Podcast – Targets in the Emergency Department (2014)

Welcome back to the St. Emlyn’s podcast. I’m Iain Beardsell, and I’m Simon Carley. Today, we’re going to take on a topic that is controversial in the UK. Many of you worldwide will be very aware that in our beautiful land, the emergency department has quite a lot of targets that we have to achieve. We have been world leaders in targets. This comes from our last podcast talking about trauma team leadership, which set Simon and me thinking a little bit about the targets we have to achieve in trauma and throughout the whole of the ED. So, I thought we’d just have a little chat about things.

Now, I’d need to let you know that Simon is moderately anxious and nervous about talking about this topic because it could be regarded as controversial, but we have never at St. Emlyn’s shied away from those difficult topics. So Simon, we have one major, very famous target in the UK for emergency medicine. But it’s just one of a myriad that we have to achieve. Let’s start with the four-hour access target. Could you give us a quick description of what that is and how you think it’s maybe affected emergency medicine in the UK over the last few years?

You’ve just given me that topic because I’m older than you and I can actually remember what was life before the four-hour target. Just. Is that true? Only just. I was a clinical fellow when the target came. And I remember the hospital I started at when the target was in. We were achieving 60% when it first happened and we thought we were doing really well. Tell us what the target is that we have to achieve now.

Okay, well the target is the four-hour access target or standard. They don’t like us to call them targets in written documentation, but they are the targets. Okay, so the four-hour target is an interesting one. It’s the one that focuses everybody’s mind in the ED. Pretty much all the time really. And what it means is it’s got to get 95% of our patients out of the door of the ED within four hours. So that’s either home or admitted into the hospital. That’s essentially it. 95% of them have to be out of the department, seen, sorted, and out within four hours. And crucial to that was the 5% that we have as the leeway are supposed to be clinical exceptions.

So actually we’re supposed to have 100% of our patients sorted, but we’re allowed 5% for those patients who take just that little bit longer. So the one in 20 patients who need prolonged resuscitation or further intervention, CT scanning, that sort of thing. That’s where the leeway is supposed to be. It’s not supposed to be, well don’t worry about it for one in 20 people chaps. They don’t mind so much. This target has now been adopted internationally. So what evidence do you think there is that this target is actually beneficial to patient care?

Well, as I said, I am very old, so I remember life before the four-hour target. And before the four-hour target it was a disaster. We had people waiting in the ED for days on end. I remember people being discharged three days after admission. I remember doing advanced dysrhythmia management on the corridor because we just had people piling up all over the place. We used to have regular meal trolleys that used to come around the ED because patients had been there for such a long period of time. They’d be giving out menu cards in the waiting room for patients. And you look back at those days and you think that’s absolutely unacceptable.

It was pretty awful. And so when the four-hour target came in, there was a great deal of benefit actually. Because what it did is it made the target of getting people into the hospital something which the entire organization was supposed to own. And so therefore there was much more encouragement for people to be pulled out of the ED as well as pushed out. So pulled out into services. It also allowed us to get a lot more staffing and a lot more senior staffing. So overall, and I know this may be a bit controversial, compared to where we were, I think the four-hour target has been a massive benefit to both the specialty and to our patients.

Overall, but it’s not perfect. It does have some problems. I don’t think that can be understated actually. My job was probably created on the back of the four-hour target. Without the target, I think my department in Southampton would probably still be functioning with six or seven emergency consultants rather than the 18 we have now. And the amount of resources we get compared to what we had. And it’s only 10 years ago, really, that this all started. The situation you’re describing was early 2000s in fact. It was unacceptable. Well, a lot of people will say, but the target is wrong. And it forces this clipboard mentality. And I can see that that’s been a problem. We’ve had very high provocations in the UK.

Midstaffs, obviously the major one, where the target has become the pure focus. So how do you balance up achieving a target or aiming to achieve a target whilst providing good patient care? I think you use it to achieve that. So you look at your systems and you look at how your emergency departments are working. And where we’re getting failures to get people through the system within four hours. How can we improve that? So you mentioned things like CT scanning or access to radiology. One of the great benefits of a four-hour target is if we are struggling to get our patients through because we’re waiting for diagnostic interventions such as CT, plain radiography, blood tests coming back from the lab, etc.

