Report on the 4-h rule and National Emergency Access Target (NEAT) in Australia: time to review
Andrew Staib A D E , Clair Sullivan A B D , Bronwyn Griffin A , Anthony Bell C and Ian Scott AA Princess Alexandra Hospital, Metro South Health, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. Email: clair.sullivan@health.qld.gov.au; Bronwyn.Griffin2@health.qld.gov.au
B Mater Research Institute, University of Queensland, Translational Research Institute (TRI), 199 Ipswich Road, Woolloongabba, Qld 4102, Australia.
C Royal Brisbane and Women’s Hospital, Metro North Health, Bowen Bridge Road, Herston, Qld 4129, Australia. Email: Anthony.Bell@health.qld.gov.au
D These authors contributed equally to this paper.
E Corresponding author. Email: Andrew.Staib@health.qld.gov.au
Australian Health Review 40(3) 319-323 https://doi.org/10.1071/AH15071
Submitted: 9 April 2015 Accepted: 17 July 2015 Published: 5 October 2015
Journal Compilation © AHHA 2016
Abstract
Objective The aim of the present study was to provide a summary of a systematic review of literature reporting benefits and limitations of implementing National Emergency Access Target (NEAT), a target stipulating that a certain proportion of patients presenting to hospital emergency departments are admitted or discharged within 4 h of presentation.
Methods A systematic review of published literature using specific search terms, snowballing techniques applied to retrieved references and Google searches was performed. Results are presented as a narrative synthesis given the heterogeneity of included studies.
Results Benefits of a time-based target for emergency care are improved timeliness of emergency care and reduced in-hospital mortality for emergency admissions to hospital. Limitations centre on using a process measure (time) alone devoid of any monitoring of patient outcomes, the threshold nature of a time target and the fact that currently NEAT combines the measurement of clinical management of two very different patient cohorts seeking emergency care: less acute patients discharged home and more acute patients admitted to hospital.
Conclusions Time-based access targets for emergency presentations are associated with significant improvements in in-hospital mortality for emergency admissions. However, other patient-important outcomes are deserving of attention, choice of targets needs to be validated by empirical evidence of patient benefit and single targets need to be partitioned into separate targets pertaining to admitted and discharged patients.
What is known about the topic? Time targets for emergency care originated in the UK. The introduction of NEAT in Australia has been controversial. NEAT directs that a certain proportion of patients will be admitted or discharged from an emergency department (ED) within 4 h. Recent dissolution of the Australian National Partnership Agreement (which provided hospitals with financial incentives for achieving NEAT compliance) has prompted a re-examination of the 4-h rule, the evidence underpinning its introduction and its benefits and risks to patients
What does this paper add? This paper is executive summary of key findings from a systematic literature review on the benefits and limitations of NEAT (the 4-h rule) commissioned by the Queensland Clinical Senate to inform future policy and targets.
What are the implications for practitioners? There is evidence that a time-based target has been associated with a reduction in in-hospital mortality for emergency admissions to Australian hospitals. Concerns remain regarding a time-based target alone being used to drive redesign efforts at improving access to emergency care. A time-based target should be coupled with close monitoring of patient outcomes of emergency care. Target thresholds need to be evidence based and separate targets should be reported for admitted, discharged and all patients presenting to the ED.
References
[1] Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, McConnell KJ, Pines JM, Rathlev N, Schafermeyer R, Zwemer F, Schull M, Asplin BR. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009; 16 1–10.| The effect of emergency department crowding on clinically oriented outcomes.Crossref | GoogleScholarGoogle Scholar | 19007346PubMed |
[2] Gubb J. Have targets done more harm than good in the English NHS? Yes. BMJ 2009; 338 a3130
| Have targets done more harm than good in the English NHS? Yes.Crossref | GoogleScholarGoogle Scholar | 19151062PubMed |
[3] Commonwealth Government of Australia. Expert Panel: review of elective surgery and emergency access targets under the National Partnership Agreement on improving public hospital services. Canberra: Commonwealth of Australia; 2011.
[4] Council of Australian Governments. The National Health Reform Agreement: national partnership agreement on improving public hospital services. Canberra: Commonwealth of Australia; 2011. Available at: http://www.federalfinancialrelations.gov.au/content/npa/health_reform/national-agreement.pdf [verified 19 August 2015].
[5] Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006; 184 213–16.
| 16515430PubMed |
[6] Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006; 184 208–12.
| 16515429PubMed |
[7] Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust 2003; 179 524–6.
| 14609414PubMed |
[8] Richardson DB. Responses to access block in Australia: Australian Capital Territory. Med J Aust 2003; 178 103
| 12558474PubMed |
[9] Clinical Access and Redesign Unit. Service improvements and delivery models. Brisbane: Queensland Health; 2014. Available at: http://www.health.qld.gov.au/caru/improving-services/service-models.asp [verified 16 January 2015].
