The 4-hour window: UK Government targets versus clinical priorities

Abstract

IntroductionIn 2002, the Department of Health (United Kingdom) introduced a 4-hour target due to long waiting times. It is expected that 95% of patients who attend the A&E (Emergency) Department should be registered and admitted/discharged within 4 hours. Exceeding this is termed a “breach”.ObjectivesThe aim of this re-audit was to assess for a response following recommendations after an initial audit with concerning results. Forth Valley Royal is an acute public hospital in Central Scotland with 860 in-patient beds, covering a population of 300,000. It contains two general adult wards (42 beds), one IPCU (12 beds) and two Elderly wards (40 beds).MethodsReferral data was sourced across 4 consecutive months: April–July 2015 (initial audit) and October 2015–January 2016 (re-audit). These included all referrals from A&E to Psychiatry. Times were calculated for the 4 subprocesses listed in Table 1 below.Conclusion/discussionFollowing the initial audit, interventions such as training A&E staff to better manage psychiatric patients and encourage earlier referrals, led to a positive response in the re-audit (Subprocess 1). Breach rates reduced to 28% (from 35%) on re-audit. Less breaches (81% compared to 88%) were referred after 2-hours by A&E. Overall, the breach rates have reduced and they are less attributable to the A&E referring patients late. The outcome of patients leaving A&E without being seen by a psychiatrist was unknown – adverse outcomes would strengthen the debate to enforce the 4-hour window.Disclosure of interestThe author has not supplied his/her declaration of competing interest.Table 1Initial audit = 222 referrals (35% breach rate)Re-Audit = 348 referrals (28% breach rate)