4 hour rule successful in reducing ED overcrowding
A study has proven that the Australia-wide strategy to limit the time people spend in emergency departments (EDs) is helping to reduce chronic overcrowding.
Lead author of the study and senior research fellow at UNSW, Dr Roberto Forero, said the impact of the Four‐Hour Rule/National Emergency Access Target (4HR/NEAT) has been effective in decreasing access block – a symptom of ED overcrowding.
“At the beginning in 2002-2008, there was a 50-60% delay in patients waiting to be admitted to hospital in EDs, and these patients could end up spending more than 24 hours in the ED.”
He said the first change since implementing 4HR/NEAT has been a reduction in access block to 30-40%
ED trends across 16 hospitals were analysed
The longitudinal cohort study used data from 16 hospitals across WA, NSW, the ACT and QLD to assess the impact of 4HR/NEAT.
4HR/NEAT was introduced as a means of driving hospital performance by applying a time target. This target was set for all Australian EDs in response to evidence that ED overcrowding and prolonged length of stay was leading to increased in-hospital mortality.
The research team assessed data from before and after the introduction of the four-hour rule in Western Australia in 2009 and the four-hour National Emergency Access Target in participating states in 2012. Mortality trends were analysed using an interrupted time series technique.
From nearly 4 million visits to EDs, there were 952,726 emergency admissions and 40,281 deaths. All jurisdictions, except ACT, had improved flow and access block after the implementation of 4HR/NEAT. The ED flow recorded in ACT hospitals did improve but at a less pronounced rate.
Post-intervention, WA had a significant reduction of mortality rate of -0.28 per 1000 patients per quarter. However, QLD had mixed results and NSW/ACT mortality trends did not change significantly.
‘Whole-of-hospital’ approach is driving change
Dr Forero said that while the results varied from state to state due to differences between hospitals, the effect of 4HR/NEAT has been positive.
“In addition, the overall improvement was achieved by changing and innovating workplace practices in ED. This often involved improved clinical staffing in ED, and specific roles to address patient flow. We saw that hospitals changed the structure of the ED and involved the rest of the hospital in patient flow, looking at new ways to improve the process of discharging patients overall”
The implementation of 4HR/NEAT has generated a great deal of change within a relatively short period of time and Dr Forero says there is a clear reason for this.
“It was identified that the problem wasn’t an emergency department problem, but a whole-of-hospital problem, and required solutions at a health system level.”
Mortality link not as strong – but more analysis is needed
Dr Forero said there were potential explanations as to why the study did not find a strong link between the implementation of 4HR/NEAT and a reduction in mortality.
“We were expecting to find a strong association between the decreased mortality and the decreased levels of access block and overcrowding, but this relationship was not as strong.”
“Basically, we couldn’t compare the same periods of time after the policy was implemented across the states because the data wasn’t available”, Dr Forero said.
“We only had 2 years after the implementation policy in eastern states, and 4 years after the implementation of policy in WA, so that may explain why there wasn’t a significant association.”
Dr Forero said this could be a measuring error, “but it will probably just require more time.”
“One of the things we need to do now is get more data and have more years for the analysis. And we also need to have more states involved – the states we didn’t have in this study.”