Implications of England's Four-hour Target for Quality of Care and Resource Use in the Emergency Department

Study Objective: In 2005, England implemented a controversial target limiting patient stays in the emergency department (ED) to 4 hours. We determine the effect of the "4-hour target" on quality of care and resource use.

Methods: This was a retrospective study of 15 purposively sampled EDs in England, representing a range of performance on the target. The EDs provided administrative data on all visits for May and June, 2003 to 2006. These years spanned the period before the target until more than a year after full implementation. We assessed changes in admission rate, investigations, deaths in the ED, and return visits within 1 week for all patients and separately for those aged 65 years or older. Regression analyses adjusted for clustering at the hospital level and changes in acuity reflected by ambulance arrivals. Results are expressed as the estimated annual change in the percentage of patients experiencing the outcome, with 95% confidence intervals (CIs).

Results: A total of 772,525 ED visits were analyzed; visits increased 19% during the 4-year period. Between 2003 and 2006, the percentage of patients arriving by ambulance decreased from 27.8% to 25.8% (annual change from 2003 -0.80%; 95% CI for change: -1.48% to -0.12%). Visits by individuals aged 65 years or older were stable (19.9% to 19.1%; annual change -0.19%; 95% CI for change -0.44% to 0.06%). Between 2003 and 2006, admissions from the ED were unchanged, at 23% (95% CI for change -0.43% to 1.11%). The percentage of patients receiving blood tests increased from 13.8% to 19.8% (annual change 1.00%; 95% CI for change -0.09% to 2.08%). Frequency of radiologic studies decreased slightly, from 38.0% to 35.7% (annual change -0.60%; 95% CI -1.58% to 0.37%). Deaths in the ED and return ED visits within 1 week were unchanged. Return visits resulting in hospital admission increased initially and then returned to 2003 levels (annual change -3.10%; 95% CI -7.32% to 1.11%).

Conclusion: England's 4-hour target did not appear to have a negative effect on quality or safety of ED care and had little effect on test use.