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Scrapping A&E targets not 'clinically justified'

By Craig Kenny

Proposals to scrap NHS A&E waiting time targets should be abandoned, warn researchers who have established a clear link between longer waiting times and risk of death on discharge.

A Canadian study published in the BMJ evaluates the histories of around 14 million patients who attended A&E departments and were discharged. The risk of adverse events increased with the mean length of wait.

High acuity patients who waited more than six hours were 1.79 times more likely to die within seven days of discharge than patients who waited less than an hour. The increased risk for low acuity patients was 1.71 times.

Risks of admission to hospital showed similar rises with increasing length of wait. Leaving A&E without being seen was not associated with an increase in adverse events.

‘It is unlikely that delays in treatment alone account for adverse outcomes in the patients we studied,' says lead author Astrid Guttmann of the Institute for Clinical and Evaluative Sciences in Ontario.

‘It is possible, however, that during shifts with long mean waiting times important processes of care are impeded and decision making altered. Examples might include reluctance to order time consuming tests or consultations and shortened observation periods (both of which could increase missed diagnoses), incomplete treatment, or inadequate planning and communication of care after discharge.'

They conclude: ‘Our findings provide strong support for policies in Canada, Australia, and England targeting reductions in length of stay in emergency departments and call into question the recently announced plan to abandon English targets for lack of "clinical justification".'

‘Our study suggests that there is clinical justification to reduce lengths of stay, although taken alone it cannot guide specific policy interventions or targets to achieve this goal.'

However, the authors warn that their findings may not be generalisable to other healthcare systems.

BMJ 2011; 342:d2983

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