12th May 2017,
Peter Jones, James Le Fevre, Alana Harper, Susan Wells, 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 Aotearoa New Zealand.1 One of these was the Shorter Stays in Emergency Departments…
The full contents of this page is only available to subscribers.
To view this content please login or subscribe
This study explored the association between the introduction of a mandatory national target for emergency department (ED) length of stay, which was introduced in New Zealand in 2009, and five key indicators of quality of care. We did this study as there is some evidence from overseas that focusing on a process target for the time spent in the ED may divert attention away from other aspects of quality of care. Our study found that more people left the ED within six hours after introduction of the shorter stays in ED target. There was no difference in the quality of care for patients in pain, with severe infections, with heart attacks, with appendicitis and with fractured hips when comparing the outcomes for these conditions before and after the introduction of the target.
To determine whether implementation of a national health target called Shorter Stays in Emergency Departments impacted on clinical markers of quality of care.
A retrospective pre- and post-intervention study from 2006 to 2012 examined quality of care metrics for five different indicators at different sites in relation to the implementation of the target using a general linear model for times to treatment. Explanatory variables included period (pre- or post-target), ethnicity, age, deprivation and severity of condition. Back transformed least square means were used to describe the outcomes.
The times to treatment for ST elevation myocardial infarction; 36.9 (28–49) vs 47.6 (36–63) minutes p=0.14, antibiotics for severe sepsis; 105.9 (73–153) vs 104.3 (70–155) minutes p=0.93, analgesia for moderate or severe pain; 48 (31–75) vs 46 (32–66) minutes p =0.77, theatre for fractured neck of femur; 35.4 (32.1–39.1) vs 32.4 (29.2–36.1) hours, and to theatre for appendicitis; 14.1 (12–17) vs 16.4 (14–20) hours were unchanged after implementation of the target. Treatment adequacy was also unchanged for these indicators.
Introduction of the Shorter Stays in Emergency Departments target was not associated with any clinically important or statistically significant changes in the time to treatment and adequacy of care for five different clinical indicators of quality of care in Aotearoa New Zealand. For those indicators measured at one site only, it is unknown whether these results can be generalised to other sites.
- Ryall T. Fewer more focussed targets 2009 [16/12/2015]. Available from: http://www.beehive.govt.nz/release/fewer-more-focussed-targets
- MOH. Shorter Stays in Emergency Departments Health Target 2009 [08/04/2011]. Available from: http://www.moh.govt.nz/emergencydepartments
- Sprivulis PC, Da Silva J, Jacobs IG, Frazer ARL, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia. 2006; 184(5):208–12.
- Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Medical Journal of Australia. 2006; 184(5):213–6.
- Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The Effect of Emergency Department Crowding on Clinically Oriented Outcomes. Academic Emergency Medicine. 2009; 16(1):1–10.
- Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang LJ, Han W, et al. Effect of emergency department crowding on outcomes of admitted patients. Annals of Emergency Medicine. 2013; 61(6):605–11.e6.
- The NHS Plan: a plan for investment a plan for reform. Cm 4818-I. Report number 010481829, Department of Health. Department of Health, UK; 2000. p. 1–147.
- Expert Panel Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services: Australian Government; 2011 [16/12/15]. Available from: http://www.coag.gov.au/sites/default/files/Expert_Panel_Report%20D0490.pdf
- Gubb J. Have targets done more harm than good in the English NHS? Yes. BMJ. 2009; 338:442.
- Geelhoed GC, de Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust. 2012; 196:122–6.
- Hauck K, Street A. Do targets matter? A comparison of English and Welsh National Health priorities. Health Econ. 2007; 16(3):275–90.
- Wood H, Fontain P, Harvey D, Catford G, Hills A, Holland B. Investigation into Mid Staffordshire NHS Foundation Trust. Healthcare Commission, 2009 March. Report No.: ISBN: 978-1-84562-220-6.
