UK’s four-hour wait limit

Long waits have become so typical in the ED that it seems cliche to even mention them. But it’s still a serious problem. The average for a patient in the U.S. is something abysmal, but I don’t even want to ask about the maximum wait. I’m guessing you’d measure it in days, not hours. And until today, I assumed that any solution to this problem would have to be a bottom-up approach, not mandated from on high. However, I had the chance to have a few words with Dr. Edward Glucksman, the emergency physician in charge of international emergency medicine in the United Kingdom, and what he told me shed new light on the issue. 

According to Dr. Glucksman, a few years ago, Tony Blair’s government made a bold, seemingly over-reaching claim. They stated to the public that after a finite period of reforms initiated by the government, no one in the ED would wait more than 4 hours to be in a bed or sent home. Ever. This statement set off a series of extensive studies into what exactly caused wait times in the UK and how hospitals could attempt to meet this goal. According to Glucksman, the mandate actually put heat on hospitals and administrators in a way that physicians had been unable, and progress started to be made. Now, a few years out, 98% of all ED patients in the UK are in a bed or out the door in under 4 hours. That’s the max, mind you, not the mean. Now don’t get me wrong, I don’t want the federal government micromanaging the ED any more than the next guy, but this certainly got me thinking outside the box…   

-Logan Plaster

Emergency Physicians Monthly


Comments

  1. I worked in the NHS for 4 years, 3 at an acute hospital. Those target were nuts. They drove staff up the wall, had so much micro-management to the point EACH week day, there was a 30 min meeting with some execs and other middle management trying to stay on top of it, there were loop holds and extra ‘wards’ being set up to get around the targets. Patient’s got re-directed to their GPs or the local ‘walk in’ centre. There were more jobs created in emergency (with no extra money) so it put greater financial pressure on the entire hospital (and the funding model is completely different to the US).
    Most people in the UK have a GP- however getting an appointment is easier said than done.
    I’m all for redirecting patients to appropriate care, but PATIENTS need to be education about what an emergency is!

  2. Hey Logan — with all due respect you need to do some deeper research. Apparently the ED’s meet this requirement (noboday seems to know how many) by leaving patients in the ambulance and not admitting them to the ED right away. I’ve blogged on it, it’s in the BBC. I have no idea how common the practice is but I bet some of you’re ED collegues from the NHS could tell you. I think the mandate is counter productive. Rather than trying to achieve real progress there trying to meet what appears to be an unreasonable goal given the resources they have.
    http://www.waittimes.blogspot.com

  3. There’s an interesting Canadian blog about shortening wait times at http://waittimes.blogspot.com/.

    He’s got some good ideas, and some interesting studies (I’m not affiliated with the blog in any way, just find it interesting.)

  4. Thanks for the comment Ian. What you are saying makes total sense, and I’m glad there’s someone out there blogging about this. It sounded nuts to me too, but here I was, talking to a gentleman who had experienced it up close and personal and was actually feeling quite optimistic. I’ll try to bring up your questions to the UK docs here at the convention if I have a chance.

  5. Patient’s got re-directed to their GPs or the local ‘walk in’ centre.

    Am I the only one that thinks this part is a fantastic concept?

  6. Thanks for the vote of confidence guys. I emailed a friend in the NHS (physician with emerg interest redoing training in anaesthesia) and asked him to pass on my blog address to anyone that he thought might be interested. His response, in a nutshell, was that he & his collegues just feel like a cog in the machine. They don’t seem to feel the need or benefit from lower wait times (or maybe no control over them). I think the NHS took an interesting approach but I don’t think it’s working.

    Ian.
    http://www.waittimes.blogspot.com

  7. The Knifeman has a blog post about the four hour limit and how it can result in documentation of discharge prior to actually being seen by a physician.

  8. I agree with every misgiving that has been presented, but for the sake of healthy debate, I pose a question. Are there changes that need to be made at the hospital administration level, difficult decisions, in order to address long wait times? And if so, does there need to be pressure brought to bear beyond that of emergency physicians? I’m not saying it should be the federal government, I’m just raising the question. What do people think?