We can then work with those departments. And we have a lever to help those associated departments and associated services to work with us to improve speed and efficiency. So that can be really good. It’s also allowed us to develop associated specialties within the EM. So short stay medicine. So short stay ward. We’ve got loads more of those than we used to have. And they’re taking a much greater variety of patients. It’s allowed us to develop a whole range of protocols and formalize how we investigate things like chest pain, thromboembolism disease, cellulitis, asthma, etc. So it has driven innovation, ingenuity, services, associated services and it allows us to expand our own departments as well. So there are a huge number of positives.

So can you give good patient care in four hours? Yes. Can you be a good emergency doctor if you only have four hours to see a patient? Yes, but, but, but, only if you’ve got capacity. So if I told you that you’re going to go to the best emergency department in the world, has got fantastic associated services, everything’s there at your discretion. And you can get anything you like as soon as you want it. And there is no queue of patients waiting to come in the door. They’re only coming in one hour and you’re there waiting to see the patient. Yeah, you can do it. The problem comes when you have the natural ebb and flow of emergency department. So you have a sudden surge of patients arrive in our department. We can get up to 60 patients arrive in an hour. I think that’s our record. That’s a bad day.

But it doesn’t matter how many emergency physicians, many emergency nurses you’ve got on, that’s going to overwhelm your systems. And therefore then patients are not getting seen until three hours in any department. And all of a sudden your four-hour target effectively becomes one hour. And of course the hospital says, well, I’d like half an hour, 45 minutes to find a bed for the patient at the end if they need admission. So then your contact time with the patient from seeing them to make a decision becomes 15 minutes. And when that happens, no, I don’t think you can be a good emergency physician. I think the challenges are really on then.

So we’re dependent on capacity and we’re to some extent vulnerable to those user ebbs and flows, but it’s more like surges, isn’t it? That’s surge capacity when you just get so many people come in that you just can’t handle it. And we don’t have a health system in the UK that capacity plans for anything less than 100% really. So we don’t have beds sitting there waiting for patients to go to them that often. It’s one in one out really. It’s like the nightclub on a Saturday night, isn’t it? And when you’re waiting in the queue outside to get in, I suppose that metaphor means that we’re then the bouncers. But I am with you. I think the target has been a good thing.

It does require very strong clinical management to ensure that you still do good emergency medicine, which I think is possible. And actually it encourages you to focus your efforts on a history and examination. And I think you become less reliant on diagnostic testing. And I think that’s important. It is so long as it doesn’t go too far. So long as people don’t feel pressurized to making risky decisions when they don’t need to or shouldn’t have to. That they’re not trying to just send people away without doing the appropriate tests. And that can happen. And if people get getting close towards the four-hour target, you can get pressure put on junior doctors to make a decision.

Now people often don’t bother whether it’s the right decision. They just need a decision. Is this patient going to go home or do they need to come in? If they need to come in just to refer them. Now it could be that a longer period of time would have made a more sensible disposition for that patient to the patient’s benefit. And probably also the system’s benefit. But if the pressure is on to make a decision, it can be very challenging. And we do see people make not necessarily harmful decisions but poor quality decisions which are not necessarily in the patient’s best interest. So that’s just one of the targets we have in the emergency department.

As I say, we are world leaders in targets. And I just scribble down a couple of others. So not just the four-hour target, we also have seven further quality indicators they’ve been called, which were developed a few years ago. And they cover all sorts of different things about the numbers of patients who leave before being seen. The time it takes to see a senior decision maker, the vital signs recording when they first arrive in the department. The list goes on and on. For international listeners, if you’ve just got the four-hour target, you’re just beginners at this. Because not only do we have those ones, we also have new targets related to financial penalties if we don’t achieve them.

