them, it is vital to think carefully about where our priorities lie. As for the four hour rule, my priorities lie elsewhere.

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