Has the implementation of time-based-targets for emergency department length-of-stay influenced the quality of care for patients? A systematic review of qualitative literature

Background: Time-based-targets for emergency department length-of-stay were introduced in England in 2000; followed by Canada, Ireland, New Zealand, and Australia after emergency department crowding was associated with poor quality of care and increased mortality. Objectives: The aim of the systematic review was to evaluate qualitative literature to investigate how implementing time-based-targets for emergency department length-of-stay has influenced the quality of care of patients. Methods: Systematic review of qualitative studies that described knowledge, attitudes to or experiences regarding a time-based-target for emergency department length-of-stay. Searches were conducted in Cochrane library, Medline, Embase, CInAHL, Emerald, ABI/Inform, and Informit. Individual studies were evaluated using the Critical Appraisal Skills Programme tool. Individual study findings underwent thematic analysis. Confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research approach. Results: The review included thirteen studies from four countries, incorporating 617 interviews. Themes identified were: quality of care, access block and overcrowding, patient experience, staff morale and workload, intrahospital and interdepartmental relationships, clinical education and training, gaming, and enablers and barriers to achieving targets. The confidence in findings is moderate or high for most themes. More patient and junior doctor perspectives are needed. Conclusions: Emergency time-based-targets have impacted on the quality of emergency patient care. The impact can be both positive and negative and successful implementation depends on whole hospital resourcing and engagement with targets. Funding: The Australasian College for Emergency Medicine provided administrative support for the study, no funding was received. Registration: PROSPERO CRD42019107755 (prospective)