Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments

Roberto Forero; Nicola Man; Hanh Ngo; David Mountain; Mohammed Mohsin; Daniel Fatovich; Ghasem Sam Toloo; Antonio Celenza; Gerry FitzGerald; Sally McCarthy; Drew Richardson; Fenglian Xu; Nick Gibson; Shizar Nahidi; Ken Hillman

doi:10.1111/1742-6723.13151

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. 2019 Feb;31(1):58-66. doi: 10.1111/1742-6723.13151. Epub 2018 Jul 30.

Authors

Roberto Forero^{1

2}, Nicola Man^{1

2}, Hanh Ngo³, David Mountain^{3

4}, Mohammed Mohsin^{5

6}, Daniel Fatovich^{3

7

8}, Ghasem Sam Toloo⁹, Antonio Celenza^{3

4}, Gerry FitzGerald⁹, Sally McCarthy^{10

11}, Drew Richardson^{12

13}, Fenglian Xu¹, Nick Gibson¹⁴, Shizar Nahidi^{1

2}, Ken Hillman^{1

2}

Affiliations

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.

PMID: 30062847
DOI: 10.1111/1742-6723.13151

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.

Keywords: 30 day mortality; National Emergency Access Target; access block; emergency department overcrowding; trend analysis.

MeSH terms

Australia
Cohort Studies
Crowding*
Emergency Service, Hospital / organization & administration
Emergency Service, Hospital / statistics & numerical data
Hospital Mortality / trends*
Hospitalization / statistics & numerical data
Humans
Longitudinal Studies
Outcome Assessment, Health Care / standards*
Outcome Assessment, Health Care / statistics & numerical data
Regression Analysis
Time Factors*