A+E targets- does it include people who came along but then gave up as the wait was so long

[cakeorwine]

Waiting times to see a doctor can be very long at A+E at the moment.
I can see the target for when the "clock starts" and the "clock stops" and the target:

All UK countries have a "four-hour standard" that at least 95% of attendances are admitted, transferred, or discharged within four hours of their arrival at any type of A&E department. In December 2022, England implemented an intermediate minimum standard, where at least 76% of A&E attendances should be seen within four hours following increased pressures on the NHS.

If someone turns up, waits to be seen, looks at the wait time and then after say 3 hours, they decide that they don't want to wait and leaves - is that measured and if so, does that count towards the being discharged in less than 4 hours?

Or are there any metrics that record how many people turned up and how many of those "gave up" as the wait time was too long for them?

Are you an accident or an emergency?

Or are you attending for an out of hours gp on the same site, because I don't think the targets for OOH are the same. Surely if it was really urgent & worrying, you would wait.

If they are well enough to leave within that time then they shouldn’t have been there in the first place and could’ve used another service. So they shouldn’t be included anyway?

Not necessarily true - imagine someone with heart pains who doesn't think it's anything but their partner made them attend reluctantly.

They give up after 3.5 hours and go home and die.

No - just something that happened to someone recently - and I was thinking about the data analysis, targets and definitions.

exactly. Too many people use A&E when they should use OOH. or Minor Injuriees Service.

Maybe
Maybe not

What if OOH say go to A+E and you are told it's a massively long wait.
Like 10 hours

Or like my DD referred by GP for suspected broken arm, waited 6 hours, mobile phone failing, on her own, it’s past midnight, she scared and in huge pain, and feeling utterly overwhelmed.
Returned to her student digs.

DH and I drive to her early the next morning, (several hours away) helped her dress, took her back to A&E waited a further 6 hours to have confirmation arm was indeed broken.

I am utterly ashamed that this is the best the nhs can offer.

I’ve had people attend for a splinter anyone could get out at home with a pair of tweezers and a bit of digging around. I’ve had people attend for a hell of a lot less also. Advice to go away on triage does not get through to these people. The aim is to make them give up essentially, because they don’t need to be there, and others SHOULD be seen instead. You want that included in a 4hr metric🙄.

Then you have followed the advice. It’s those that head to a&e first when OOH or pharmacist etc could help.

They would be triaged quicker because in A and E it isn't done in order of when you got there but on what you are presenting with. So they wouldn't be waiting for 3 hours to be triaged.

They would have bloods done, blood pressure and oxygen levels recorded and an ECG. From the results of these tests they would be able to tell if the patient was in danger of having a heart attack.

That's awful - and is exactly what I am talking about

So what does that first 6 hours count as?

She left but was not seen.

Then came back again - and was discharged after 6 hours - so I guess that was post target.

It's also a strange target as it's over a whole time period - yet I guess the wait times vary massively over a week and a year. It would be interesting to see the daily data / hourly data - to see what it's like.

That's not what I am saying.

But in a sense - how do you capture people who maybe should be seen by A+E, who are initially assessed, and who are then told, we will see you - but the wait time is 9 hours.

And they leave after a bit.

It was interesting when Covid happened, the A&E departments were sitting on their hands with nothing to do, partly because all those people who shouldn't have been in A&E in the first place chose not to risk it.

If OOH said they needed A&E, an xray or something, then they should have stayed. Otherwise they can't have been very worried.

On the statistics question, I imagine they aren't counted because they chose to exclude themselves by leaving.

The only time I have been to A&E (3am) I felt so ill, so likely to collapse that I felt safer being near a nurse, regardless of the wait, than going home. In that instance I needed immediate surgery and a week on women's surgical ward.

I've left A&E when I needed to be there.

I've got a phobia of hospitals. Although I probably shouldn't call it a phobia because that suggests an irrational fear when actually my fears developed from experience of horrific events.

