Do target waiting times in emergency departments affect patient care? New Zealand has followed England's lead end introduced target waiting times for those presenting at emergency departments. An emergency care nurse in England looks at the impact of target waiting times and explores some issues nurses here should consider.
Article Type: Report
Subject: Nurses (Practice)
Hospitals (Emergency service)
Hospitals (Laws, regulations and rules)
Patients (Care and treatment)
Patients (Methods)
Hospitals (Waiting lists)
Author: Yarwood, Sally
Pub Date: 10/01/2010
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: Oct, 2010 Source Volume: 16 Source Issue: 9
Topic: Event Code: 200 Management dynamics; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand; England Geographic Code: 8NEWZ New Zealand; 4EUUE England
Accession Number: 241179370
Full Text: The introduction of a four-hour target for stays in emergency departments (ED) in England has brought about dramatic change in the health care system. There has been a move away from prolonged patient stays on stretchers in ED corridors, ambulance off-toad delays and patients remaining in EDs over night, causing difficulties for nursing staff.

In New Zealand the Government, as part of its hearth reforms, has introduced a six-hour ED stay standard. (1) Target times for ED stays are also being introduced in other countries, eg Canada. This article explores the affect of the four-hour target since its introduction in England and the impact it has had on quality of patient care and nurses' practice.

As a New Zealand-educated registered nurse specialising in emergency nursing and working in an English National Health Service (NHS) hospital I have experienced the positive and negative impacts of the four-hour target on nurses and on patient care.

Original target 'unrealistic'

In 2001, the British government implemented targets in the NHS, with the aim of ending tong ED stays for patients and providing accessible and appropriate hearth care. (2) The original target was for 100 percent of all patients arriving at EDs to be seen, admitted, discharged or transferred within four hours. (3) However, this was revised in 2005, as it was realised it was unrealistic. (3) The current standard is for 98 percent of patients to be admitted, discharged or transferred within four hours of arrival at the ED. The aim of the target was to increase the speed of treatment and improve the patient experience. (3)

The implementation of the four-hour target was considered necessary in response to a higher demand on health services, ever increasing ED waiting times, ambulance off-load delays and patients staying overnight in EDs--all of which caused increased stress levels, concerns about quality of care and nurses' and other health professionals' workloads. (4,5) In an effort to prevent further escalation of these problems, England introduced the reforms, which to date, have had mixed results.

The introduction of the four-hour target has created an increased need for staff training and staff specialisation, eg the number of nurses "seeing and treating" minor injuries has increased. It has been argued that in this situation the patient is neglected as ED nurses tack time, which results in inadequate assessment and planning of care or intervention. (3)

Expansion of advanced nursing roles

With the introduction of the four-hour target has come an expansion of advanced nursing rotes, with the use of emergency nurse practitioners (ENP) and emergency surgical nurse practitioners (ESNP), with beneficial results. The ESNPs' rote of co-ordinating patients' progress through the system has led to "developed protocols and guidelines that allow the prescription and administration of intravenous fluids and ordering chest and abdominal X-rays." (6) Although this in itself does not necessarily lead to better outcomes, there is evidence that patients seen by ENPs are less likely to "seek unplanned follow-up advice about their injuries than those seen by doctors".(7)

A literature review found that with the four-hour target, patients no longer had excessive waits on trolleys in corridors. (3) Nurses have also benefited, insofar as some no longer feet the stress and anxiety produced by prolonged ED stays, which meant patients waiting in corridors.

In a 2008 Royal College of Nursing (RCN) survey of 500 ED nurses, 52 percent felt the four-hour target was a positive initiative. (8) However, they also felt that for improved patient care, the percentage of patients seen within four hours needed to be lowered.

The pressure on health professionals to meet targets can have a negative impact on patient care. Inappropriate patient discharge has seen an increasing number of re-admissions to EDs. (9) In 2002/2003, 11.6 percent of people aged over 75 were readmitted to an ED within 28 days of discharge. This had increased to 13.82 percent in 2006/2007. (9) Appropriate community services for discharged patients is one suggestion to prevent readmission. (9)

A number of English newspapers have suggested the government's obsession with health care targets may read, not only to financial repercussions for hospital managers unable to meet targets, but also to a decline in the quality of patient care, as hospitals constantly function at 100 percent occupancy. (10) The financial burden and high occupancy rates have already led to an increase in pressure on both ED and ward nurses. The RCN survey revealed that nine out of ten EB nurses felt unduly pressured to meet the four-hour target. (8) A survey completed by the British Medical Association in 2005 stated that 91 percent of the respondents had experienced direct or indirect pressure to meet the four-hour target. (11)

Increased pressure on ED nurses

According to the then chief executive and general secretary of the RCN, Peter Carter, nurses found the targets "restrictive and unrealistic in providing the care they would like". (8) This increased pressure on ED nurses has had negative consequences on patient care, including inappropriate admissions to unsuitable wards. (8) A Health Commission report suggests assessment and/or treatment is tacking, due to demanding targets and understaffing. (3)

