Monday, June 16, 2008

Should the US & Canada Adopt England's 4 Hour ER (A&E) Wait Time Guarantee

The National Health Service of the UK is extolling the virtues of their recently enacted 4 hour ER (A&E) wait time guarantee. The goal of the program was to have 98% of the patients who entered an emergency (or accident and emergency) treated within 4 hours of registering. Implemented in 2003, the goal was achieved within 4 years.

How it Works

Each month hospitals in the NHS submit electronic data on the disposition of A&E (ER) patients. Starting in fiscal 2003/04 hospital accident and emergency departments had to meet a standard of 98% of patients dead, discharged or admitted within 4 hours of registration or face financial punishments. There are penalties of $1,000 assessed for each 0.1% a hospital emergency department falls below the 98% goal (assessed monthly). Conversely, if greater than 65% of minor patients are seen within 2 hours, rewards of $10,000 are assessed for each 1% above (assuming the 4 hour target is being met). If a patient is readmitted to the ER within 14 days all fees are paid at 50%.

The Result

The results of the program are impressive*. Despite a similar volume of patients the number of patients that had to wait greater than 4 hours went from 10-12% to 2% within 4 years of implementation. During the same period short stay admissions to the wards increased. Although the report “Trends in children and young people's care: Emergency admission statistics, 1996/97 - 2006/07, England” does not address it a dramatic upsurge is noted in short stay admissions for adolescent and emergency consultations coinciding with the implementation of the 4 hour wait time policy. The mandate has also spawned a new job description; “breach avoidance officer/consultant”. Although morbidity and mortality data is available I was unable to draw conclusion as it relates to the 4 hour window.

The Scuttlebutt

While publicly lauded as a major achievement it is hard to find public words (that are not government documents) that praise the policy. The NHS Blog Doc who is rarely at a loss for words has an entire post dedicated to the A&E targets.

Dr Rant uses more colourful language to describe the policy
“… the total fuckwwittery that is the NHS Government targets”.

Nelly and I says “You see I’m not sure that staying less than 4 hours in an A&E department is necessarily good for you, or what we would call ‘in the patient’s best interest’.”

Even anti-Michael Moore sites are taking notice of the problems of ambulance stacking.

Since bloggers are notorious for ‘stirring the pot’ I also contacted friends in the NHS. The scuttlebutt from insiders is that major patients are being compromised to meet minor goals because funding does not differentiate between the two types of cases. It is easier to push through minor cases and claim the $10,000 reward. Rumor has it that the three main ways to beat the system are to allow longer, tougher cases to wait, admit more cases who would normally be dealt with in the emergency department or convince patients to sign out and see their family physician in the morning. There are other more inventive ways to deal with the situation (like not accepting ambulance cases from the ambulance dock) but the small number of these cases are apparently minor compared to the vast number of people going coming through the doors.

My Take

There is an obvious difference between what the politicians are saying and what the staff claim is reality. The 4 hour goal is laudable but has it increased the total time to the patient because a greater percentage are being admitted? Does the goal somehow endanger people by promoting quick rather than quality care?

Most lean systems create a metric and alter the systems until a goal is met. Implicit in lean changes is an awareness of quality. The 4 hour ER wait time guarantee sets the standard then allows the systems to change around it. Management is controlling the goal not the systems. The public servants are put in the unenviable position of having to cheat the system to maintain funding for the very patients seeking care. As employees of the government they don’t directly benefit from meeting the goals.

While I’m sure there have been some improvements in efficiency because of this policy my suspicion is that corners are simply being cut. The government has taken the ER wait time statistic which is easy to calculate and sensitive to staffing, patient load, inpatient beds and arbitrarily set it at a fixed point. The ER wait time statistic which was sensitive (but not specific) to general hospital performance now becomes nearly useless.

In its place, statistics on bed usage, morbidity and mortality and ER usage are required. As I have described elsewhere, hospital report cards, especially related to morbidity and mortality are much more difficult to measure and control. Assuming that you could account for patient factors such as age, gender, cardiac severity and comorbid status you still have to contend with random error, variation in patient usage and other less known factors that affect report cards. It is extremely difficult to measure quality across a nation, let alone prove that it is being compromised.

Even if one assumes that quality has not been compromised (despite what is being written) there is no doubt that admissions are going up. Patients are more likely to be out of the A&E in 4 hours but they stand a much greater chance of being admitted and spending an extra 24 hours in hospital. In lean and six sigma terms it has been proven that greater complexity creates greater risk for error. An admitted patient now interacts with an exponentially greater number of staff and procedures, each of which will have an error rate.

If the NHS had used a cohort of patients as a metric (rather than the time in the A&E) they could follow the total average time. This, coincidentally, correlates very well to the total average cost. Take 1,000 asthmatic or diabetic patients and follow their course in hospital before and after the change. What was the average time invested at the A&E, how many died, how many ended up admitted due to poor management?

The original question was “should the US and Canada adopt a 4 hour ER wait time guarantee?”. I believe the answer to be that it is unwise to set an arbitrary number as a guarantee. Financial incentives can be an instrument of change but using those weapons against ER wait times has unintended consequences. I am impressed by the rapid control of the variation in how long patients wait but concerned by the potential risks. It is better to direct funding, personnel and lean consultants to streamline the flow of patients through the emergency and track the ER wait time as a measure of success rather than a goal to meet. A 4 hour wait time is an excellent standard to set but it should not be tied to funding.

Amendment: Someone sent me this link after I posted. The average wait time in the US is 4 hours and 8 minutes! I followed the links and found the survey is from 2006.

*all graphs are from UK Department of Health Reports

1 comment:

Anonymous said...

I have worked in both the UK and Canada as an ER nurse. The UK's 4 hour target has helped to focus everyone's attention to the goal of reducing time spent within the ER. The biggest improvement is that minor patients who had been left 12 hours waiting are now being seen and discharged/admitted within the 4 hours, sometimes at the expense of more urgent cases. Where I work in Canada, I feel that minor cases are left till last to be seen because they are not seen as an emergency by staff. Although these patients will be seen, it sends a message to them to think twice or to use alternative routes for treatment in the future. Now in the UK, everyone expects to be treated within the 4 hours, to my experience, more are attending ER instead of going to family doctors or clinics because of the ER's success. UK may have shot itself in the foot.