Validation and Impact of the Four-Hour Rule in the Emergency Department

How effective is the four-hour rule (National Emergency Access Target) in reducing access block and the adverse effects of overcrowding on patients?

Grant ID: PROJ-2010-002-BURKE

Lay Summary

This wa a national collaborative research project approved by the National Health and Medical Research Council Partnership Projects scheme. This project aims to identify how the four-hour rule is effective in reducing access block and the adverse effects of emergency department overcrowding on patients. In particular, it assessed the impact of the four-hour rule as a policy intervention in reducing emergency department length of stay (EDLOS) over time in WA and compare the outcomes against comparable hospitals in NSW, Qld and ACT.

This project hypothesised that effective intervention for reducing EDLOS would translate into improved patient outcomes, particularly in subgroups identified as associated with the most harm from overcrowding.


Outcomes

The results from this study were published in several papers. Overall, the research team found that the four-hour/NEAT policy had benefits for patients, such as reducing their length of stay in Emergency Departments without jeopardizing their health status (there was no impact on patients' morbidity and mortality in most cases).

The team found that nationally, the four hour rule 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 four-hour rule. 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 reflected the value of investing resources into the ED/hospital system to improve efficiency and patient experience.

For health care providers and practitioners, the findings confirmed that while they have felt extra workload and stress, the quality of their care was not affected, and that better resources were required to support the staff.

The study also highlighted variations between States and individual emergency departments, which could lead to improvements.


Leveraged Funds

- $41,716 NHMRC


Dissemination

Journal articles
- Hession M., Forero R., Man N.W., Penza L., McDonald W., "Gaming National Emergency Access Target performance using Emergency Treatment Performance definitions and emergency department short stay units", Emerg Med Australas, 2019 April. doi: 10.1111/1742-6723.13295
-Forero R., Nahidi S., de Costa J., Fatovich D., FitzGerald G., Toloo S., McCarthy S., Mountain D., Gibson N. Mohsin M., Man W.N., "Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective", BMC Health Services Research, 2019; 19:82. doi: 10.1186/s12913-019-3877-8
• Nahidi S., Forero R., McCarthy S., Man N., Gibson N., Mohsin M., Mountain D., Fatovich D., Fitzgerald G., Toloo S.,”A Qualitative analysis of Perceptions and Experiences of Emergency Department Staff in Relation to implementation and outcomes of the Four-Hour Rule/National Emergency Access Target in Australia”, Emerg Med Australas, 2018; 5 September 2018. doi: org/10.1111/1742-6723.13166.
• Nahidi S., Forero R., Man N., Mohsin M., Fitzgerald G., Toloo S., McCarthy S., Gibson N., Fatovich D., “Impact of 4HR/NEAT policy implementation on Emergency Department staff: A qualitative perspective of ED management changes”, Emerg Med Australas, 2018; 27 August 2018. doi: 10.1111/1742-6723.13164.
- Forero R., Man N., Ngo H., Mountain D., Mohsin M., Fatovich D., Toloo G.S., Celenza A., FitzGerald G., McCarthy S., Richardson D., Xu F., Gibson N., Nahidi S., Hillman K., “Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments”, Emerg Med Australas, 2019 Feb;31(1):58-66. doi: 10.1111/1742-6723.13151 [Epub 2018 Jul 30]
- Forero R., Ngo H., Man N., Mountain D., Fatovich D, “Response to Re: Impact of the four-hour National Emergency Access Target on 30-day mortality, access block and chronic emergency department overcrowding in Australian emergency departments (Letter to the Editor)”, Emerg Med Australas, 2019 Feb;31(1):147-148. doi: 10.1111/1742-6723.13214. Epub 2018 Dec 4
- Forero R., Man N., McCarthy S., Richardson D., Mohsin M., Toloo G.S., FitzGerald G., Ngo H., Mountain D., Fatovich D., Celenza A., Gibson N., Xu F., Nahidi S., Hillman K., "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", Emerg Med Australas. 2018 Jul 24. doi: 10.1111/1742-6723.13142
- Ngo H., Forero R., Mountain D., Fatovich D., Man W., Sprivulis P., Mohsin M., Toloo S., Celenza A., Fitzgerald G., McCarthy S., Hillman K., “ Impact of the Four-Hour Rule in Western Australian Hospitals: Trend Analysis of a Large Record Linkage Study 2002-2013”, PLOS One, 2018: 13:3: e0193902. doi: 10.1371/journal.pone.0193902.
- Forero R., Nahidi S., De Costa J., Mohsin M., Fitzgerald G., Gibson N., McCarthy S., Aboagye-Sarfo P., “Application of Four-Dimension Criteria to assess rigour of qualitative research in Emergency Medicine”, BMC Health Services Research, 2018; 18(1): 120. doi: 10.1186/s12913-018-2915-2.

