ACUTE SERVICES Study reveals 'disconcerting' levels of variation in quality of care

Published: 11/08/2005, Volume II5, No. 5967 Page 7

Breaches of the four-hour accident and emergency target for the most seriously ill or injured patients ultimately admitted to hospital are being 'masked' by the high number of patients sent home from A&E within the timescale.

A Healthcare Commission study of 170 A&E units across England reveals that only 83 per cent of patients eventually admitted to hospital between April and June last year were dealt with within the government's fourhour target. However, among patients who were ultimately discharged, 96 per cent were sent home within the specified timescale.

At the end of 2004, all trusts met the target of admitting or discharging 90 per cent of patients within four hours. The target has since increased to 98 per cent.

But Healthcare Commission lead researcher in A&E and author of the report Bill Alexander said the Department of Health did not require separate results for admitted and discharged patients.

'The relatively higher risk of a stay longer than four hours for those who are admitted can be masked within the overall measure, ' Mr Alexander writes in the report.

Speaking to HSJ, he said: 'Patients who are admitted tend to take longer to clear than discharged patients and you cannot be certain that it is for clinical reasons.

'What it probably means is the hospital is short of beds or is not managing its beds as well as it might. The monitoring process needs to recognise that admitted patients have separate problems from discharged patients. They tend to be sicker, more seriously injured and it is more difficult to clear them from A&E because they need a bed if they are going to be admitted.' Mr Alexander said it was up to strategic health authorities and trusts to monitor performance when it came to admitted patients.

The report described the variable quality of care in A&E departments as 'disconcerting'. It established that only 40 per cent of A&E departments have separate facilities for children which are staffed 24 hours a day. An additional 20 per cent have separate facilities, but they are only staffed for part of the day.

Mr Alexander said the lack of children's nurses was a continuing problem: 'It is a cause for concern, but it doesn't mean that those A&E departments not retaining children's nurses are not catering for children.' The report recommends trusts to review their services for children to ensure their needs are met.

Healthcare Commission chief executive Anna Walker said: 'Monitoring standards of quality must become a core part of the day-today management of these units.

'Our new annual health check will examine quality standards relevant to A&E. Are patients treated with dignity and respect? Are they cared for in a secure environment?

Are trusts taking into account nationally agreed best practice on clinical issues?' Quality standards relevant to A&E will now be brought into the commission's new assessment system after the report found half of all children and elderly patients were waiting too long for pain relief.

Healthcare Commission report: the key findings

Just over 53 per cent of children in moderate or severe pain after fracturing an elbow or wrist and 42 per cent of hip fracture patients received analgesia within an hour of arrival at accident and emergency.

British Association for Emergency Medicine guidance says relief from severe pain should be received within 20 minutes.

Some 71 per cent of patients rated their overall standard of care as excellent or very good.

Minor injuries and walk-in centres now handle more than 20 per cent of all A&E attendances.

Since 2000, the average department has 20 per cent more nurses, 27 per cent more doctors and 37 per cent more consultants.

There is more use of bank and agency staff in London, which has an average nurse vacancy rate of 16 per cent. This may be a reason for patient survey results showing less satisfaction in the capital.