This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. OBJECTIVE
RESULTS
METHODS
The 4-Hour Window
- Government targets and clinical challenges in
A&E and psychiatry
Forth Valley Royal Hospital (Scotland)
INTRODUCTION
Dr U Javed (CT3),
Dr D Cumming
(Consultant
Psychiatrist)
In 2002, the Department of Health (United
Kingdom) introduced a 4-hour target due to
long waiting times. It is expected that 95% of
patients who attend the A&E (Emergency)
Department should be registered and admitted/
discharged within 4 hours. Exceeding this is
termed as a “breach.”
Referral data was sourced across 4 consecutive
months: April-July 2015 (Initial Audit) and
October 2015-January 2016 (Re-audit). These
included all referrals from A&E to Psychiatry.
Times were calculated for the 4 subprocesses of
the referral pathway listed in the Results section,
as well as breach rates.
The aim of this re-audit was to assess for a
response following recommendations after an
initial audit with concerning results. Forth Valley
Royal is an acute public hospital in Central
Scotland with 860 in-patient beds, covering a
population of around 300,000. It contains two
General Adult wards (42 beds), one PICU (12
beds) and two Elderly wards (40 beds).
Following the Initial Audit, it was shown that the specialist
Psychiatry service takes approximately 120 mins, after being
contacted by A&E. Therefore, any A&E referrals made after
120 mins would likely breach the 4h target. Interventions
such as training A&E staff to better manage Psychiatric
patients and encourage earlier referrals, led to a positive
response in the Re-audit (Subprocess A). Overall the
Breach rates reduced from 38% to 28% since A&E reduced
‘late’ referrals (ie. before the 120 minute mark). However,
the outcome of patients deciding to leave A&E without being
assessed by a Psychiatrist was unknown – adverse outcomes
would strengthen the debate to impose the 4-hour target.
DISCUSSION
Subprocess (in minutes)
A. Time from Arrival to Psych Referral
B. Psych referral to Psych assessment
C. Psych assessment to Discharge
D. Total time (Target = 240mins)
0"
50"
100"
150"
200"
250"
A" B" C" D"
The 4 Hour Target
Initial Audit
Re-Audit
Breach Rates
• Initial Audit = 35%
• Re-Audit = 28%