It's a horrible place for anyone to be in, phobia or not. I can very easily understand why people would prefer to be ill in their own bed rather than languishing on a cold hard chair (if they're lucky. If not, the floor) for endless hours.

Apparently up to1 in 5 leave (2022 figures)

Revealed: one in five patients leave some A&E departments in England without treatment | NHS | The Guardian

Experts told the Observer that the increase was probably driven by a combination of long A&E waiting times and by difficulties accessing NHS facilities such as GPs, community health services and NHS 111.

The figures apply to patients who left A&E before an initial assessment; after an assessment but before treatment started; or before treatment was completed. They include patients who left to find treatment elsewhere.
Across England, 124,202 patients left A&E departments in these circumstances in March, the most recent month for which NHS data is available. This amounts to 6.2% of all patients attending A&E – a rate three times higher than that of 2019, and the highest in any month since records began in April 2011.

There can be benign reasons for patients leaving A&E before completing treatment, but the sharp increase since the peak of the pandemic has accompanied much longer A&E waiting times, with many 12-hour waits, as well as rising pressures elsewhere in the NHS.

I imagine that the clock stops when they come out and call your name, see you're not there, and mark you down as self-discharged?

I was in A&E last weekend (kid, broken arm) and it was absolutely heaving, people sitting on the floor as there weren't enough seats. Everyone was triaged within 5 mins of arrival, we were seen, x-rayed, plastered and out within 4.5 hours. I don't know how they do it!

In my hospital a suspected broken arm would be referred to minor injuries which has its own separate waiting area. I have been there with an elderly lady within the last six months who had hurt her wrist. We waited about 10 minutes to be triaged where her blood pressure was taken etc. We then went back into the waiting area to be called for an x ray. That was about a 2 hour wait. After x ray we then went back to the waiting area to be called to see a doctor to discuss results of x ray. Luckily no bones broken. Altogether I would say we were there for between 3-4 hours.

This cohort are captured as their discharge reason and destination is recorded, however you would have to drill down into the raw data to understand if they really needed to be seen in ED.

In answer to your first question, yes, people who leave without being seen at 3 hours are captured but should be removed from the dataset before the metric is calculated as they have not completed their ED journey. In reality this is a very small number.

Daily/hourly data is interesting, the general theme is peak attendance (time of booking in) is 14:00 - 02:00 but this is compounded by long length of stay in departments, so you have more people booking in on top of people waiting for long times leading to intense overcrowding.

If you leave then A&E was probably the wrong place to be. Many of the people who don't get seen within the target time will be people who shouldn't have come to A&E in the first place (obviously some genuinely urgent cases go over the target time when resources are too stretched). Everyone gets triaged on arrival and the really urgent cases get seen within a few minutes, then there's some that will be seen within 30 minutes or within an hour - it's not a queue. If you are still waiting after 4 hours it's because you are stable and not in any danger. There should be more walk-in centres and out-of-hours GP services that would deal with a lot of these cases, which are neither accidents nor emergencies.

A particular A&E department shouldn't have their effectiveness and efficiency measured on the basis of to what extent has the wider NHS trust failed to establish (not been given sufficient funding to establish) appropriate non-A&E resources.

In answer to your first question, yes, people who leave without being seen at 3 hours are captured but should be removed from the dataset before the metric is calculated as they have not completed their ED journey. In reality this is a very small number

Up to 1 in 5 people leave without being seen - according to that data. Do people who leave after the 4 hour target get counted in any metric - or are they excluded as well?

Regarding the broken arm, I imagine that as part of the triage, children and the elderly will be prioritised over an otherwise healthy 21 year old.

RE ref to minor injuries, by this point DD had contacted 111, had telephone appointment with GP, then face to face appointment, then sent to a & e with GP referral

So she had (correctly) interacted with NHS 3 times before going to A&E. I don’t know if there’s a minor injuries unit but that’s not where she was referred. She was sent to A&E.

If someone presented at A+E with chest pains, they would be urgently triaged and dealt with, not left in the waiting room for hours on end.