It was reported this week that a senior administrator from ACT Health had falsified figures on Canberra Hospital's emergency department waiting times. One explanation of this fraud is that hospitals are increasingly coming under pressure from new Federal Government emergency patient throughput targets, and ACT Health administrators are clearly eager to be seen to be meeting these new bureaucratic benchmarks.
The Federal Government's imminent National Emergency Access Targets (NEAT), have set a goal that by 2015 90% of patients should leave emergency departments within four hours of attendance, either by being admitted to a hospital bed, transferred or discharged. This new target is particularly challenging for ACT hospitals who, compared to all other states and territories, rank the lowest in achieving this 4-hour goal.
The NEAT policy also comes with incentive payments of almost $100 million over four years in financial rewards to hospitals for improving their rates of processing patients within four hours, so it is not difficult to see why the ACT Health administrator was motivated to fudge the figures to make their hospitals look like they are performing better than they are.
It is widely recognised that overcrowding and prolonged lengths of stay in emergency departments are associated with poorer patient outcomes, and that access block results in non-admitted patients remaining in emergency departments for longer than necessary, reducing access for new patients and delaying ambulance offloads. The aim of the NEAT Four Hour Rule is to resolve this problem by improving the 'patient journey' by minimising the length of time it takes for a patient to be assessed, treated, and moved out of emergency departments. The policy is intended to engage hospital executives and managers in recognising that emergency department dysfunction and access block are hospital-wide problems, in which everyone has a role in improving performance.
The Four Hour Rule is a policy based on good intentions, however in practice emergency doctors and nurses are concerned that the imposition of arbitrary targets like these will compromise the care given to patients.
In the UK National Health Service (NHS), where the Four Hour Rule has existed since 2004, concerns over the implementation and impact of the Four Hour Rule have been significant. A UK newspaper recently reported that an investigation into care at the Mid-Staffordshire Hospitals Trust found that reception staff, rather than trained nurses and doctors, were expected to judge the seriousness of the condition of patients arriving at the emergency department. Because the Trust was in danger of breaching the Government's four-hour waiting time target, doctors were diverted from seriously ill patients to treat ones with minor problems, to make the patient throughput times look better. The Trust was criticised for being preoccupied with 'hitting targets' and had 'lost sight of its responsibilities for patient care'.
A report by the British Medical Association found that one third of 500 doctors surveyed said data had been manipulated to ensure government targets were met, and a quarter of hospitals had cancelled routine surgery to ensure they could meet the targets. It also quoted the BMA President as saying 'the level of performance in many departments is proving unsustainable and these departments are finding it difficult to cope on a daily basis'.
Closer to home, the Western Australian health system implemented the Four Hour Rule in 2009, and research published in the Medical Journal of Australia stated that the policy has been effective in reducing mortality rates and overcrowding, but that it had also led to some staff, especially junior doctors, coming under increased stress and pressure.
Triage is a clinical tool to prioritise patients and the bureaucratic tendency to use these figures as a precise measure of emergency department performance is perverse. Triage figures have even less meaning when the result of the triage process is that acutely ill or injured patients, potentially vulnerable to sudden deterioration, are placed in corridors or waiting rooms supervised by overworked nursing staff, or worse, by paramedics untrained in hospital patient care, as was reported at Canberra Hospital.
Policymakers and bureaucrats should remember that emergency department staff are highly educated, skilled and committed to the welfare of their vulnerable patients, but faced with a genuine chance to improve the system, manipulation of figures to achieve a pat on the back or to avoid responsibility for poor hospital performance betrays us all.
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