Conference Proceedings/Abstracts:
- Australasian College for Emergency Medicine Annual Scientific Meeting 2017, Sydney, Australia, 19–23 November 2017:
i. Forero R, Ngo H, Man N, Mountain D, Mohsin M, Fatovich D, Toloo S, Fitzgerald G, Celenza A, McCarthy S., "The four-hour rule/national emergency access target and its impact on 30-day mortality among admitted patients: a trend analysis of record-linkage data from WA, NSW, QLD, and ACT", [abstract] Emergency Medicine Australasia. (2018) 30(S1), 3–40. [Oral]
ii. Forero R, Nahidi, S, Gibson N, McCarthy S, Fatovich D, Mohsin M. Emergency department staff perceptions and experiences during the implementation of the four-hour rule/national emergency access target (neat) in Australia: a social dynamic perspective. [abstract] Emergency Medicine Australasia. (2018) 30(S1), 3–40. Oral.
iii. Man N, Forero R, Ngo H, Toloo S, Fitzgerald G, Fatovich D, Mountain D, Mohsin M, Richardson D., "Impact of the national emergency access target (neat) on time-based and admission-related outcomes in emergency departments (ed) in NSW, ACT and QLD", [abstract] Emergency Medicine Australasia. (2018) 30(S1), 3–40. [Oral]
iv. Ngo H, Forero R, Man H, Mountain D, Toloo, Fitzgerald G, Richardson D, Fatovich D., "Impact of the four-hour rule / NEAT in EDs on ambulance ramping: preliminary analysis of linked administrative data from three Australian states (WA, NSW and QLD)", [abstract] Emergency Medicine Australasia. (2018) 30(S1), 3–40. [Oral]
v. Hession M, Forero R, McDonnell G, McDonald W, Prodan A, Pensa L, Wang W., "ynamic simulation for achieving 4HR/NEAT in a local district hospital in metropolitan Sydney: a guide for managers", [abstract] Emergency Medicine Australasia. (2018) 30(S1), 3–40. [Oral]
- Australasian College for Emergency Medicine Annual Scientific Meeting 2015, Sydney, Australia, 22–26 November 2015:
i. Forero R, McDonnell G, Golding M, Yap C., "Using Dynamic Modelling to Improve Daily Ed Performance", [Abstract]. Emergency Medicine Australasia; 2016: 28:29. [Oral]
ii. Hession M, McDonnell G, Bodsworth M, Ali R, Melvin D, Forero R., "pening Pandora’s Box?: A Simulation Model In The ED To Achieve The National Emergency Access Target (Neat) At A District Hospital In Sydney, Australia", [Abstract]. Emergency Medicine Australasia; 2016: 28: 27. [Oral]
iii. Ngo H, Mountain D, Forero R., "The Four-hour Rule in WA Hospital Emergency Departments: How Did It Fare?" [Abstract]. Emergency Medicine Australasia; 2016: 28:18. [Oral]
iv. Forero R, McDonnell G, Clay-Williams R, Hillman K., "Systems resilience and end-of-life care", [Abstract].Emergency Medicine Australasia; 2016: 28: 30. [Oral]
- Australasian College for Emergency Medicine Annual Scientific Meeting 2014, Melbourne, Australia. 7–11 December 2014:
i. Forero R, McDonnell G, Hillman K., "Dynamic modelling to explore systems resilience in the ED for patients at the end-of-life ", Abstract]. Emergency Medicine Australasia, 2015, 27: 37. [Poster]
ii. Forero R, McDonnell G, Lenne B, Fatovich D, McCarthy S, Mountain D, Sprivulis P, Hillman K, et al., "Validation and Impact of the Four Hour Rule/NEAT in the Emergency Department. A large data-linkage study-Progress Update", [Abstract]. Emergency Medicine Australasia, 2015, 27: 8-9. [Oral.]
-Forero, R, Hillman, K, McDonnell, G, Xu, F, Lenne, B, Fatovich, D, McCarthy, S, Mountain, D, Sprivulis, P, Celenza, A, Ngo, H, Tridgell, P, Mohsin, M, Daly, F, Burton, K, Rohwedder, E, Green, S, Hoy, S, Fitzgerald, G, Toloo S, Burke, J, Richardson, D, Gibson, N, Braithwaite, J, Middleton, PM., "NEAT: Building a cart before evaluating the horse", 4th Annual NHMRC Symposium on Research Translation jointly with CIPHER, Sydney, 27-28 October, 2015. [Oral]


SHARE

Amount Awarded
$50,000


Program


Grant Scheme


Status
Completed (December 2018)


Principal Investigator:
Dr John Burke


Co Investigators:
Prof Gerry FitzGerald


Institution


Collaborating Institutions


CONTACT US +61 7 3720 5700 info@emfoundation.org.au Suite 1B, Terraces, 19 Lang Parade, Milton Qld 4064