The negative repercussions of the four-hour target and the burden this can place on health professionals, as well as hospitals' drive for financial stability, is illustrated in what occurred at the Staffordshire NHS Hospital. In 2008 the Healthcare Commission began investigations into Staffordshire Hospital due to a consistently high mortality rate for patients admitted as emergencies. (12) The Commission's investigations uncovered understaffing that had been exacerbated by recent lay offs, poorly equipped departments, eg a lack of defibrillators, unsupervised junior doctors and a lack of staff training. (12) lack of proper assessment and/or treatment, due to the four-hour target, and rushed admissions occurred. Clinicians' attention was being diverted from critically unwell patients to those with less life threatening illnesses. (3) Hospital managers were so obsessed with targets they didn't correct serious failings, such as staff shortages (30 patients to one nurse), which led to multiple deaths and poor quality care. (13)


Other examples of inappropriate care due to four-hour targets include "patient stacking" or "ambulance ramping", where patients are left in ambulances until they can be seen and treated within the target. (14) Manipulation of numbers to show targets are being met (15) and neglect of staff education (3) are other examples of inappropriate activity due to the four-hour target. In the Staffordshire example, targeted staff education could have prevented deaths, as health professionals were found to be ill equipped to handle certain situations.

Since the four-hour target was introduced in England, both New Zealand and Canada have introduced target times for ED stays. As in England, this has been in response to an increase in patient numbers, leading to overcrowding, prolonged waiting times, ambulance off-load delays and cancellation of operations. (16,17) Following the 2008 general election, the New Zealand government, concerned about ED waiting times and triage targets not being met, formed a "working group" to examine these concerns. (17) The working group comprised six senior ED clinicians (medical and nursing), two senior district health board managers, three Ministry of Health officials and one professor of emergency medicine. (17) The working group decided to follow England's example and introduced targets, including the introduction of an operational standard. This standard, that "95 percent of patients to be admitted, discharged or transferred from an ED within six hours", was introduced on July 1, 2009. (18)

Target times for ED stays are considered necessary to assist in reducing patient stretcher stays and to facilitate timely access to health care. They also free up ambulance and other health professionals for other services required. However, in the English health system the financial implications of failing to meet specific targets has shifted the focus from patient-centered care to an economically-driven government mandate.

Positive and negative effects

Through examining both the positive and negative effects of the NHS's four-hour target in EDs, it is possible to develop some recommendations for future practice. A recent RCN conference suggested current hospital targets failed patients because of the shift of focus from patient care to an economic target. (8) A recommendation from the conference was to reduce target percentages to 95 percent, with a view to re-establishing the priority of improving health care rather than on meeting targets. (15)

It seems New Zealand's working group has already learned from the English experience, because it extended the English target of four hours at 98 percent, to six hours at 95 percent of the time. (17) This means potential adverse effects, such as "ambulance ramping", a decline in patient care and outcomes and manipulation of numbers, can be avoided.

Another issue in this debate is staffing levels, particularly for nurses and doctors, as both are fundamental to efficiently functioning hospitals. The use of ENPs and the implementation of "seeing and treating" will expedite patient flow through EDs. Using ENPs at the Royal United Hospital in Bath has been effective in increasing patient flow and reaching targets. (6) In a submission to the Ministry of Health, the NZNO acknowledged the need to develop, not only NP roles in ED, but educator roles as well. (19)

Interestingly, a decrease in waiting times has seen a rise in the number of attendances at all EDs. (3) This rise is not necessarily causal rather more coincidental The rise in ED attendance has necessitated an increase in the number of beds, community services and health professionals required to provide services. To manage the rising numbers of patients, the NHS introduced "off-loading wards" for direct admissions--certain ED patients go directly to these medical and surgical assessment units to assist in achieving the four-hour target. These units have been described as specialised "assessment" units. Their role it is to "assess and treat" GP-referred and expected patients and ED patients for up to 24 hours post presentation at ED. (6)


With the introduction of a target time for ED stays and the ensuing management pressure, it is important nurses maintain their role as patient advocates to prevent inappropriate patient discharge and admission to unsuitable wards. This avoids catastrophes such as those at the Staffordshire Hospital, while ensuring patients are directed to the most appropriate treatment places . (3)

To ensure an efficient and effective patient journey through the health system, health professionals need to collaborate and communicate effectively. One way is "discharge liaison services" with GPs, to set up community placements, and patient services such as practice and district nurse visits. (6) Patient risk assessments and closer collaboration between hospital and community services to ensure a decrease in readmission rates are also essential. (9)


The introduction of the government-driven four-hour target to EDs in NHS hospitals has decreased patient waiting times and stretcher corridor stays, and has ensured prompt patient assessment and treatment. But it has come at a price, including inappropriate admissions and patient discharges, rushed and inefficient patient care, ambulance ramping, and increased stress and anxiety for nurses and other staff.