Whether or not our patients in our short-stay ward have VT risk assessments done, do you have those Simon? As a national one, I think. So 95% of all patients in a short-stay ward. Well, inpatients have to have a VT risk assessment. We have ones about signposting to psychological services. The list goes on and on. How do you, in your department, make sure the focus stays on clinical care and not just box ticking? I think that’s about clinical leadership. It’s clinical leadership on the shop floor and it’s about having good managers. We have some excellent managers where we are who do recognize that clinical care is extremely important.

The problem with the introduction of many of these is they do take quite a bit of time. During my working day, in my head, I divide it up into direct patient care. So me, at the bedside, doing stuff with patients and then other stuff, which includes really important stuff like writing the notes and liaison with specialties and stuff. And I have found over the years with the increasing number of bureaucratic processes that I’m spending slightly less of my proportion of time with patients, which is a great shame. Now, there’s nothing wrong with any of those standards that you said. They’re all motherhood and apple pie, aren’t they? They’re all good things to do. And that’s where I find a lot of the dilemma.

You can’t argue very, very sensibly against safety, against making sure that we do the things that we should. The tricky bit comes when they become universally applicable, which means we end up asking people things which probably isn’t relevant to them. And also that they become cumulative. So you spend more and more, it’s only two minutes to do this one particular extra thing. But if it’s two minutes for every patient, and you see 200 patients a day, that’s 400 patients. And if you add another two minutes for the next thing, next week, another two minutes for the next thing, next week. You end up in a situation where you can almost have no ability to see a quantity of patients during a shift because you’re just spending too much time doing an administration.

So we have to be very careful that we don’t overburden our colleagues with too many administrative tasks. But their aim is laudable in that all the things they want us to do to look at, they’re good things in general. Some of them lack a particularly robust evidence base, but they’re hard to argue with most of them. I think the problem I have is that our specialty, which I love, gets talked down because of the number of targets we have to achieve. And also departments that are functioning really well, and I know this is close to both our hearts, where they’re supplying good patient care, get put in a league table for a particular target.

And it appears that that department is doing badly for that particular thing. Yet it has strong clinical leadership and provides good clinical care. But if you look at a league table, and let’s not forget that if you looked at midstaffs a few years ago, the hospital that had so many problems, they would have functioned very well on a league table. That becomes a way in which that department’s morale and the way in which it’s regarded locally by its patients and regionally by its colleagues can become less admired than it perhaps deserves to be. And good practice can go unrewarded because it doesn’t focus necessarily on a target.

And that takes me back to where we were before is that you use the target to improve clinical care. So if you’re close to the wire or if you are failing to meet the target, and I don’t like that word failure, but it’s used a lot. So if people come around and say you’re failing to meet the target, you as a clinical leader and as a manager use that information to support the services so that you can achieve the target, but in doing so you improve the lot of your patients. And I actually do feel slightly sorry for some of our colleagues who don’t have a target because they don’t get the same coverage that we get in the press and they don’t get the same funding that we get.

At the moment, you can’t really go a week without seeing an emergency department story on the front page of a major national newspaper. And we get money thrown at us whether that’s winter pressure money or other money to try and help us achieve these targets. And I do have a sympathy with our colleagues in, for example, psychological medicine who don’t get the same amount of funding that we get. We do need to remember that we’re quite lucky with the support we get to achieve these targets, even though for some people they’re not the greatest thing that they enjoy about their jobs.

So Simon, the reason that we thought about this was related to our last podcast about trauma team leadership and the targets that we have for trauma. And I know that you have some concerns about that which we’ve reflected in a blog post. Just talk us through some of your thoughts about the trauma targets that we have to achieve and how that can be both beneficial and detrimental to patient care. Well, the major trauma systems have recently hit the UK. And that’s great. And as part of that, there are series of standards which major trauma systems should have. And all for that, I think it’s good that we have calibrated care and we’re all trying to achieve the best that we can.

The ones which I think are very interesting to you and me are the targets for the trauma team leaders. And the first of those is that they need to be seen by a consultant within five minutes of arrival. And that’s for any patient who subsequently is found to have an ISS of more than 15, which is an anatomical measure of injury. The second target is that of those patients, they should all get to CT within 30 minutes of arrival. I think that’s incredibly challenging. So take two of those separately. Take the first one.

