ACADEMIC EMERGENCY MEDICINE 2011; 18:1239–1241 © 2011 by the Society for Academic Emergency Medicine
During the 1990s, relentlessly increasing emergency department (ED) attendances in the United Kingdom led to major dysfunction and ED overcrowding. The situation was exacerbated by outdated ED design, inadequate ED capacity, traditional ED processes, a predominantly junior doctor–based workforce, and insufficient in-hospital beds for patients requiring admission.
The crisis led to high-profile lobbying by the U.K. emergency medicine body (British Association for Emergency Medicine) and in the populist media. This led to the Reforming Emergency Care initiative and the 4-hour target.
This article describes the benefits and disadvantages associated with a single time-related measure of ED performance. The article also describes the subsequent development of a raft of quality indicators designed to provide a greater breadth of ED measurement, reflecting timeliness, quality, and safety. The intention is for these indicators to act as levers for change and to generate a program of continuing improvement in emergency care.
The indicators were introduced in England in April 2011, and currently there is a period of bedding-in and collective learning. The quality indicators will be reviewed and refined as required, with any amendments introduced in April 2012.
During the later years of the last millennium, emergency departments (EDs) in the United Kingdom saw a steady increase in patient attendance numbers that significantly outpaced improvements in the ED workforce, development of hospital-wide processes, and in-hospital bed capacity. As a result, EDs became the pinch point in the system, and overcrowding became a major issue with waits for hospital admission of up to 72 hours. Photographs of elderly patients “warehoused” in EDs appeared in the media, and there was a political recognition that action was required. As a result, the Reforming Emergency Care initiative occurred in the early 2000s, which generated a major focus on system-wide emergency care, ED workforce, and physical plant and recognized the need for a time-related incentive—the 4-hour target.
This stipulated that all patients attending the ED should be admitted, transferred, or discharged within 4 hours. A 2% buffer of “clinical exceptions” allowed those patients who might deteriorate unexpectedly, or other legitimate clinical factors, to be accommodated within the overall measures. During the initial few years, the target appeared to be highly successful and many benefits accrued, including improvements in the ED workforce, recognition of the need for better processes, and some improvement in hospital capacity. Unfortunately, these changes were not universally adequate to address an ever-increasing emergency care demand, and from 2006 many EDs were struggling to meet the target on a sustained basis. There was immense pressure on hospital managers to comply with the target, often it seemed at almost any cost. This led to pressures on managers and clinicians to achieve the target. In turn, this led to distortion of clinical care, gaming, and manipulation of data, all products of an unhealthy target culture.
During 2010, a new administration was elected in the United Kingdom and the new Secretary of State for Health was receptive to the concerns expressed by the College of Emergency Medicine and others regarding the dysfunctional state resulting from the use of a single time measure, particularly as this was an inadequate way of recognizing issues of quality and safety. There were some high-profile examples in the United Kingdom of major safety compromise resulting from the target culture. The initial response from the coalition government was to abandon the target. There were great concerns, however, that the abolition of the target would result in immediate dilution of focus on emergency care, which would compromise the entire system and patient care.
As a result of these concerns, the College of Emergency Medicine, Royal College of Nursing, and the Department of Health worked closely together to develop a new set of quality indicators designed to reflect timeliness, quality, and safety. These measures were designed as a group of 8, in theory of equal importance, designed to ensure focus across the range of ED activity. Details of the indicators and the rationale behind them are available from the Department of Health website (http://www.dh.gov.uk/publications) and a guide to implementation at the College of Emergency Medicine website (http://www.collemergencymed.ac.uk).
In summary, the indicator groups are:
- 1Service experience—quarterly feedback from patients, carers, and staff.1
- 2Left ED without being seen—this reflects the satisfaction of patients with the initial care provided in the ED. The rate should be minimal, and best practice would be below 5%. This is a group of patients potentially at high risk of subsequent adverse events.
- 3Unplanned reattendances—this is another known high-risk group. Good practice is for a reattending patient to be seen by a different and more senior clinician. Rates above 5% are likely to reflect poor quality, but rates below 1% may reflect excessive risk aversion.