- Jones P, Chalmers L, Wells S, Ameratunga S, Carswell P, Ashton T, et al. Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol. BMC Health Serv Res. 2012; 12(1):45.
- Jones P, Harper A, Wells S, Curtis E, Carswell P, Reid P, et al. Selection and validation of quality indicators for the Shorter Stays in Emergency Departments National Research Project. Emergency Medicine Australasia. 2012; 24(3):303–12.
- Jones P, Harper A, Kumar D. Shorter Stays in Emergency Departments National Research Project Raw Data Definitions 2012 [24/3/2016)]. Available from: http://static-content.springer.com/esm/art%3A10.1186%2F1472-6963-12-45/MediaObjects/12913_2012_1949_MOESM3_ESM.PDF
- Clare Salmond PC, Atkinson J. NZDep2006 Index of Deprivation 2007 11th March 2011. Available from: http://www.wnmeds.ac.nz/NZDep-info.html
- Levy MMM, FCCP; Fink, Mitchell P. MD, FCCP; Marshall, John C. MD; Abraham, Edward MD; Angus, Derek MD, MPH, FCCP; Cook, Deborah MD, FCCP; Cohen, Jonathan MD; Opal, Steven M. MD; Vincent, Jean-Louis MD, FCCP, PhD; Ramsay, Graham MD; For the International Sepsis Definitions Conference,. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003; 31(4):1250–6.
- Dellinger RPMD, Levy MMMD, Carlet JMMD, Bion JMD, Parker MMMD, Jaeschke RMD, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. [Article]. Critical Care Medicine January. 2008; 36(1):296–327.
- Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2005; 6(1):2–8.
- Thygesen K, Alpert JS, White HD, on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction, TASK FORCE MEMBERS: Chairpersons: Kristian Thygesen JSA, Harvey D. White, Biomarker Group: Allan S. Jaffe C, Fred S. Apple , Marcello Galvani , Hugo A. Katus, L. Kristin Newby , Jan Ravkilde, et al. Universal Definition of Myocardial Infarction. Circulation. 2007; 116(22):2634–53.
- New Zealand Guidelines Group: Acute Management and Immediate Rehabilitation after Hip Fracture Amongst People Aged 65 years and Over. Wellington, New Zealand: New Zealand Guidelines Group, 2003 Contract No.: ISBN: 0-473-09091-0.
- Omundsen M, Dennett E. Delay to appendicectomy and associated morbidity: a retrospective review. ANZ Journal of Surgery. 2006; 76(3):153–5.
- Jao K, Mc DTD, Taylor SE, Khan M, Chae J. Simple clinical targets associated with a high level of patient satisfaction with their pain management. Emergency medicine Australasia: EMA. 2011; 23(2):195–201.
- Nash L, Tacey M, Liew D, Jones C, Truesdale M, Russell D. Impact of emergency access targets on admissions to general medicine: a retrospective cohort study. Internal Medicine Journal. 2013; 43(10):1110–6.
- Perera ML, Gnaneswaran N, Roberts MJ, Giles M, Liew D, Ritchie P, et al. The ‘four-hour target’ and the impact on Australian metropolitan acute surgical services. ANZ J Surg. 2015.
- Jones P, Wells S, Harper A, LeFevre J, Stewart J, Curtis E, et al. Is a national time target for emergency department stay associated with changes in the quality of care for acute asthma? A multicentre pre-intervention post-intervention study. Emergency medicine Australasia : EMA. 2016; 28(1):48–55.
- Harper A, Jones P, Wimsett J, Stewart J, Le Fevre J, Wells S, et al. The effect of the Shorter Stays in Emergency Departments health target on the quality of ED discharge summaries. Emerg Med J. 2016.
- Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti ML, Rowe BH, et al. Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ Qual Saf. 2015.
- Jones P, et al. Impact of a national time target for ED length of stay on patient outcomes. NZ Med J 2017; 130(1455):15–34.
The downloadable PDF version of this article is only available to subscribers.
To view this content please login or subscribe