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Message from the President: The Four Hour Target

You may be aware that the Secretary of State for Health plans to abolish the 4-hour Emergency access target from April 2011.  The council of the Society for Acute Medicine along with other National groups is concerned about this proposal as we feel this will adversely affect the quality of care for acute medical patients.

We believe the points listed below are pertinent:

  • Acute Medicine developed as specialty to improve the quality of care for patients admitted to hospital as a medical emergency
  • Over the last 10 years there have been significant improvements in the speed with which patients are moved to a hospital bed following attendance in the Emergency Department.  A key component in this improvement has been the development of Acute Medical Units and the speciality of Acute Medicine.
  • Virtually all acute hospitals in the UK now have an AMU, and more than 80% of patients admitted to hospital as emergencies require initial treatment by a multidisciplinary team on the AMU that can provide high quality care to medical patients in the period following their admission.  Delaying this would have an adverse impact on their care.
  • It has been suggested that the 4-hour target has had a detrimental impact on patient care due to difficulties with initial assessment and treatment in this time period.  However there is little evidence to support this assertion indeed published evidence demonstrates that overall <0.05% of breaches are for clinical reasons.  The key is to ensure patients are moved promptly from the emergency department into a ward area where high quality care can be delivered in an environment that provides comfort, safety, privacy and dignity.  Current evidence shows that a delay in reaching medical specialty opinion and beds correlates significantly with mortality.  The Acute Medical Unit and the acute medical team are ideally placed to provide such care for patients.  The report of the Acute Medicine Task Force in 2007 emphasised the improvement in patient care that would result from the development of acute medical units as the ‘hub’ of acute medical care within all UK hospitals1.
  • It has been suggested that the increase in the number of patients admitted to hospital for less than one day indicates a rise in ‘inappropriate’ hospital admissions.  In reality this increase is likely to reflect a reduction in length of hospital stay as a result of improvements in the process of care on the AMU.  Published data have demonstrated the benefits of an acute medical consultant presence within an AMU in reducing hospital stay for patients admitted as emergencies2.  Advances in the provision of ‘ambulatory’ care have enabled patients who would previously have required a prolonged hospital stay to be managed in a community setting.  Ambulatory care is a key component of the curriculum for training in Acute Medicine and most AMUs have developed an ambulatory care unit to enable provision of this service3.
  • We know that the 4 hour target has an evidence base that demonstrates an improvement in the speed with which patients are assessed and treated.  There are no other evidence based quality measures defined for the undifferentiated patient who presents with acute medical illness that can readily replace this target.  In addition SAM raised this important issue as part of the National Consensus Conference4.

The council for the Society for Acute Medicine supports the principle whereby quality is placed at the forefront of urgent care.  However, we feel strongly that the beneficial effects of the 4-hour target must not be lost.  It should be remembered that the 4 hour target was originally a patient-driven initiative.  Abolition of this time-based measure may allow inefficiency to flourish at a time when optimum use of resources will be so important.

The SAM council is keen to engage in discussions on how quality can be ensured within this challenging environment and thus we have written to the Secretary of State for Health for Health and are canvassing support widely. If you would like to send me any comments please do not hesitate and send them to sam@rcpe.ac.uk.

Dr Philip Dyer
President

References

  1. Acute Medicine Taskforce.  Acute medical care. The right person, in the right setting – first time. Report of the Acute Medicine Task Force. 2007. The Royal College of Physicians.
  2. McNeill GBS, Brahmbhatt DH, Prevost AT and Trepte NJB  What is the effect of a consultant presence in an acute medical unit? Clinical medicine 2009; 9: 214-218
  3. Ian Scott, Louella Vaughan, Derek Bell.  Effectiveness of acute medical units in hospitals: a systematic review. International Journal for Quality in Health Care 2009; Volume 21, Number 6: pp. 397–407
  4. Bell D; Douglas L. (Jan 2009). What are the appropriate standards for acute medicine?. Br J Hosp Med (Lond). 70:S26-S30.

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