Patients who come with an ISS of 15, if you’re pre-alerted and you know the patient is going to arrive, they’ve been full enough the motor cycle, they’re coming in by helicopter, they’ve been seen by the pre-hospital emergency medicine team, they’ve had an RSI and thoracostomies on scene. You’re going to know about it and you’ll be waiting at the front door. It’s not a problem. But what about Mrs. Miggins? Mrs. Miggins is 85. She fell over a stool at home a couple of days ago.

She had some pain in her chest, it’s been a bit sore, breathing’s not been so good. She bumped her head and then when her daughter came out, she was a little bit confused, not quite right. So she brought her into hospital a couple of days later. You CT her, she’s got a small subdural and a broken rib. She is a major trauma patient. And because she was not seen by a consultant within five minutes of arrival, you have failed to achieve your target. And it’s the same standard, but these are wildly different patients. And I’m really struggling with this. I don’t know what you think.

It’s important also to say that this target isn’t just about a leak table, but this relates to money. As far as I understand it, if you don’t achieve every aspect of the major trauma target series, you don’t get the tariff for the patient. So as a major trauma center, we’re shipping people in or having them shipped into us from what you could describe as out of our area. That will mean the hospital in essence won’t get cash for the treatment they provide if they don’t have the consultant.

So if Mrs. Miggins needs an inpatient stay and she needs some other bits and pieces doing, the hospital may not get the right amount of money to pay for that. In fact, the hospital is paying for her themselves. They’re not getting the funding. The funding in the UK is incredibly complicated. It seems to change every couple of years. I struggle to keep up with it, but that’s the essence of the thing, I think.

The problem with targets is that we use the same one for everybody, like you describe for psychiatric patients with a 95% target. Sometimes we pick out patients who don’t apply because it suits us. But for these trauma patients, that’s really hard. You could be absolutely fabulous at the 25 year old motorcyclist who’s been tubed who needs to get to CT. You do everything for them.

But when you look at that leak table again, of how well you’re performing, because you live in an area with lots of elderly patients who come in as you describe, you don’t look like you’re doing so well. And you have to sit in a meeting and the people leading the meeting said, “But your major trauma service needs completely reconfiguring.” And that doesn’t represent what you’re doing.

It’s really interesting. And my other concern with it is the CT target, getting to CT within 30 minutes. That’s incredibly challenging. If you do take a multi-traumatized patient who maybe hasn’t been seen by your helicopter service with this advanced trauma team pre-hospital, and they come in with very little done.

To get interventions safely done, such as RSI, chest drains, intravenous access, maybe even a major hemorrhage pack, get a pelvic binder on. These take a degree of time. And I have great concerns that if we’re pushing people against a time target, that we risk safety. So I put it to you. Iain, we’re not going to do the RSI checklist because we’re close to time to get to CT, just get the patient tubed. And these are lessons we should learn from the four-hour access target about how we should manage all these other ones.

I think it’s the role of the clinical lead on any shift to ensure that the patients are safe. I’ve got to say in recent years, I don’t think we’ve had as many problems with that as we used to in the very early days when we were trying to achieve a 98% target. And it was pretty rough many, many years ago when it first came in. I think we do have good quality management and good quality colleagues who do understand that if we turn around and go, “This is a clinical exception, this patient’s not safe to go, or it’s not in their interests to go.” It’s unusual that we come across major arguments anymore.

And I’d agree with that. Things have got a lot better. And we can only talk from our positions of two different hospitals in the UK, but not just because this is going out publicly, but my trust has very strong leadership, and I’m very lucky with that. So I don’t really have these discussions that often, but I think we’ve learned through experience from the mid-staff experience about the way in which hospitals need to conduct themselves with these targets. And hopefully we can keep using these for the benefit of patients.

The one thing I just, we always have to bear in mind is that any hospital system is running with multiple targets, so the ED has targets. Now our surgical colleagues also have targets, but these are often longer. So the 18-week wait to get in and have your diagnostic process once you’ve been referred by a GP. And I don’t envy the hospital management, they have to balance those different competing priorities.

