What is the impact of delayed discharge on A&E targets?

The link between discharge and admission:

Historically the winter is the hardest season for the NHS. With higher incidents of seasonal illnesses and vulnerable people more likely to be hospitalised, meeting increasing demand is a significant challenge for the NHS.

With more people trying to access hospital care, efficient discharge of patients who are ready to leave is vital. Unfortunately, this can be a challenge, with latest figures showing around 12,000 people a day are ready to be discharged but left waiting to leave. For many systems, hospital discharge can come to a complete standstill over winter.

The link between the ‘back door’ of hospital discharge and the ‘front door’ of the hospital, is highlighted by a recent report from the Health Foundation:

“Patients who stay in hospital when they are ready to be discharged are at higher risk of hospital-acquired infections and of losing mobility and independence. Delays in discharging patients also impact on the availability of hospital beds, leading to delays in ambulance handovers and in admitting patients from A&E.”

Operational targets:

To address winter pressures, the government has again set out a plan to deliver operational resilience across the NHS. This plan aims to contribute towards two key ambitions related to recovering Urgent and Emergency care:

• 76% of patients being admitted, transferred, or discharged within four hours by March 2024
• Improving ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24

Category 2 ambulance calls are those that are classed as an emergency or a potentially serious condition that may require rapid assessment, urgent on-scene intervention and/or urgent transport. All ambulance trusts should respond to Category 2 calls in 18 minutes on average and respond to 90% of Category 2 calls in 40 minutes.

The operational standard set for Emergency departments in 2010 stated that at least 95% of patients attending A&E should be admitted, transferred, or discharged within four hours. In December 2022, an intermediary threshold target of 76% was introduced with further improvement expected in 2024/25.

Current trajectory:

To understand if these targets will be hit, Xyla has analysed the last 18 months of NHS data. Though there has been a slight increase in the percentage of attendances in 4 hours or less, the trend of 2023 to 2024 closely follows that of 2022 to 2023.

Based on the current trajectory, by December 2023 only 66% of A&E attendances will be admitted, transferred, or discharged within four hours or less. Furthermore, by March 2024, only 72% of A&E attendances will be in four hours or less thus falling short of the 76% target set by the NHS.

This is particularly alarming as the Royal College of Emergency Medicine argues that performance below 75% is the point at which patient safety risk becomes seriously elevated. This is due to patients having to wait for long periods of time in overcrowded and uncomfortable A&E department waiting rooms leading to conditions worsening significantly before treatment can be given.

Data has also revealed that an estimated total of 23,003 excess deaths in 2022 were associated with long wait times in the Emergency Department, meaning there was an extra death for every 72 patients who spent eight to twelve hours in A&E. Dr Adrian Boyle, President of the Royal College of Emergency Medicine, stated:

“We must see a renewed focus on the four-hour access standard. We believe the new four-hour target of 76% is unambitious and is too low, it presents the risk that the sickest and most vulnerable patients will continue to face the longest waits.”

Despite the 76% target being considered unambitious, according to the current trajectory, this target won’t be reached if last year’s trend is followed. With A&E times worsening, it is expected ambulance response times will follow.

In 2022 to 2023, the average ambulance response time for category 2 incidents was 49:54. If trends from last year continue, it is projected that ambulance response times will be 36:36 for 2023-2024, still falling short of the average 30-minute target. With category 2 calls responding to people who need urgent care such as suffering from a heart attack or stroke, there are severe consequences associated with ambulance delays.

Working together this winter:

It is clear that significant operational challenges are on the horizon. Hospital discharge impacts heavily on the whole system, including A&E and ambulance handovers. With winter almost here, outcome-focused action is urgently needed, and improving patient flow offers a route to improvement. We must invest in bespoke initiatives to ensure every aspect of the system is getting the support they need.

Xyla brings over 25 years’ experience in improving patient flow through outcome-focused commitments to you and your patients. We are ready to mobilise, offering you flexible ways to partner with us, and helping to operate your integrated discharge system.

We have designed a range of services – underpinned by knowledge and understanding of what works – and we will work with you on an outcome-focused basis. From free and pay-as-you-go services to longer-term partnerships, working together we guarantee to improve your average hospital discharge performance by 5 days or less.

Our team has accumulated the tools, knowledge, and expertise to improve patient flow. Through our proven delivery solutions, since 2020 we have successfully supported more than 50,000 people to be safely discharged and transferred patients into the right care they need.

Get in touch to talk to us about our flexible and easy to implement solutions.

Contact Maria Knowles maria.knowles@xylaservices.com for further information.

References:

A&E waiting times | Nuffield Trust

One in four A&E wards is unsafe, say doctors (thetimes.co.uk)

https://www.nuffieldtrust.org.uk/resource/ambulance-response-times

Data show 1.65 million patients in England faced 12-hour waits from time of arrival in A&Es in 2022 | RCEM