- 4Time to initial assessment—this must be meaningful and therefore should include a pain score and vital signs to derive a physiological early warning score. The aim is for this assessment to occur within 15 minutes of the patient’s arrival. In the first instance, this will be in patients transported to the ED by ambulance—a surrogate measure for potential severity of the presentation.
- 5Time to treatment2—expert clinical opinion suggests patients should be seen by a decision maker within 60 minutes of arrival, with more prompt assessment for time-critical presentations, for example, sepsis, stroke, and myocardial infarction. A median above 60 minutes from arrival to see a decision making clinician may trigger intervention.
- 6Total time in the ED3,4—excessive total time in the ED is linked to poor outcomes. A 95th percentile wait above 4 hours for admitted patients and nonadmitted patients is not good practice. The indicator also suggests that the single longest wait should be no more than 6 hours.
- 7Consultant sign-off—at present much emergency care in the United Kingdom is delivered by relatively junior, although excellent, doctors who are inevitably inexperienced, particularly with regard to the challenging ED case mix. The aim is to increase the number of patients who are reviewed in person by the ED consultant. The aim of this is twofold: to improve quality of care for high-risk conditions and to drive the agenda for increasing emergency medicine consultant numbers. In the first instance, three exemplar conditions have been selected for consultant sign-off—adults with nontraumatic chest pain, febrile children less than 1 year old, and unplanned returns.
- 8Ambulatory care—practice in conditions suitable for ambulatory care varies widely. Two exemplar conditions, cellulitis and deep vein thrombosis (DVT), have been selected, as these are, in the most part, better managed on an outpatient basis following initial assessment and diagnostic workup in the ED. Evidence suggests that 60% to 90% of cellulitis cases and over 90% of DVT patients may be managed on an ambulatory basis.
It is intended that the suite of indicators should act as a group to provide a comprehensive set of balanced measures reflecting timeliness, quality, and safety. However, to provide focus and engagement, five indicators were initially identified as representing potential triggers for intervention according to the performance management program of the National Health Service. These are:
- 1Unplanned reattendances—greater than 5%.
- 2Total time in the ED—95th percentile wait above 4 hours.
- 3Left without being seen—a rate at or above 5%.
- 4Time to initial assessment—95th percentile time to assessment above 15 minutes.
- 5Time to treatment—a median above 60 minutes from arrival to seeing a decision-making clinician across all patients.
The spirit and intent is that these should function as indicators—not targets—to allow individual organizations to measure their current performance, establish the reasons for underachieving, and identify the measures required to improve followed by implementation of the new strategies.
Perhaps inevitably, the early experience of the new quality indicators as they have bedded in is that a target culture has rapidly emerged. In the worst-case scenarios, this has represented a multiple of the adverse issues surrounding the single 4-hour target, and clearly this is distant from the intention of these new quality indicators.
Unfortunately, the political imperative resulted in the quality indicators being implemented without the opportunity to undertake proper piloting and evaluation. We all are therefore in a collective piloting exercise, and it is inevitable that this should be a somewhat bumpy ride during the first few months.
There is a very definite balance that should be struck between soft indicators, which may not generate focus and improvement, against a target culture, which results in distortion and dysfunction. The indicators must have teeth to be effective as edentulous indicators are impotent. However, a balance must be struck between the two tensions to ensure that patient care is optimized as intended.
The College of Emergency Medicine is confident that these new quality indicators will result in significant improvements in patient care and is working with the Department of Health and other organizations responsible for monitoring and regulation to ensure that the correct balance is achieved. The current quality indicators will be subject to detailed review and refinement with amendments as required in the second iteration due in April 2012.
In addition, it is important to note that there is a statement within the new indicators (although not formally performance managed as yet) that no patient should be in the ED for more than 6 hours. The significance of this applies to particular subsets of patients, in particular those requiring admission to intensive care and mental health patients. The College believes that this will provide a major drive to better systemwide processes and capacity planning, although clearly much work is required in this area.
The quality indicators are an important step in providing focus on care in the ED and prioritizing this on the clinical and managerial agenda. However, they must be regarded as indicators for improvement and levers to drive change, not sticks with which to beat clinicians. Careful ongoing evaluation is essential to ensure the maximum benefit from these changes.