Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013

Abstract

BackgroundIn 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning.MethodsA state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique.FindingsThere were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients.After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most ‘crowded’ ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing.ConclusionsThe FHR had a consistent effect on ‘flow’ measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.

Impact of the Four‐Hour Rule/National Emergency Access Target policy implementation on emergency department staff: A qualitative perspective of emergency department management changes

“…Previous research has reported benefits and disadvantages of introduction and assimilation of time‐based targets in ED . Our findings have confirmed that change in management practices was necessary at the introduction and during implementation of the policy, because the majority of the Policy‐associated changes required an oversight of the whole hospital, not just the ED.…”

The goldilocks effect: the rhythms and pace of hospital life

“…Faced with ever-increasing cost constraints as well as demands for services, hospitals have experienced accelerating pressures to step up the pace [6, 13]. For example, time-based targets, such as the rule in Emergency Departments in the United Kingdom and Australia that people need to be seen within four hours [14, 15] and throughput pressures exemplified by elective surgery wait lists [16, 17] are pushing staff to fit more and more tasks into a set amount of time. Work is expanding in other ways too, such as with the introduction of burdensome documentation, rules and regulations [18].…”

Impact of the National Emergency Access Target policy on emergency departments’ performance: A time‐trend analysis for New South Wales, Australian Capital Territory and Queensland

“…This is a recommended statistical technique for time-trend analysis of populationwide interventions. 4 The impact of NEAT on the outcome measures was assessed statistically with period (pre/post) and calendar quarters as the explanatory variables in the segmented regression model (Appendix S1).…”

“…[6][7][8][9][10] The National Emergency Access Target (NEAT) policy was implemented in January 2012 by the Australian government to increase ED flow. 4 The aim of this study is to assess changes in time-based measures as proxies for ED crowding and access block before and after NEAT in New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). [15][16][17] In the UK, at its zenith, 98% of all patients left EDs within 4 h. 15 New Zealand also improved with most district health boards reaching their 95% 6 h target.…”