Exploring emergency department 4-hour target performance and cancelled elective operations: a regression analysis of routinely collected and openly reported NHS trust data

Abstract

ObjectiveTo quantify the effect of intrahospital patient flow on emergency department (ED) performance targets and indicate if the expectations set by the National Health Service (NHS) England 5-year forward review are realistic in returning emergency services to previous performance levels.DesignLinear regression analysis of routinely reported trust activity and performance data using a series of cross-sectional studies.SettingNHS trusts in England submitting routine nationally reported measures to NHS England.Participants142 acute non-specialist trusts operating in England between 2012 and 2016.Main outcome measuresThe primary outcome measures were proportion of 4-hour waiting time breaches and cancelled elective operations.MethodsUnivariate and multivariate linear regression models were used to show relationships between the outcome measures and various measures of trust activity including empty day beds, empty night beds, day bed to night bed ratio, ED conversion ratio and delayed transfers of care.ResultsUnivariate regression results using the outcome of 4-hour breaches showed clear relationships with empty night beds and ED conversion ratio between 2012 and 2016. The day bed to night bed ratio showed an increasing ability to explain variation in performance between 2015 and 2016. Delayed transfers of care showed little evidence of an association. Multivariate model results indicated that the ability of patient flow variables to explain 4-hour target performance had reduced between 2012 and 2016 (19% to 12%), and had increased in explaining cancelled elective operations (7% to 17%).ConclusionsThe flow of patients through trusts is shown to influence ED performance; however, performance has become less explainable by intratrust patient flow between 2012 and 2016. Some commonly stated explanatory factors such as delayed transfers of care showed limited evidence of being related. The results indicate some of the measures proposed by NHS England to reduce pressure on EDs may not have the desired impact on returning services to previous performance levels.

Why are there long waits at English emergency departments?

“…As has previously been found [17], our study confirms that long waits are less common in Trusts with lower bed occupancy rates, so efforts to reduce bed occupancy might also help reduce long ED waits by allowing patients to be admitted more quickly to an inpatient bed. Depending on the drivers of inpatient occupancy rates, this might be achieved through an increase in the supply of inpatient beds or by changes to admission and discharge policies.…”

“…For each quarter, we calculate the average percentage of available overnight beds that are occupied, after excluding maternity beds. 10 The higher the occupancy rate, the lower the capacity to admit new patients from EDs [17,26,27]. This might result directly in a wait over 4 h for patients to be admitted, or indirectly affect all ED patients by contributing to crowding within the ED.…”

“…With one exception, previous studies have examined the impact of single factors on breaches of the 4-h target, but not explored the effects of these factors in combination [2,11] or have been limited to a single ED [7]. In a more comprehensive analysis, Keogh et al explore the relationship between breaches of the 4-h waiting time target and other performance measures, notably cancelled operations, using quarterly data from 2011 to 2016 [17].…”

A simple prognostic score predicts one‐year mortality of alert and calm emergency department patients: A prospective two‐center observational study

“…In addition, the decision to admit or discharge patients in both cohorts was made by whatever the treating physician encountered and not by explicit evidence‐based criteria. Others have reported that decisions to admit patients to hospital can show considerable variation and can take a long time and many resources . Moreover, the decision to admit can be influenced by numerous factors such as the patients' perceived instability, concern about the patients' ability to look after themselves, their or their relatives' preferences or institutional reasons such as bed‐availability, available technology etc .…”

“…This is largely explained by the fact that most Esbjerg patients were assessed by a can take a long time and many resources. 29 Moreover, the decision to admit can be influenced by numerous factors such as the patients'…”