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Does the four-hour A&E target hinder patient care?

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Avoiding A&E breaches is central to staff nurse, Ben Mullin’s, every shift. He questions if the target shifts focus to the wrong priority.

In 2000, the Department of Health established a four hour target for A&E departments. The target dictated that by 2004, 100% of patients (revised to 95% in 2010) should be triaged, and treated, admitted or discharged within four hours of arrival at the department. When this was introduced I was far from a nurse, in fact I was seven years old!

But fast forward 16 years and it now governs my day-to-day endeavours. I work on a surgical admission unit in a major trauma centre and the clock is always hanging in front of us – like a carrot on a stick.

I understand that the target aims to make sure treatment is giving without delay, but I cannot help feel this sometimes gets in the way of high quality care.

”I strongly believe in not treating patients as numbers”

As a staff nurse on the ‘shop floor’ my goal is to provide a high standard of safe care to my six patients. I’m not motivated by shipping patients in and out - some might say I don’t belong in an admissions area. I strongly believe in not treating patients as numbers. I absolutely hate waking somebody up at 04:00am, packing up all their belongings and wheeling them to other side of the building.

It seems that everyone above me in the chain of command is driven by patient flow. Personally, when I get home from a busy day I don’t think to myself “I admitted and moved so many patients today”. That’s not what makes me proud after a day’s work. Making patients laugh, comfortable and feel reassured is what gives me my sense of achievement.

So why do I feel that the four hour target affects my ability to achieve this?

Take this scenario: It’s 5pm, dinner time, a notoriously hectic time on the unit.

”Making patients laugh, comfortable and feel reassured is what gives me my sense of achievement”

All of the discharges from the surgical base wards are now completed – which means transfer time! The bed manager arrives on the ward like clockwork with an abundance of bed moves.

At this point A&E is backing up with patients waiting for our beds to free up, so the pressure builds. Matrons and bed managers appear and ask why people haven’t moved to their allocated beds. Often it’s because they’re mid-meal (whatever happened to protected meal time?), or it could be because they’re unstable for transfer, or not had their medication.

Regardless of the reason, they want the patient moved from A to B, apparently disregarding patient experience.

It’s difficult to be motivated by politically derived goals when they hinder quality of care. If time and pressure were not problems the service we would provide would be impeccable.

I’m not saying that a system isn’t needed, but we also need to find a way of motivating staff who work on the shop floor to political targets. 

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Readers' comments (1)

  • The four hour target is key to patient care in A&E. Whilst it has become viewed as too simplistic in the current field of practice, those who remember the days before the target and patients spending significant amounts of time in A&E will remember the positive impact that the introduction had.

    Is the target right for the future? Probably yes, we need something that is going to bring together the different elements of the system. The Four hour target is not just about A&E but about the whole system. If we see and treat the patient in less than 2 hours, but then wait 8 hours for a bed, there is nothing A&E can do to address that.

    If we only applied the 4 hour target to patients who were admitted? - probably just as good, as until you have seen the patient you don't know if they are going to be admitted, you would have to run an efficent A&E to ensure you still met the target.

    There are other Care Quality Indicators that are also used, just not as readily reported on at a national level in the press. The headline number needs to be something that is easy to understand by all.

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