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Clinical Updates

Four-hour A&E targets are in ‘the best interests of patients’, claim Doctors

Last month only two hospital trusts hit the target to see and treat 95% of patients within four hours.



A&E Waiting Room

Changes to the four-hour target should be in the ‘best interests of patients’ rather than ‘political will’.

The Royal College of Emergency Medicine (RCEM) has said it supports the continued use of the four-hour A&E target but admits it needs to be supported other metrics that will help regulators understand the causes of long waits and over-crowding in Emergency Departments.

Earlier this week NHS England signalled the end to the four-hour A&E target that was introduced in the 1990s to tackle a serious of clinical incidents caused by long waits in emergency departments.


Last month only two hospital trusts hit the target to see and treat 95% of patients within four hours.

The college claims that, despite representing A&E doctors, it has not been consulted on the proposed changes and emphasises that decisions made about the four-hour target should be in ‘best interests of patients’.

‘Catastrophic impact on patient safety’.

In January, Dr Taj Hassan, President of the RCEM, warned that scrapping the four-hour target will have a “catastrophic impact on patient safety”.

Yestrday he added; “While we are dismayed by many of the myths being pedalled around the four-hour standard, we are keen to ensure that any changes are not imposed due to political will but are developed responsibly, collaboratively and are based upon clinical expert consensus in the best interests of patients.”

“We note the Prime Minster made a commitment to involve clinicians in the development of new standards. While we have been disappointed to not have been involved from the outset of this process, and that there has been little clarity around who has been involved, we now look forward to providing our clinical expert advice to NHS England and NHS Improvement to assist them in their review.”

“Only by collaborating and sharing expertise will we be able to develop a suite of additional standards that enhance clinical care and maintain a focus on safety.”

Since the announcement, the RCEM states has come to an agreement with NHS England to retain the four-hour target if a better flow metric cannot be developed.

Clinical Care

Hourly rounding ‘may not be the best way for nurses to deliver care’, finds study

Hourly rounding places an emphasis on ‘tick box’ care.



Nurse with patient in bed

Hourly rounding made a minor contribution, if at all, to the way nurses engage with patients.

A new report by researchers at King’s College London has found that the widespread practice of hourly or intentional rounding, may not be the best way for nurses to deliver care to patients.

The report also found that rounding makes a minor contribution, if at all, to the way nurses engage with patients.

Hourly or intentional rounding involves standardised regular checks with individual patients at set intervals and was introduced in hospitals in England in 2013, with 97% of NHS acute Trusts in England implementing it in some way.

The majority of NHS trusts adopted the ‘4Ps’ (Position, Pain, Personal needs, Placement of items) model of rounding.

The research was commissioned and funded by the National Institute for Health Research (NIHR) and was led by Professor Ruth Harris in the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care.

Hourly rounding places an emphasis on ‘tick box’ care.

The NIHR report – Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation – is the first study of its kind in the world.

The study found that rounding placed an emphasis on transactional ‘tick box’ care delivery, rather than individualised care. However, patients were found to value their interactions with nursing staff, which the study argues could be delivered during other care activities and rather than through intentional rounding.

The report also found that rounding was implemented without consultation, careful planning and piloting in the interests of political expediency following the Francis Inquiry Report into care failures in the NHS.

Ruth Harris, Professor of Health Care for Older Adults at King’s College London, said; “Checking patients regularly to make sure that they are OK is really important but intentional rounding tends to prompt nurses to focus on completion of the rounding documentation rather than on the relational aspects of care delivery.

“Few frontline nursing staff or senior nursing staff felt intentional rounding improved either the quality or the frequency of their interactions with patients and their family.”

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Clinical Updates

Nurses’ ‘worry’ better than most early warning scores, finds study

Nurses were asked to grade patients between ‘no concern’ and ‘extreme concern’. 




A sense of worry can provide important information for the detection of acute physiological deterioration.

Nurses’ worry has a “higher accuracy” than most published early warning scores (EWS) at predicting if a patient is becoming more unwell, according to a recent study.

The study looked at 31,159 patient-shifts for 3185 patients during 3551 hospitalisations across two surgical and two medical wards. Researchers compared if the nurses were worried about a patients potential for deterioration using ‘the Worry Factor’ with early warning score indicators.

Nurses were asked to grade each patient between “no concern” and “extreme concern”.

The Worry Score

Out of 492 potential deterioration events identified, researchers found that when nurses had an increasing worry factor the patient was more likely to require emergency medical treatment – 7 cardiac arrest calls, 86 medical emergency calls and 76 transfers to the intensive care unit.

The study also revealed that accuracy rates were significantly higher in nurses with over a year of experience.

The researchers concluded that “nurses’ pattern recognition and sense of worry can provide important information for the detection of acute physiological deterioration” and was often more reliable than traditional early warning systems.

They also noted that the worry score could be used alone or easily incorporated into existing EWS to potentially improve their performance.

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