Dalton and Mackey: Do everything you can to hit the four hour target

Some people have said that the four hour standard is no longer relevant. We don’t agree. Meeting the four hour standard in our emergency departments is a patient safety issue.

We know that we are experiencing difficulties: workforce shortages which impede the rate of change, primary care often struggles to meet demands, and social care funding requires fundamental reform.

It is also true that staff are working incredibly hard, as are their senior leaders in supporting them through these difficult times. It is because this is one of the toughest periods that the four hour standard matters more than ever.

The causes of the problems are often complex and in many cases the solutions are peculiar to the particular locality, reflecting as they do, the multiple interactions associated with patient referral, flow and transfer inside and outside the hospital.

The four hour standard was introduced so the NHS could be assured that timely care was being provided to patients

It is incredibly important though that we do not despair and accept things the way that they are. To do so would take us down the slippery slope of normalising things that we would all agree are unacceptable. On the occasions when the four hour standard is breached – it must never be acceptable to breach core standards of patient safety or patient care.

Let us remember that the four hour standard was introduced so that the NHS could be assured that timely care was being provided to patients who had urgent medical needs. It became part of a set of standards in 2004 and is now enshrined in the NHS constitution.

It affects all types of patients attending an ED – although it should be accepted that what matters most is that our sickest patients are assessed, diagnosed and admitted in the shortest time possible.

Vigilant leadership

We understand there is a need to identify legitimate low acuity activity so that the percentage reported reflects the total number of patients being seen in the urgent care system. We must be alert to the risk of leadership attention being deflected from the needs of type one accident and emergency activity.

Let us never, ever allow the counting of patients to camouflage poor care to our sickest patients just because we have been able to report a reassuringly high number to NHS Improvement.

We must be aware at all times that someone’s mother, partner or child who waits an excessive time is at risk of being denied safe and dignified care. Some patients may come to harm and some may have a terrible experience.

We must accept the responsibility for safe care as soon as the patient crosses the threshold or our ED

Being vigilant about the patient’s experience in your ED provides the barometer of the standard of care that you are prepared to accept in your hospital and what you would wish for your own loved one.

That is why the Care Quality Commission’s recent helpful guidance is a reminder that the four hour standard matters to us all. We must accept the responsibility for safe care as soon as the patient crosses the threshold or our ED – it cannot be right that we allow ambulance crews to look after patients on the tarmac or in the corridor.

We also know that we will experience surges and so our escalation plans must be fit for purpose. Rapid initial clinical assessment of a patient is vital, as is specialty review with clear admission protocols based on pathology and severity.

A simple message

Bristol’s patient safety checklist, which scooped a prestigious HSJ patient safety award this year, is probably the best tool available which helps staff from being overwhelmed by the volume and complexity of tasks in the ED.

If what matters most to you as a chief executive or hospital leader is assuring the safety of your patients, then you will want to make sure you have a method like Bristol’s to avoid omissions in basic clinical care and to help staff to recognise those patients most at risk of deterioration.

Sometimes long waits will be inevitable. When they occur, we need to ensure that standards for safety, dignity and personal comfort are upheld and that communication with patients and relatives is both timely and clear.

Our message to system leaders is a simple one: do everything within your power to meet the four hour standard and always support your staff to provide safe care.