Wide variations in A&E departments warns watchdog

The Healthcare Commission urges hospitals to monitor variations in the quality of care in accident and emergency departments. Publishing a report on 200 A&E departments in England, the watchdog says that hospital trusts should systematically measure care quality as well as waiting times.

The report says the majority of patients are happy with the standard of care they receive in A&E, but it suggests that performance varies widely.

It also found that some patients in some emergency departments are not receiving the standard of care that A&E consultants recommend. In particular, some children and older people do not receive pain relief for fractures promptly enough.

The Commission measured the quality of clinical care for three common conditions. Measures were made against standards set by the British Association for Emergency Medicine (BAEM) for the treatment of:
· children with a broken elbow or wrist;
· patients with hip fractures (mostly over 75 year-olds);
· people who have taken an overdose of paracetamol.

This found:
· In the average department, just over half (53%) of children in moderate or severe pain as a result of a fractured elbow or wrist received analgesia within an hour of arrival. Six departments achieved 100% compliance, but in eight (5%) it was below 20%. BAEM guidance says they should receive pain relief within 20 minutes of arrival for severe pain or at triage for moderate pain.
· In the average department, 42% of patients with hip fracture were offered or received analgesia within 60 minutes of arrival. Performance varied from 100% of patients in the best department to less than 15% in the worst. BAEM guidance says people should receive relief from severe pain within 20 minutes of arrival or triage.
· For patients who have taken an overdose of paracetamol it is important to allow four hours after the overdose before taking a blood test. Most departments observed this for all or nearly all patients, but seven departments did not allow the full four hours for 25% or more of their patients.
· A&E departments were given the option of re-auditing services in March 2005 after reports that the 2004 audit triggered improvements. Forty seven departments resubmitted data showing beneficial changes. For example, for those departments that responded the average percentage of children with wrist and elbow fractures receiving pain relief within 60 minutes increased from 60% to 70%. The equivalent figure for recording pain relief scores increased from 10% to 42%.

The Commission’s report also analyses the results of a national survey of more than 50,000 patients and other audit data on A&E departments.

Findings include:
· The great majority of patients are happy with the overall standard of care. On average, 71% of patients rated their overall standard of care as excellent or very good. But this varied between trusts from 85% of patients to 39%.
· Patients are increasingly taking advantage of minor injuries units and walk-in centres for basic emergency treatment. These now handle more than 20% of all emergency attendances.
· Since 2000, there have been substantial staffing increases, with the average department having 20% more nurses, 27% more doctors and 37% more consultants.
· The report found no association between waiting time reduction and increases in staff at department level. This suggests that hospitals should only appoint extra staff for a specific purpose and monitor the results
· There is more use of bank and agency staff in London departments, which have an average nurse vacancy rate of 16%. This may partly account for patient survey results showing less satisfaction with London departments.
· Only 60% of A&E department have separately staffed facilities for children, despite 22% of all patients being under the age of 16.

The Commission’s A&E report follows the recent publication of its annual state of healthcare report and its annual star ratings, which show the performance of NHS trusts. These highlighted improvements in A&E waiting times, despite rising numbers of attendances.

By the end of 2004, all trusts had met the government’s target of 90% of patients being admitted or discharged within four hours. But currently, many acute trusts are struggling with the government’s now revised higher target of 100% of patients (minus exceptions) spending no more than four hours in the emergency department.

Anna Walker, Chief Executive of the Healthcare Commission, said: “It is particularly good news that consultants are leading the way to find measures of quality that are meaningful to patients.

“A&E departments have overall made great strides in improving services, in particular on waiting times which are very important to patients. A&E departments now have to go the extra mile if they are to deliver the care that patients need and that means focussing on quality as well as waiting.

“This report suggests serious variations in the quality of care. Monitoring standards of quality must become a core part of the day-to-day management of these units. This review is our first attempt to measure nationally A&E quality in addition to the work we do on waiting. We will
continue to develop ways of assessing these issues.

"Our new annual health check will examine quality standards relevant to A&E. Are patients treated with dignity and respect? Are they cared for in a safe secure environment? Are trusts taking into account nationally agreed best practice on clinical issues?

“Trusts will have to tell us whether they are taking into account these quality standards. Data from this report will be among the things we use to plan our programme of targeted inspection."

The Commission recommends that NHS trusts and strategic health authorities should:

· measure quality of care in A&E departments, as well as time spent waiting

· develop new measures of waiting times and quality of care for use in minor injury units and walk-in centres.

· review services for children to ensure their special needs are met.

· ensure that additional A&E staff are deployed efficiently and effectively.

There are 202 24-hour A&E departments in England. In total, they handle some 13 million attendances every year, with the largest departments dealing with around 100,000 patients per anum.

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