[10] Kelly A-M, Bryant M, Cox L, Jolley D. Improving emergency department efficiency by patient streaming to outcomes-based teams. Aust Health Rev 2007; 31 16
| Improving emergency department efficiency by patient streaming to outcomes-based teams.Crossref | GoogleScholarGoogle Scholar | 17266484PubMed |
[11] Geelhoed GC, de Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust 2012; 196 122–6.
| Emergency department overcrowding, mortality and the 4-hour rule in Western Australia.Crossref | GoogleScholarGoogle Scholar | 22304606PubMed |
[12] Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011; 342 d2983-d
[13] Goh SL. Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia. Med J Aust 2012; 197 148
| Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia.Crossref | GoogleScholarGoogle Scholar | 22860787PubMed |
[14] Mitra B, Cameron PA. Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia. Med J Aust 2012; 196 499
| Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia.Crossref | GoogleScholarGoogle Scholar | 22571302PubMed |
[15] Plunkett PK, Byrne DG, Breslin T, Bennett K, Silke B. Increasing wait times predict increasing mortality for emergency medical admissions. Eur J Emerg Med 2011; 18 192–6.
| Increasing wait times predict increasing mortality for emergency medical admissions.Crossref | GoogleScholarGoogle Scholar | 21317786PubMed |
[16] Sullivan C, Staib A, Eley R, Scanlon A, Flores J, Scott I. National Emergency Access Targets metrics of the emergency department-inpatient interface: measures of patient flow and mortality for emergency admissions to hospital. Aust Health Rev 2015;
| National Emergency Access Targets metrics of the emergency department-inpatient interface: measures of patient flow and mortality for emergency admissions to hospital.Crossref | GoogleScholarGoogle Scholar | 26278814PubMed |
[17] Sullivan CM, Staib A, Flores J, Aggarwal L, Scanlon A, Martin JH, Scott IA. Aiming to be NEAT: safely improving and sustaining access to emergency care in a tertiary referral hospital. Aust Health Rev 2014; 38 564–74.
| Aiming to be NEAT: safely improving and sustaining access to emergency care in a tertiary referral hospital.Crossref | GoogleScholarGoogle Scholar | 25297518PubMed |
[18] Kelman S, Friedman JN. Performance improvement and performance dysfunction: an empirical examination of distortionary impacts of the emergency room wait-time target in the English National Health Service. J Public Admin Res Theor 2009; 19 917–46.
| Performance improvement and performance dysfunction: an empirical examination of distortionary impacts of the emergency room wait-time target in the English National Health Service.Crossref | GoogleScholarGoogle Scholar |
[19] Jones P, Schimanski K. The four hour target to reduce emergency department ‘waiting time’: a systematic review of clinical outcomes. Emerg Med Australas 2010; 22 391–8.
| The four hour target to reduce emergency department ‘waiting time’: a systematic review of clinical outcomes.Crossref | GoogleScholarGoogle Scholar | 20880296PubMed |
[20] Maumill L, Zic M, Esson AA, Geelhoed GC, Borland MM, Johnson C, Aylward P, Martin AC. The National Emergency Access Target (NEAT): can quality go with timeliness? Med J Aust 2013; 198 153–7.
| The National Emergency Access Target (NEAT): can quality go with timeliness?Crossref | GoogleScholarGoogle Scholar | 23418696PubMed |
[21] Mortimore A, Cooper S. The ‘4-hour target’: emergency nurses’ views. Emerg Med Australas 2007; 24 402–4.
| The ‘4-hour target’: emergency nurses’ views.Crossref | GoogleScholarGoogle Scholar |
[22] Mason S. Keynote address: United Kingdom experiences of evaluating performance and quality in emergency medicine. Acad Emerg Med 2011; 18 1234–8.
| Keynote address: United Kingdom experiences of evaluating performance and quality in emergency medicine.Crossref | GoogleScholarGoogle Scholar | 22168184PubMed |
[23] Mountain D. Introduction of a 4-hour rule in Western Australian emergency departments. Emerg Med Australas 2010; 22 374
| Introduction of a 4-hour rule in Western Australian emergency departments.Crossref | GoogleScholarGoogle Scholar | 21040480PubMed |
[24] Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Quality Health care 2001; 13 475–80.
| 1:STN:280:DC%2BD38%2FktlWhtw%3D%3D&md5=8fe457f09e5fe68639ceb6f001163f68CAS |
[25] Queensland Audit Office. Emergency department performance reporting. Report 3: 2014–15. Brisbane: Queensland Audit Office; 2014.
[26] Wood H, Fontain, P., Harvey, D., Catford, G., Hills, A., Holland, B. Investigation into Mid Staffordshire NHS Foundation Trust. London: Healthcare Commission; 2009.
[27] Mason S, Weber EJ, Coster J, Freeman J, Locker T. Time patients spend in the emergency department: England’s 4-hour rule-a case of hitting the target but missing the point? Ann Emerg Med 2012; 59 341
| Time patients spend in the emergency department: England’s 4-hour rule-a case of hitting the target but missing the point?Crossref | GoogleScholarGoogle Scholar | 22088495PubMed |
[28] National Health Service (NHS)The NHS: a plan for investment, a plan for hospital reform. London: The Stationery Office Ltd UK; 2010.
[29] Clinical Access and Redesign Unit. Emergency department: monthly performance report. Brisbane: Queensland Health; 2014.
