Implications of England's Four-Hour Target for Quality of Care and Resource Use in the Emergency Department

Study objective

In 2005, England implemented a controversial target limiting patient stays in the emergency department (ED) to 4 hours. We determine the effect of the “4-hour target” on quality of care and resource use.

Methods

This was a retrospective study of 15 purposively sampled EDs in England, representing a range of performance on the target. The EDs provided administrative data on all visits for May and June, 2003 to 2006. These years spanned the period before the target until more than a year after full implementation. We assessed changes in admission rate, investigations, deaths in the ED, and return visits within 1 week for all patients and separately for those aged 65 years or older. Regression analyses adjusted for clustering at the hospital level and changes in acuity reflected by ambulance arrivals. Results are expressed as the estimated annual change in the percentage of patients experiencing the outcome, with 95% confidence intervals (CIs).

Results

A total of 772,525 ED visits were analyzed; visits increased 19% during the 4-year period. Between 2003 and 2006, the percentage of patients arriving by ambulance decreased from 27.8% to 25.8% (annual change from 2003 −0.80%; 95% CI for change: −1.48% to −0.12%). Visits by individuals aged 65 years or older were stable (19.9% to 19.1%; annual change −0.19%; 95% CI for change −0.44% to 0.06%). Between 2003 and 2006, admissions from the ED were unchanged, at 23% (95% CI for change −0.43% to 1.11%). The percentage of patients receiving blood tests increased from 13.8% to 19.8% (annual change 1.00%; 95% CI for change −0.09% to 2.08%). Frequency of radiologic studies decreased slightly, from 38.0% to 35.7% (annual change −0.60%; 95% CI −1.58% to 0.37%). Deaths in the ED and return ED visits within 1 week were unchanged. Return visits resulting in hospital admission increased initially and then returned to 2003 levels (annual change −3.10%; 95% CI −7.32% to 1.11%).

Conclusion

England's 4-hour target did not appear to have a negative effect on quality or safety of ED care and had little effect on test use.

Introduction

Emergency department (ED) crowding is an international problem, with well-documented negative influences on quality and safety of care.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 In 2005, England instituted an emergency care target, setting a maximum limit on the length of stay of 4 hours from time of arrival to discharge home or moving to an inpatient bed.13, 14 Australia, New Zealand, and parts of Canada have since followed suit with targets of 4 to 8 hours.10, 11, 15

In the United States, where crowding has been labeled a “crisis” for years, the Centers for Medicare & Medicaid Services is just beginning to monitor ED length of stay.16, 17 Although potentially speeding ED patient flow and reducing waits for physician evaluation or admission, a focus on time risks causing perverse consequences. Emergency physicians could simply choose to admit patients rather than attempt to evaluate them within the 4-hour window, resulting in more admissions. In addition, the number of laboratory tests and radiographs might increase as a substitute for a period of observation, and ED deaths or return visits might increase because of incomplete evaluations, diagnostic errors, or insufficient discharge instructions and follow-up arrangements as providers keep an eye on the clock.

In 2011, England's coalition government de-emphasized the 4-hour target in favor of quality measures.18, 19 Yet the target was never formally evaluated. We therefore conducted a study to evaluate how quality of care and resource use was affected by the 4-hour target.