The 4 hour target

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So, a while back, the ConDem government said they’d be getting rid of lots of health service targets. There are, of course, multiple ways to look at this. As someone pointed out to me, when they instigate one target, they don’t really know what effects it’s going to have on any other part of the system, nor the subtle ramifications of the target itself. They skew treatment priorities – for example, the four hour ‘standard’ in the ED has meant that patients with more serious conditions sometimes end up waiting longer to be seen because we have to clear a backlog of minor injuries. And to ensure that gets done within the four hours, we’ll steal doctors from the ‘majors’ team.

Patient experience can be compromised as we push and push teams to accept patients they’ve not reviewed onto wards – with the intention that they’ll be reviewed there – because we need them out of our department within four hours. We do, or at least I do, only push for ‘stable’ patients to have this done, and we do ensure they have analgesia – and often other medications written up. But still, it’s an effect that was probably not forseen when they were implemented.

We have a ‘sepsis’ protocol which means that patients who meet the sepsis criteria should have antibiotics given within one hour of attendance, which sounds like plenty of time, but for patients who come through triage it’s a struggle. If you wait 15 minutes for triage, and 25 minutes to get an initial assessment done* another 10 to get antibiotics prescribed & mix them (and some of these are not the easiest to mix); get them checked and administered. For that hour you’ll often find you’ve got two nurses tied up ensuring that all that is done, and other patients just have to wait.

Staffing levels haven’t changed to take account of how much more we’re doing as an ED, and for nurses, how many more tasks we’ve taken on that used to be the doctor’s jobs.

So anyhow, wandered off from my point there. The main point I’m getting at is, as an ED nurse I’ve often argued that the four hour target is not always a great thing. Indeed, I’ve condemned it for skewing care, for making me feel pressured, for making me move patients who I’m not really 100% happy to move, etc. But the concept of losing the target completely worries me deeply.

Before the target came in, I spent an enjoyable 12 hours in the ED in Bristol waiting to be seen for my ‘back pain’ (this is before I was a nurse) which turned out to be a pyelonephritis. I was in loads of pain for those 12 hours, and quietly getting sicker and sicker in the waiting room. I’m one of those disconcerting people who goes quiet when their in pain. Really, really quiet. Which is not necessarily a good thing. I know nurses who vividly recall full EDs with patients not moving because the hospital was full. Patients from the previous shift were still there the next day, and ED nurses became pseudo ward nurses, complete with drug-rounds for patients who’d been there so long they’d otherwise miss their medication.

The four hour target forces the entire hospital to work hard at admitting and discharging patients. It means we’ve developed better methods of caring for people at home, and access to rapid input for social care. Not just that, it’s good to be able to say to a patient roughly how long they’re likely to be in the ED – and how long before they get a ‘proper bed’ – because ED trolleys are not comfortable.

It does, however, instill a level of patient entitlement which really winds me up. Yesterday I triaged someone at 20 minutes after arrival – who stropped about waiting so long for triage, then ranted about the concept of waiting 2 hours to see the doctor (for his day-old hand injury). Indeed, he ranted so much that I gave up on triaging him, because he kept stalking off when I tried to explain and so I never did assess his hand; just documented that he was aggressive, and that he had a non-specific hand injury that he wouldn’t let me assess. Another family (triaged at 10 minutes and advised that their child had broken their wrist (even I could see that on the X-ray they’d had in another department), and advised it’d be around an hour ’til they saw the doctor (offered analgesia for their child in the mean time), did the whole “How long?!”. This from people who’ve seen me triaging five-at-a-time (we have a minimal triage scheme for minor injuries which is, with the patient’s permission, performed in the waiting room**) to try and get through vast number booking in (seriously, I did five patients, came back, and found four more had booked in). As a side point, I asked if they’d had someone talk to them about the Xray – they said ‘no’ so I brought them in, I’m not giving out confidential medical information in the waiting room, just so as you know.

And while I can wax lyrical about how this culture of entitlement is (a) really annoying, and (b) inappropriate, and (c) really annoying. And I can go on at length about the patients who I’ve had to move at inappropriate times, or who’ve had their care interrupted, or the worst possible experience thanks to the four hour target, I think as a *target* it’s a good thing.

The problem is that this whole 98% standard forces staff, from us lowly RNs up to the senior management to behave erratically to try and meet something which isn’t necessarily appropriate for the individual patients. But remaining in place as some sort of moderated target? I think that’s appropriate and ‘a good thing’.

I’ll miss it when it’s gone, but I expect it’ll nicely cover the falling investment in the NHS. Because without the targets, and the figures**** that go along with it, the quiet disintegration of the NHS will be neatly undocumented.

* Observations, note that they meet the criteria, find a free ‘majors’ bay, changed into a gown, enough history to decide a most probable cause of infection, blood taken and cannulated (from multiple sites for individuals with existing access devices), perform a venous gas (same as an arterial gas but with venous blood. Lord help you if they’ve got ‘difficult’ veins and no existing access devices. I’ve got much better at cannulating people who’ve had chemotherapy (which often screws up your veins), but they’re still enough people that I struggle with.
** Yes, seriously. I am aware of the confidentiality issue here, but it’s policy, and for minor injuries – which is what it’s for, if the patient happily gives consent*** (even a brief hesitation leads to the ‘would you rather we talk inside’ offer) I’m reasonably happy to do it.
*** In general the questions I ask are “What’s brought you in today?”, and “Would you like any pain killers”. Sometimes it requires “Can I just see both wrists/ankles/hands”. And in some cases that leads to “let’s just get you inside for an X-ray”.
**** Lies, damn lies and statistics.


Kate's allegedly a human (although increasingly right-wing bigots would say otherwise). She's definitely not a vampire, despite what some other people claim. She's also mostly built out of spite and overcoming oppositional-sexism, racism, and other random bullshit. So she's either a human or a lizard in disguise sent to destroy all of humanity. Either way, she's here to reassure that it's all fine.