New Zealand now has a target time for ED stays. It is essential the lessons from the English experience are learnt, thus avoiding a repetition of what happened at Staffordshire Hospital. Recommendations to ensure quality patient care is maintained when targets are in place focus on increasing the number of nurses and doctors, and staff training in specialised practice areas, bed management and hospital policies.

Using and supporting ENPs and ESPNs in EDs is one way of supporting and relieving pressure on other nursing staff. Increasing bed numbers and facilities within the hospital, eg establishing acute medical and surgical assessment units, are also recommended, as is enhancing hospital and community co-operation and communication when patients are discharged.

Acknowledgement: I would like to thank Eastern Institute of Technology lecturer Gill Scrymgeour for her help with this article.

This article was reviewed last month by Sandra Richardson, BA, RN, DipSocSci, PGDip(Health Sci), Dip Teach (tert), PhD candidate, nurse researcher at Christchurch Hospital's emergency department (ED) and a senior lecturer at the Centre for Postgraduate Nursing Studies, Christchurch School of Medicine and Health Sciences, University of Otago; Iona Bichan, RN, MN, ED charge nurse at Palmerston North Hospital; and Lucien Cronin, RN, MN, ED staff nurse at Tauranga Hospital.


(1) Ministry of Health. (2009) Recommendations to Improve Quality and the Measurement of Quality in New Zealand Emergency Deportments: A Report from the Working Group for Achieving Quality in Emergency Departments to the Minister of Health.$FiLe/quatity-ed-jan09.pdf. Retrieved 07/07/10.

(2) Department of Health. (2001) Reforming Emergency Care. dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4058836.pdf. Retrieved 07/03/10.

(3) Elston, K. (2010) Effects of the four-hour operational standard. Emergency Nurse; 17: 9, 3-15.

(4) Lamont, S.S. (2005) "See and Treat": spreading like wildfire? A qualitative study into factors affecting its introduction and spread. Emergency Medical Journal; 22, 548-552.

(5) Mortimore, A. & Cooper, S. (2007). The "4-hour target": emergency nurses' views. Emergency Medical Journal; 24, 402-404.

(6) Baker, J., Ashton, N., Williams, C., Rumble, M., French, J., Pressley, S. & Salamon, T. (2004) On target in A&E. Nursing Management; 11: 7, 19-22.

(7) Jarvis, M. (2007) Satisfaction guaranteed? Emergency Nurse; 14: 9, 34-37.

(8) Royal College of Nurses. (2008) A&E nurses under pressure to meet four hour target, p1. a_and_e_nurses_under_pressure _to_meet_four_hour_target Retrieved 04/03/10.

(9) Duffin, C. (2008) Targeting early discharge. Emergency Nurse; 16: B, 16-18.

(10) Ellis, R. (2008) Why are so many doctors sending their patients home too early? Record numbers are readmitted to hospital after surgery. The Daily Mail; 41, December 30. London: Associated Newspapers Ltd.

(11) Health Policy & Economic Research Unit. (2007) Emergency Medicine: Report of national survey of emergency medicine, p10. medicine/Emergencymedsurvey07.jsp. Retrieved 22/04/10.

(12) Healthcare Commission. (2009) Investigation into Mid Stoffordshire NHS foundation Trust. %20report.pdf . Retrieved 22/04/10.

(13) Carvel, J. (2009) National: Minister rejects calls for public inquiry into hospital scandal: Brown apologises for patients deaths in Stafford: Health tsar to ask why failings persisted for years. The Guardian; 15, March 19. Manchester: Guardian News and Media Ltd.

(14) Cockcroft, L. (2008) A & E patients 'kept in ambulances to meet time targets; The Daily Telegraph; 8, February 18. London: Telegraph Media Group Ltd.

(15) Lipley, N. (2009) Nursing staff warned not to 'fiddle' waiting time figures: call for change in four-hour operational standard at RCN Emergency Care Association conference. Emergency Nurse; 17: 7, 4.

(16) Priest, L. (2008) Emergency-room nightmares spur calls for action. The Globe and Mail; A10, November 3. Toronto: CTVgtobemedia Publishing Inc.

(17) Tenbensel, T. (2009) Emergency department waiting time targets, p2, New Zealand/13/Emergency department_waiting_time_targets.html/ Retrieved 04/03/10.

(18) Ministry of Health. (2009) Shorter stays in ED health target, Retrieved 04/03/10.

(19) New Zealand Nurses Organisation. (2009) Submission to the Ministry of Health on the recommendations to improve quality and the measurement of quality in New Zealand emergency departments, www.nzno. Retrieved 04/03/10.

Sally Yarwood, RN, BN, is a staff nurse in the emergency department of the Royal United Hospital, Bath, United Kingdom.
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