A concerted national effort to limit patients’ stay in a hospital emergency department (ED) to four hours has led to reduced overcrowding and better access to medical resources.
But the jury is still out as to whether these measures are effective in reducing the numbers of patients dying within 30 days of visiting the ED.
These are some of the findings of a National Health and Medical Research Council (NHMRC)-backed study led by UNSW researchers
In the largest longitudinal study conducted in Australasia to date using linked data from 16 hospitals in Western Australia, NSW, Queensland and the ACT, researchers examined data before and after the introduction of the four-hour rule (4HR) in Western Australia in 2009 and the four-hour National Emergency Access Target (NEAT) in participating states in 2012.
The study examined data of almost 4 million visits to EDs that resulted in more than 950,000 hospital admissions in a period spanning 12 years in WA and eight years in NSW, ACT and QLD.
UNSW Senior Research Fellow Dr Roberto Forero, who led the study, said while the results varied from state to state, the overall picture was that implementing 4HR and NEAT had a positive effect on ED flow and was consistent with other smaller-scale studies that have reported similar findings.
He said that prior to having four-hour targets, hospitals were operating at a baseline ED flow (ie. patients treated in four hours or less) of between 35 and 50 per cent. In other words, as many as half of all patients presenting to ED spent more than four hours being assessed before being discharged or admitted into hospital for specialised treatment.
“After 4HR/NEAT was implemented, the number of people spending more than four hours in ED decreased on average to as low as 30 per cent in WA and Queensland, and about 40 per cent in NSW,” Dr Forero said.
The ED flow recorded in ACT hospitals also improved, but at a less pronounced rate.
The overall improvement was achieved by changing and innovating workplace practices in ED. This often involved improved clinical staffing in ED, and specific roles to address patient flow.
“We saw that hospitals changed the structure of the ED and involved the rest of the hospital in patient flow, looking at new ways to improve the process of discharging patients.” Dr Forero said.
“So they improved processes while making sure the person was safe to be discharged.”
The effect of this was that more beds were available in the ED and the hospital, which allowed attention to be given to new patients in need of acute care.
"Overall, the policy has had a positive effect. Access block still occurs, but at a much more reduced rate than before."
The study also looked at whether the policy reduced ‘access block’, a symptom of hospital overcrowding where patients spend more than eight hours in ED.
“These are admitted patients still in ED after eight hours for reasons outside its control such as limited bed capacity in the hospital,” Dr Forero said.
“Overall, the policy has had a positive effect. Access block still occurs, but at a much more reduced rate than before the targets were introduced.”
One result that the researchers were hoping to confirm was a stronger correlation between ED overcrowding and 30-day mortality. However, only WA showed a significant improvement in these numbers, leading the researchers to conclude that the purported link between access block and mortality rates as put forward in previous studies remained a controversial one.
Other innovative aspects of the study included a qualitative analysis of how ED staff experienced the top-down policy implementation as noted in a paper published on Wednesday.
Dr Forero and his team reported that ED staff on the whole perceived improvements in quality and safety of care as a result of innovations to achieve the new targets, as well as observing a lessening of access block and overcrowding.
But a negative perception was that education and training suffered, as some participants now had less time and opportunity to practise procedural skills.
Despite subsequent federal governments withdrawing financial incentives for state-run hospitals to meet the NEAT targets, EDs around Australia value the positive impact of the policy in their daily operations, Dr Forero said.
He added: “There are still challenges that need to be addressed by both federal and state government alike, such as the policy's effects on patient communication, the reduction in training and education, and the long term impact on the profession.”