Just a Minute…? #1 / Needing a win in A&E? Forget about the final third!
Photo by Abigail Keenan on Unspash
Have you noticed how football pundits are fixated with the final third? Managers are losers and strikers can’t score because of a lack of investment in the final third.
If you’re losing your 4-hour fight in A&E, here’s a surprise: it’s all about the first two-thirds. Work out how to get two-thirds of your patients through in 2 hours and the final third will be OK. Actually, A&E will be OK because the NHS is the world’s best universal emergency service.
How do I know? Part science, part hunch and part marketing.
The science is compelling but it’s also incomplete and if you’re that interested, you’ll get to it anyway.
So, let’s start with marketing. Chip and Dan (Made to Stick) say good ideas need a memorable tagline that confounds our intuition. We’ll start there: the end of 4 hours is the wrong focus.
Next, the hunch. Health services are packed with smart people and make staggering breakthroughs but can trip up when simply trying to copy what others do well. Metrics are a case in point, where A&Es run two conflicting systems in parallel: one logistical (patients in 4 hours) and one clinical (neediest first). They can’t both set the pace, hence the compromise: get as many as you can through in 2 hours to allow time for whoever is left.
The science? Eight years ago, a group of us studied the footfall of every A&E Department in England over several years. In the end, we focused on three cohorts of patients discharged or admitted to hospital: those within 2 hours; those in the last 20 minutes of the allowed 4 hours; and those who breached the target. We wrote some of this up in, Performing or not performing: what’s in a target?
Basically, the fewer people leave within 2 hours, the worse the breaches, and just before the deadline the more are discharged or admitted (often hastily or inappropriately). The threshold for visible problems seemed to be around 50% but it isn’t a game of two halves, and you need a margin of safety.
This won’t eliminate your most besetting problems, change patients’ behaviour, or magic up extra beds. Moreover, discovering how to make it work and tracking it in real time are huge challenges. But A&E is a game of fine margins, and this guideline could give you a critical edge in extra time.