COMMENTARY

A&E Perspective: Can We Trust England's 12-Hour Breach Statistics?

Dr Dan O'Carroll

Disclosures

February 28, 2019

"The greatest trick that the Devil ever pulled was convincing the world that he didn't exist." This rephrasing of the French poet Charles Baudelaire 's work made famous in the movie The Usual Suspects came to my mind recently as the UK's Emergency Departments (ED) struggled to keep up with demand, and the worst ever 4-hour performance figures were released by NHS England.

The figures come as no surprise, and once again challenge ED staff beyond what many would consider acceptable or safe.

   

Dr Dan O'Carroll

  • The total number of attendances in January 2019 was 2,112,000, an increase of 5.6% on the same month last year

  • There were 564,000 emergency admissions in the month, 7.2% higher than the same month last year and the highest number on record. Emergency admission growth over the last 3 months is 6.0% and over the last 12 months is 5.7%  

  • 76.1% of patients were seen within 4 hours in type 1 A&E departments, which is the lowest since this collection began, compared with 79.3% in December 2018 and 77.2% for the same month last year

And once again the performance of the staff should be commended,

  • The number of attendances admitted, transferred or discharged within 4 hours was 1.78m, a 4.4% increase on the equivalent figure for January 2018

Although that seems a small percentage, this represents nearly 70,000 extra patients. A medium sized ED would see somewhere around 80,000 patients per annum.

  • There were 83,519 4-hour delays from decision to admit to admission in January, which compares with 81,231 in the same month last year and is the highest number since this collection began

Worryingly, of these patients that breached 4 hours, many of them waited many hours more. Unacceptable delays occurred whilst waiting for a bed.

  • Of these, 616 were delayed over 12 hours (from decision to admit to admission), which compares with 1054 in the same month last year

'Misrepresentation of The Scale of The Problem'

Twelve-hour breaches are hugely significant, as these must be reported on the daily sit-rep to NHS England and can bring unwelcome scrutiny to the trust. More importantly than that, the 12-hour breach needs to be considered in terms of a poorly patient, not being admitted to an appropriate bed, and sometimes not being given the in-patient care that they have been referred for in a timely fashion. This may include the omission of critical drugs, such as anti-parkinsonian medication, which may prolong their hospital stay

I'd suggest that most of us working in emergency medicine would question the validity of such a small number of 12-hour breaches, and I believe that this number is a gross misrepresentation of the scale of the problem. Unfortunately, the reported data measures the 12-hour target as commencing from decision to admit. This means it is open to 'interpretation', if being generous, or 'gaming', if being more cynical.

I'd suggest that most of us would consider a 12-hour time to be measured from the time of arrival until the time of admission/departure, as the most honest and appropriate way of reporting this parameter. To the patient, this is probably the only way it would be considered. 

Unfortunately the guidance from NHS England for these states:

The waiting time for an emergency admission via A&E is measured from the time when the decision is made to admit, or when treatment in A&E is completed (whichever is later) to the time when the patient is admitted.

Time of decision to admit is defined as the time when a clinician decides and records a decision to admit the patient or the time when treatment that must be carried out in A&E before admission is complete – whichever is the later.

Unrealistically Low Numbers?

So? Why is the reported number of 12-hour breaches so low in England whilst the much smaller populations of Wales and Northern Ireland are reporting proportionately much higher numbers? In the final 3 months of last year, Northern Ireland reported 6102 patients breaching 12 hours whilst Wales' figures reveal 3800 breaches in September 2018.

I've noted that Wales' apparently poorer performance often comes up in political discussion between the opposing parties and is often used as a stick to beat the opposition. Are the systems in England more robust and are the patients getting a vastly better experience? Unfortunately, I don't think so.

Wales reports its 12-hour breeches in the manner that most of us think to be fair and appropriate i.e. it is measured from time of arrival until departure. Trusts in England use various different methods for delaying the 'start of the clock'.

Ways in which the reported figures can be 'manipulated' involve the definition of the decision to admit time (DTA):

  1. Starting the 12-hour clock at the time of the referral and taking that as the DTA, this often occurs 2-3 hours into the patient attendance time, i.e. after they've waited to be seen by the ED team, investigations and initial treatments carried out, and then the decision made

  2. Starting the clock after the patient has been reviewed by the speciality team after referral and them agreeing with the ED assessment and that the patient required admission. This can be several hours after time of arrival, and often over 3-4 hours from time of referral.

  3. If a patient is 'bounced' between specialities, the latest DTA is the one considered for the purpose of reporting

  4. Our unfortunate mental health patients seem to be in a completely different time zone

These are just four of the ways that patients can spend much longer than 12 hours in the ED, and yet they don't show up on the reported figures.

I'd suggest that the national picture is even worse than is being reported and may be unsolvable in the current political climate, and that this, ultimately, is one of the reasons for the proposed review/changes to the ED 4-hour target. Keeping a much larger number of 12-hour breaches out of the public record avoids media scrutiny and condemnation, but does nothing but worsen the patients' experience, and causes poorer outcomes including increasing the length of stay, for many.

It's a trick that even Keyser Soze would be proud of.

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