THE Royal College of Emergency Medicine Scotland believes strongly that the four-hour standard is a vital measure of performance and safety (“Is the four-hour A&E target backfiring on NHS?”, The Herald, May 25).

We think that is it important that at all patients attending Emergency Departments (EDs) are seen and discharged or admitted within four hours, and that this data is recorded.

Your article rightly points out that the four-hour standard is imperfect, however it is simple, easy to measure and has broad support among UK emergency department specialists, and indeed those clinicians in other urgent and acute specialties, who know that long waits cause patient harm.

When used intelligently the standard is a vital barometer of safety, quality and wider system issues. It allows us to identify good outcomes and best practices, and highlights areas where improvement is required.

The data is not just about tedious waits for patients, but about safety. Studies have repeatedly shown that there is an increased mortality in people who spend a long time in emergency departments; crowding kills patients.

The four-hour data gives us an insight into this risk posed by acute care delays, ED crowding and exit block, while helping improve patient and staff experience.

It can help as a device to act as a prompt to review ED functions, hospital processes, bed occupancy and delayed discharge rates. It has been used effectively to improve emergency department staffing and focus attention on efficiency in other hospital wards by increasing senior review, nurse facilitated discharge, use of discharge lounges and weekend and pre-noon discharges.

Having a published national standard also allows comparison between processes in different departments such that best practice can be identified and shared.

Scotland’s EDs have the best four-hour performance among the UK nations. While there is always room for improvement, this should be recognised as a huge achievement - particularly when other nations measure from the moment a decision is made to admit the patient, rather than from when they arrive.

However, a drive to “hit the target” without an understanding of its role as a measure of the effectiveness of the whole hospital system rather than an end in itself can be counter-productive and sometimes harmful.

There is a misconception that the standard is a “time to be seen” gauge rather than a measure of the time to complete assessment and initial treatment in an ED. Another misconception is that although redirection to primary care may provide better care to a minority of patients, “inappropriate attender”’ are not the main cause of missing the standard.

The data and the clinical evidence show that those patients who wait longest in Scotland’s EDs, and who suffer the disproportionate and dangerous consequences of exit block and crowding, are the frail elderly. These patients require a hospital or social care bed following ED assessment, diagnosis and treatment. This has obvious and adverse effects on those subsequent patients requiring access to our clinical areas and expertise.

Any decisions made on performance data must be based on how the data aids the delivery of quality patient care; the four-hour standard does just that.

Dr Martin McKechnie,

Vice President for the Royal College of Emergency Medicine Scotland,

c/o Bream’s Buildings London.