12th May 2017, Volume 130 Number 1455

Peter Jones, Susan Wells, Alana Harper, James Le Fevre, Joanna Stewart, Elana Curtis, Papaarangi Reid, Shanthi Ameratunga

In May 2009, the Ministry of Health formally announced six national health targets for public hospitals in New Zealand.1 One of these was the ‘Shorter Stays in Emergency Departments’ target,…

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Summary

The Shorter Stays in ED target was introduced to reduce ED crowding, which is known to have adverse effects on patient care. Although similar targets introduced overseas have not always resulted in the improved quality of care, this study shows that in New Zealand, people waited less time in the ED before they were admitted to hospital after the target. This was associated with a substantial reduction in ED crowding and a reduction in the number of deaths in the ED compared to what was predicted if pre-target trends had continued. Fewer people left the ED before their care was complete and admission rates to hospital did not change substantially. Overall, people spent an average of seven hours less in hospital after they were admitted to a ward, but there was a small (1%) increase in the number of readmissions to hospital at 30 days after the target.

Abstract

Aim

The impact of national targets for emergency department (ED) length of stay (LOS) on patient care is unclear. This study aimed to determine the effect of New Zealand’s six-hour time target (95% of ED patients discharged or admitted to hospital within six hours) on a range of quality indicators.

Method

A nationwide observational study from 2006 to 2012 modelled differences in changes over time before and after target introduction in 2009. The observed model estimates in 2012 were compared to those predicted if pre-target trends had continued. Differences are absolute values except for morality, which is presented as a relative change.

Results

There were 5,793,767 ED presentations and 2,082,374 elective admissions from 18 out of a possible 20 district health boards included in the study. There were clinically important reductions in hospital LOS (-0.29 days), EDLOS (-1.1 hours), admitted patients EDLOS (-2.9 hours), ED crowding (-26.8%), ED mortality (-57.8%), elective inpatient mortality (-42.2%) and the proportion not waiting for assessment (-2.8%). Small changes were seen in time to assessment in the ED (-3.4 minutes), re-presentation to ED within 48 hours of the index ED discharge (-0.7%), re-presentation to ED within 48 hours from ward discharge (+0.4%) and acute admissions (+3.9%). An increase was observed in re-admission to a ward within 30 days of discharge (1.0%). These changes were all statistically significant (p<0.001).

Conclusion

Most outcomes we investigated either improved or were unchanged after the introduction of the time target policy in New Zealand. However, attention is required to ensure that reductions in hospital length of stay are not at the expense of subsequent re-admissions.

Author Information

Peter Jones, Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, Section of Epidemiology and Biostatistics, University of Auckland, Auckland; Susan Wells, Section of Epidemiology and Biostatistics, University of Auckland, Auckland; Alana Harper, Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland; James Le Fevre, Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland; Joanna Stewart, Section of Epidemiology and Biostatistics, University of Auckland, Auckland; Elana Curtis, Te Kupenga Hauora Māori, University of Auckland, Auckland; Papaarangi Reid, Te Kupenga Hauora Māori, University of Auckland, Auckland; Shanthi Ameratunga, Section of Epidemiology and Biostatistics, University of Auckland, Auckland.

Acknowledgements

The authors would like to acknowledge Mr Dinesh Kumar for assistance with data management for this study.
The SSED National Research Project was supported by a grant of NZD1,138,000 from the Health Research Council of New Zealand (10–588). Dr Sue Wells was the recipient of a Stevenson Fellowship in Health Innovation and Quality Improvement. 

Correspondence

Dr Peter G Jones, Director of Emergency Medicine Research, Adult Emergency Department, Auckland City Hospital, Park Road, Grafton, Auckland 1142.

Correspondence Email

peterj@adhb.govt.nz

Competing Interests

During his time as a research fellow on this study, JLF was also an elected member of one district health board. This potential competing interest was declared to all relevant parties prior to commencing the research activities, and his work was supervised directly by the corresponding author (PJ). The relevant parties and all other authors were satisfied that this potential conflict did not influence JLF’s contributions to the submitted work. No other authors have any conflict of interest to declare.

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