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Clinical Updates

Scrapping the 4-hour target would lead to “endless hours of waiting in A&E departments”

In December, only 86.4% of patients were seen within the target.



accident and emergency department

Scrapping the four-hour target would lead to “near catastrophic impact on patient safety” and “endless hours of waiting in A&E departments”.

The Chief Executive of NHS England, Simon Stevens, confirmed during yesterday’s Health and Social Care Committee meeting that the hospital target of admitting, treating or discharging all A&E patients within four-hours is to be significantly altered.

Altering the target for 95% of patients to be seen at A&E within four hours will mean that patients with less-serious illness or injuries could be forced to wait longer. Clinical staff say they are worried this may cause patients to ‘slip through the gaps’.


In December, only 86.4% of patients were seen within the target.

Healthcare unions and professional bodies have warned that scrapping the four-hour A&E target would have a “catastrophic impact” on patient safety.

‘Tinkering with targets’.

Anna Crossley, the Royal College of Nursing’s Professional Lead for Acute and Emergency Care said: “It is imperative that hospitals have the staff and resources to give timely care within current guidelines – tinkering with targets to make them easier to hit is the wrong approach. Axing it or loosening it without evaluating alternatives puts patient safety at risk and sends a terrible signal that waiting times do not matter.”

“In fact what matters most right now is that we guarantee the safety of our patients by committing to their health and the four hour target. This evidence-based measure isn’t arbitrary and we agree with other royal colleges that its removal would have an adverse effect on patient safety.

“Nurses must be involved in any substantial reconfigurations of the standards they’re working towards. But more urgently, NHS England and the Government must solve the workforce crisis that leads to missed targets by investing in nurse numbers, nursing higher education and enshrining safe staffing levels in law.“

The body representing over 8,000 Emergency Medicine clinicians, The Royal College of Emergency Medicine, says it has not been consultant on these significant changes.

‘Endless hours of waiting’.

President of the Royal College of Emergency Medicine, Dr Taj Hassan said: “In our expert opinion scrapping the four-hour target will have a near catastrophic impact on patient safety in many Emergency Departments that are already struggling to deliver safe patient care in a wider system that is failing badly.

“We will be seeking urgent clarification from NHS England and NHS Improvement on their position and describing the likely unintended consequences of such a poorly thought out strategic policy shift. We will also make our position and concerns clear to the Secretary of State, Matt Hancock.

“Let’s be very clear. This is far from being in the best interest of patients and will only serve to bury problems in a health service that will be severely tested by yet another optimistic reconfiguration.”

In an open letter to Mr Stevens the RCEM added; “No-one wants to go back to the days of endless hours of waiting in A&E departments. Removing the standard will do this and hide the true scale of problems within our health service.”

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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