So you need to get your CT scan within 30 minutes. There’s also Mrs. Jones, who’s been waiting four weeks for her CT to have the diagnostic process the general surgeon has asked for. She’s going to have to get bumped to get my trauma patient in. There’s only so much capacity. We can’t keep, we do not have unlimited resources.

And I think as ED physicians, we sometimes forget that. We always think we should come first. Admit our patient to the ward. We need to get them out in four hours. But for every patient we admit to the ward, that may mean a planned elective patient isn’t able to come and have their operation.

And not just for targets, but for that patient who’s been building up for that major laparotomy to manage their colorectal cancer, that’s a big deal. And it’s important we make sure they were making the right decisions about who comes in, not just referring people because it’s easiest for that target.

And I can completely agree. And I suppose one of the risks of the four-hour target is that we make the wrong decision and actually do refer more patients than we require because that’s not good for the entire hospital system. And it’s why I’m a pretty good advocate for earlier senior intervention.

And we still struggle in the UK at the moment that many of our departments are essentially operated by doctors at junior levels of training. We’ve got a pyramidal structure with the base, the widest number of doctors, the broadest number of doctors are relatively junior. We don’t have that many attendings or consultants to see the patients.

And I think as we go forward into the future and the number of consultants increases, we can hopefully make early decisions, more robust decisions using a more senior cohort of emergency physicians. That will help, but it’s going to take time.

And it will take us changing our mentality a little bit, getting to consultant level in the UK now for almost any specialty doesn’t mean you sit in your ivory tower while your junior doctors do all the work. I don’t just get to do the trauma. It’s the same as our consultant surgeons. They’re doing the wardrobes often by themselves as our way in which we staff hospitals changes.

So it’s not just about changing the numbers we have, but as consultants we will have to change the way we think about what we do, I think. And that is a challenge. I think that’s true. So long as the high level of skills that you get from being a senior trainee and a consultant in emergency physician are not wasted, wasted is the wrong word.

We do need to make sure that we’re not moved to the minors area of the department because we can see patients very quickly and make rapid decisions at the expense of delivering high quality resuscitation to patients in the majors and the recess. And one of the things that I’m sure you’ve faced is how do you prioritize your very senior decision makers and their activity within the emergency department.

And certainly our approach has been our principal role as an emergency physician in the ED is to ensure that critically ill and critically injured patients are managed well. That’s number one priority and will always remain so.

Again, that’s down to strong clinical leadership because the temptation to move your most senior decision maker to minors to see the 20 patients who are about to reach the four-hour target at the expense of the one patient who’s in recess, who probably isn’t going to reach the four-hour target is a difficult one when you’re faced just with numbers and not with people.

And that’s why it’s sometimes helpful to bring managers into the clinical environment and to point out what it is you’re trying to achieve. As I say, we’re lucky where I work and I hope that most hospitals in the UK are the same will be interested to hear from listeners about how they feel these things are approached in their hospitals.

But our management definitely do understand that and hopefully some of things will come out of the mid-staff inquiry and this will be one of those things that will change and has changed and will continue to change. And the priority comes first and there’s no way we can emphasize that enough.

I would agree. I think the summary for me is that targets are there. I didn’t choose them. They’re not the targets I would have chosen. But if you’re clever and you’re wise, you’ll use the targets to improve clinical care and you can do that. We have done that and we should continue to do so.

But we’ve paid the money to be clinicians to look after patients and that’s where our priorities lie. Hopefully that’s been a thought-provoking discussion for you. You’ve had a bit of a think about how targets affect you. If you’re new to emergency medicine and you’ve heard bad stories about the four-hour target and how it affects what you can do, hopefully this reassures you that you can be excellent doctors within four hours and supply excellent care.

And also that your clinical leaders, your consultants and your management staff put patients first. We’d love to hear more from you about how this works in your hospital. Please do get in touch. But for now, from this St. Emlyn’s podcast, good luck with your emergency medicine and take care.