Roberto Forero1,2, Nicola Man1,2, Hanh Ngo3, David Mountain3,4, Mohammed Mohsin5,6, Daniel Fatovich3,7,8, Ghasem Sam Toloo9, Antonio Celenza3,4, Gerry FitzGerald9, Sally McCarthy10,11, Drew Richardson12,13, Fenglian Xu1, Nick Gibson14, Shizar Nahidi1,2, Ken Hillman1,2. 1. Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia. 2. Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia. 3. Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia. 4. Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. 5. Psychiatry Research and Teaching Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia. 6. School of Psychiatry, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia. 7. Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia. 8. Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia. 9. School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia. 10. Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia. 11. Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia. 12. Medical School, Australian National University, Canberra, Australian Capital Territory, Australia. 13. Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia. 14. School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia.
Abstract
OBJECTIVE: Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four-Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. METHODS: A longitudinal cohort study of a population-wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2-4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. RESULTS: There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age-standardised mortality was decreasing before the intervention. Post-intervention, WA had a significant reduction in mortality rate of -0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta-regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. CONCLUSIONS: The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long-term effects of the policy.
OBJECTIVE: Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four-Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. METHODS: A longitudinal cohort study of a population-wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2-4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. RESULTS: There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age-standardised mortality was decreasing before the intervention. Post-intervention, WA had a significant reduction in mortality rate of -0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta-regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. CONCLUSIONS: The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long-term effects of the policy.