Fewer deaths in ED when length of stay reduced

21 November 2016

Fewer deaths in emergency departments when length of stay reduced

New Zealand’s six-hour target for the time people stay in hospital emergency departments has been associated with hundreds fewer patients dying, according to new research.

The research into the effects of the mandatory six-hour national target on patient outcomes was co-led by Director of Emergency Medicine Research at Auckland City Hospital, Dr Peter Jones, and University of Auckland researcher Dr Linda Chalmers who co-led an investigation team from the university. It was supported by a $1.1 million project grant from the Health Research Council of New Zealand (HRC).

The investigation team examined various indicators of quality of patient care in 18 of New Zealand’s 20 district health boards (DHBs) over a period of seven years (2006–2012), and included an in-depth investigation of four hospitals.

The national target for length of stay in emergency departments was first introduced in June 2009 by the then Minister of Health, Hon. Tony Ryall. The target’s main goal was to reduce crowding in emergency departments, a worldwide problem that is associated with poorer outcomes for all patients regardless of whether they are discharged from the emergency department or admitted to hospital.

Dr Jones says that despite government providing no extra funding to implement the target, the DHBs collectively invested about $52 million in resources between 2008 and 2012 to try to make the target work. As the investigation team did not know what this money would have been used for if not for the target, they were unable to assess if these extra demands resulted in problems elsewhere in the health system.

“The length of time people stay in hospitals across the country has reduced on average by about 7 hours since the target was first introduced. If you multiply that by many patients, it’s a significant number of hospital bed days freed up, which may have created increased capacity for acute admissions,” says Dr Jones.

“Emergency department stays for all patients have reduced by over an hour, and for patients needing admission to hospital by about 3 hours. Where I work at Auckland City Hospital, the average time it takes for patients to get to the ward from the emergency department once the decision to admit them to hospital has been made has reduced significantly, from eight hours to about one and a half hours.”

The most striking finding from the study was the positive effects of the target on crowding and patient mortality.

“We found that the introduction of the six-hour target was associated with a substantial 50 per cent reduction in the number of patient deaths in emergency departments – that’s about 700 fewer deaths than predicted if pre-target trends had continued. This result mirrors the 50 per cent reduction in emergency department crowding,” says Dr Jones.

“There was also no increase in deaths on the wards, so there was no evidence that the observed reduction was due to ‘shifting’ deaths to elsewhere in the system.”

The researchers also found that after the target was introduced, fewer patients left the emergency department before completing their care and that admission rates did not change substantially.

DHBs used two main strategies to achieve the target. Firstly, they focused on process improvements that enabled patients to move more quickly from emergency departments to other parts of the hospital. Secondly, there was considerable investment in new emergency department facilities, and the creation and expansion of ‘short-stay’ capacity in hospitals. Short-stay units are areas where patients are kept under observation before being discharged or admitted to hospital.

Dr Jones says he was initially sceptical about the introduction of the target having witnessed first-hand the adverse effects of a stricter four-hour target in the UK while working there in the mid-2000s. He says that unlike in New Zealand, the UK target was linked to financial incentives and this, coupled with increased pressure on staff to meet the target, led to significant “fiddling of the numbers” and moving of very sick patients from the emergency department inappropriately to make it look like the target had been met.

Although the team’s investigation into New Zealand’s target outcomes was generally positive, Dr Jones says there were some areas of concern.

“We looked at the number of patients readmitted to hospital 30 days after being discharged and found that this figure had increased by about 1 per cent, which is a plausible unintended consequence of reducing the amount of time people spend in hospital.”

“There was also evidence of staff transferring patients to short-stay units so that these patients would not count as ‘breaches’ of the target. This occurred at many sites and seemed particularly evident where heavy pressure on clinical staff to meet the target was not matched by adequate resourcing. However, we haven’t completed this analysis yet.”

HRC Chief Executive Professor Kath McPherson says this comprehensive study will directly inform future health policy in the area of emergency medicine.

“This study has important implications for the way future health targets are implemented by helping identify which DHB management practices lead to success in meeting the target, and more importantly, which improve quality of care for patients,” says Professor McPherson.

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