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Ngo H, Forero R, Mountain D, Fatovich D, Man WN, 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:e0193902. [PMID: 29538401 PMCID: PMC5851625 DOI: 10.1371/journal.pone.0193902] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/22/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. METHODS A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. FINDINGS There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. CONCLUSIONS The FHR 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 FHR. 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 reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.
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Affiliation(s)
- Hanh Ngo
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Roberto Forero
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - David Mountain
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Sir Charles Gairdner Hospital, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Daniel Fatovich
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Wing Nicola Man
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Peter Sprivulis
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, SWSLHD, NSW Health, Liverpool, Sydney, NSW, Australia
- School of Psychiatry, Faculty of Medicine, UNSW, Kensington, Sydney, NSW, Australia
| | - Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Gerard Fitzgerald
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Sally McCarthy
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Emergency Care Institute, NSW Agency for Clinical Innovation, Chatswood, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Randwick, Sydney, NSW Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
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