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 is 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 will assess 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 hypothesises that effective intervention for reducing EDLOS will translate into improved patient outcomes, particularly in subgroups identified as associated with the most harm from overcrowding. This research has the potential to develop and promote long-term partnerships amongst hospitals, health services, ambulance services and researchers to conduct collaborative research related to adverse patient outcomes, overcrowding and access block in emergency departments.


Outcomes

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.

With regard to ED staff, they perceived important effects on quality and safety of care; access block and overcrowding; and medical education and training. In relation to an optimised ED role, quality of care and access block were overall felt to be improved, while education and training deteriorated.


Leveraged Funds

- $41,716 NHMRC


Dissemination

Journal articles
- Nahidi S. Forero R., McCarthy S., Man N., Gibson N., Mohsin M., Mountain D., Fatovich D., FitzGerald G., Toloo G., 4HR/NEAT Partnership Grant, “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 Sep 4. doi: 10.1111/1742-6723.13166. [Epub ahead of print]

- Nahidi S. Forero R., McCarthy S., Man N., Mohsin M., Mountain D , Fatovich D., “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 Sep 4. doi: 10.1111/1742-6723.13166. [Epub ahead of print]

- Nahidi S. Forero R., Man N., Mohsin M., FitzGerald G., Toloo G., McCarthy S., Gibson N., Fatovich D., Mountain D., “Impact of the Four‐Hour Rule/National Emergency Access Target policy implementation on emergency department staff: A qualitative perspective of emergency department management changes”, Emerg Med Australas., 2018 Aug 26. doi.org/10.1111/1742-6723.13164 [Epub ahead of print]
-Forero R., Man N., Ngo H., Mountain D., Mohsin M., Fatovich D., Toloo G., 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., 2018 Jul 30. doi: 10.1111/1742-6723.13151. [Epub ahead of print]

- 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.N., Sprivulis, P., Mohsin, M., Toloo, S., Celenza, A., Fitzgerald, G. and McCarthy, S., 2018. Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013. PloS one, 13(3), p.e0193902. https://doi.org/10.1371/journal.pone.0193902

- Forero, R., Nahidi, S., De Costa, J., Mohsin, M., Fitzgerald, G., Gibson, N., McCarthy, S. and Aboagye-Sarfo, P., 2018. "Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine",  BMC health services research, 18(1), p.120. https://doi.org/10.1186/s12913-018-2915-2

- Validation and Impact of the Four Hour Rule in the ED. A large data linkage study. Abstract submission. Emerg Med Australas, 27: 1–27. doi:10.1111/1742-6723.12415

Conference Proceedings/Abstracts:
- Hanh Ngo, The four-hour rule/national emergency access target and its impact on 30-day mortality among admitted patients: a trend analysis of recordlinkage data from WA, NSW, QLD and ACT. ACEM ASM, Sydney, November 2017
- Hanh Ngo, Impact of the NEAT on ambulance ramping: preliminary analysis of linked administrative data from three Australian states (WA, NSW, and QLD). ACEM ASM, Sydney, November 2017
- Nicola Man and Roberto Forero, Impact of the national emergency access target on time-based and admission-related outcomes in emergency departments in NSW, ACT and QLD, ACEM ASM, Sydney, November 2017
- Robert Forero, Emergency department staff perceptions and experiences during the implementation of the four hour rule/national emergency access target in Australia: a social dynamic perspective. ACEM ASM, Sydney, November 2017
- A Qualitative Study of the Four Hour Rule/ NEAT in the emergency Department (ED), ACEM ASM 2016, Queenstown New Zealand
- Mortality and the Four- Hour Rule in Western Australia: Results from Four Adult Hospital EDs (2002-2012), ACEM ASM 2016, Queenstown New Zealand
- NEAT: building a cart before evaluating the horse. NHMRC Research Translation Symposium. Oral presentation. Sofitel Sydney Wentworth, Sydney. 27-28 Oct 2015.
- The Four-Hour Rule in WA Hospital Emergency Departments: How Did It Fare? ACEM’s 32nd Annual Scientific Meeting. Oral presentation. Convention Centre, Brisbane. 22-26 Nov 2015.
- Using Dynamic Modelling To Improve Daily ED Performance. ACEM’s 32nd Annual Scientific Meeting. Oral presentation. Convention Centre, Brisbane. 22-26 Nov 2015.
- Opening Pandora’s Box?: A simulation model in the ED to achieve the National Emergency Access Target (NEAT). ACEM’s 32nd Annual Scientific Meeting. Oral presentation. Convention Centre, Brisbane. 22-26 Nov 2015.


SHARE

Amount Awarded
$50,000


Program


Grant Scheme


Status
Active


Principal Investigator:
Dr John Burke


Co Investigators:
Prof Gerry FitzGerald


Institution


Collaborating Institutions


CONTACT US +61 7 3720 5700 info@emfoundation.org.au 2/15 Lang Parade Milton Qld 4064