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The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target

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The National Emergency Access Target (NEAT) stipulates that a pre-determined proportion of patients should be admitted, discharged or transferred from Australian emergency departments (EDs) within 4 hours of presentation. Targets that varied from state to state were set for all Australian EDs by the National Partnership Agreement in 20121 in response to evidence that ED overcrowding and prolonged length of stay were associated with increased in-hospital mortality.2,3 The original aim was to incrementally increase the target to 90% in all jurisdictions by 2015, in line with the “4-hour rule” target set in the United Kingdom in 2010.

Despite the potentially major impact of the NEAT upon patient care, there was no prospective standardised framework for monitoring outcomes for patients admitted to hospital from EDs. Measuring patient outcomes is difficult, and no approach is beyond criticism. The hospital standardised mortality ratio (HSMR) is an objective screening tool designed to alert clinicians to potentially avoidable harm, and it has been accepted as a core indicator of hospital safety.4 The HSMR compares the numbers of observed and expected deaths; unlike raw mortality statistics, it excludes the deaths of palliative care patients, and attempts to adjust for clinically relevant…