  9. Patrick C says:

    I recall reading a paper, maybe where Glucksman was a co-author (I can’t find the paper now) which described a protocol, something along the following lines:

    The Emergency department had an attached primary care physician facility, with a few primary care physicians working in it. A new triage category was introduced, “primary care”, and patients could be directed to a PCP by the triage nurse. Patients were billed some nominal fee to see the PCP (about #15 if I recall), with a bit more to see the emergency doctor (maybe #20?).

    This was a patient satisfaction survey; patient satisfaction improved under this system.

    I recall thinking to myself that EDs are really not set up with patient satisfaction in mind, and really it should be a lot further down the list of goals for an ED than a PCP visit. I guess an ED works under the assumption of time pressure, the objective is to diagnose and stabilize very sick people quickly. Generally in primary care there is the luxury of time, so if a physician takes a week to get a diagnosis together it’s not a problem. This gives the PCP time to focus on patient satisfaction.

    Caveat: as I said, I can’t find the paper now, and may have misremembered some bits.

  10. I would like some more thoughts on the comment “How do we educate patients on what is a true emergency?” I am constantly amazed at the number of patients that feel that they need to be seen at 0300 for a 99 degree temp (or similarly minor complaint)

    Any suggestions for that type of patient education would be greatly appreciated.

  11. My suggestions is to allow appointments in the emergency. Sounds riduculous but when these patiens call in they can be screened. I’ve hunted down a hospital in the UK that’s doing it and I’m trying to get details to see if it has any effect. I’d worry that it’d great delays in critical care or be ineffective.
    http://www.waittimes.blogspot.com

  12. The only ways wait times can be reduced is to divert patients,hire more staff and open more beds.
    That is the only solution. Problem is that costs money and it appears that spending is of no interest to anyone.

    At first contact with the triage RN in the ER any patient presenting without an emergency (and of course an emergency is going to need to be defined) they get sent home to make an appt with their family doc or they can choose to use the hospital provided handy walk in clinic next door.
    They will be required to fill in paperwork that affirms that they had the opportunity to access medical care and they accepted or refused.

    An emergency needs to be defined clearly and then this definition needs to be disseminated through television, print and right at the front door of the ER.

    The hospital administration who just loves the revenue a thousand coughs and sniffles gets it’s revenue and the ER returns to it’s mandate.
    All that is required is the will to draw a line in the sand and to hire enough staff to move the clinic along at a lightening pace.
    People with true medical emergencies are not aware enough to worry about wait times.

  13. Northern UK Doc says:

    I’m a junior UK Doc in Emergency Medicine, so I’m one of the shop-floor guys rather than a manager. Since I’ve qualified I’ve only worked in a 4-hour maximum system, so I can’t easily compare with before. Overall I think the 4 hour wait is a good idea, but as with most targets gaming the system soon started to tale place. Whilst not unloading ambulances has been reported I’ve never seen it happen, or heard of a colleague seeing it themselves. What I have seen is “observation wards” and “assessment units” being set up which are not part of A&E and so the clock stops as soon as they go there. Sometimes this is before we’ve got a good working diagnosis, and that function shifts to another doc.
    From a personal point of view being nagged by managers as soon as a patient turns yellow (over 2 hours) and then red (over 3 hours in dept) on the system is annoying. But in 4 hours I can usually work out if someone is likely to need to stay in hospital, or can go home and see their GP.
    The major difference I believe has been that waiting times is now a hospital wide and not just A&E problem. Specialities are put under pressure to review patients in A&E promptly, Radiology and the labs return investigations quicker, and most importantly in-patient discharge planning and action got a lot of attention so that beds were available earlier in the day and patients weren’t only in A&E because there were no beds anywhere, receiving care on trolleys in corridors with no privacy is not suitable and had to change.
    One of our local A&Es is having a GP walk-in centre built onto the front of it, they will review all walk-ins before they go onto A&E (it’s all to do with budgets unsurprisingly…)
    The downside is if you are seeing most minors patients in about 2 hours then you become a victim of your own success as it maybe easier to attend A&E than see your own GP who will ask you to book an appointment.
    I also think 98% is a little too high as there are a fair few seriously ill patients, or difficult to diagnose patients who could benefit from a little more time in A&E, but the line has to be somewhere. Most docs just use their clinical judgement and take it all on the chin from the managers if an early move is not in the patient’s best interests.