Deconstructing the 4-h rule for access to emergency care and putting patients first

Abstract

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED-in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED-in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care.

Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study

“…In our study, the mean ED LOS was 4 h 18 min and significantly differed between particular years. Several countries, but so far not Poland, have implemented a 4-hour [16][17][18] or a 6-hour [19] rule as the target for 80%-95% of patients. Applying these cutoffs to our cohort, ED LOS was suboptimal in the 4-hour rule (71%) [17,18] and optimal in the 6hour rule (85%) [19].…”

Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study

“…In our study, the mean LOS was 3 h 2 min. Several countries, but so far not Poland, have implemented a 4 h [16][17][18] or a 6 h [19] rule as the target for 80-95% of patients. Applying these cutoffs to our cohort, LOS were suboptimal (71%) in the 4 h rule [17,18] and optimal (85%) in the 6 h rule [19].…”

The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study

“…Perhaps as a response to the 4-hour rule and unattainable 90% target, NEAT has recently been abolished by the Australian government [50], but it has remained a key ED performance indicator on the MyHospitals [15] and some states performance websites [51, 52]. Research also recommends the inclusion of patients’ ED clinical outcomes alongside ED time-based targets to minimise perverse incentives and unintended consequences [10, 53]. Clinical outcomes of patients in emergency care are currently not publicly reported in Australia.…”