The ‘four‐hour target’ and the impact on <scp>A</scp>ustralian metropolitan acute surgical services

Perera, Marlon; Gnaneswaran, Neiraja; Roberts, Matthew J.; Giles, Marian; Liew, Danny; Ritchie, Peter; Chan, Steven

doi:10.1111/ans.13186

Cited by 13 publications

(15 citation statements)

References 19 publications

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“…On this point, we also note some recent literature examining such issues. For example, Perera and colleagues [ 37 , 38 ] reported positive and negative outcomes such as reduction in ED waiting times and increased use of short stay units as well as prolonged inpatient stays and an increased rate in inter-unit transfers for certain subgroups of inpatients (e.g., those utilizing acute surgical services) after the FHR intervention. Our findings are consistent with these studies; however, we have not reported on specific conditions as it was beyond the scope of the study.…”

Section: Discussionmentioning

confidence: 99%

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

Ngo

Forero²,

Mountain

et al. 2018

PLoS ONE

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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.

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Section: Discussionmentioning

confidence: 99%

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

Ngo

Forero²,

Mountain

et al. 2018

PLoS ONE

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“…The NEAT, similar to the U.K.'s Four Hour Rule, is designed to improve patient safety and increase patient flow (Hughes, 2010) by limiting the time that admitted patients can spend in the ED to 4 hr after which time they must be admitted, transferred to another hospital or discharged (Crawford et al, 2014;Weber, Mason, Carter, & Hew, 2011). Unintended consequences of targets such as NEAT, bed shortages and short-stay units are that patients are frequently nursed in any bed available (Bakes, 2014;Blay et al, 2012;Corbally, Macri, & Hawkshaw, 2014;Perera et al, 2016) only to be transferred at a later time when a more suitable bed becomes available (Blay et al, 2012;West, 2010b). This results in hot-bedding, defined as the rapid turnover of patients per bedspace (Blay, Duffield, Gallagher, & Roche, 2014;Duffield, Diers, et al, 2009) and the need to move pre-existing patients from one bed to another in the same ward (defined here as a bed transfer).…”

mentioning

confidence: 99%

Intrahospital transfers and the impact on nursing workload

Blay

Roche

Duffield

et al. 2017

Journal of Clinical Nursing

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“…Twenty‐one studies met inclusion criteria for the primary analysis 6,7,9,11,18–34 . Another 12 studies were included in the secondary analysis 35–46 .…”

Section: Resultsmentioning

confidence: 99%

Review article: Has the implementation of time‐based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Jones

Haustead

Walker

et al. 2021

Emerg Medicine Australasia

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Time‐based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000–2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty‐three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short‐stay admissions were excluded, and when pre‐target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re‐presented to EDs. Short‐stay admissions and re‐admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

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The ‘four‐hour target’ and the impact on Australian metropolitan acute surgical services

Cited by 13 publications

References 19 publications

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

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

Intrahospital transfers and the impact on nursing workload

Review article: Has the implementation of time‐based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

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