Effect of the 4-h target on time-to-analgesia in an Australian emergency department: a pilot retrospective observational study
James A. Hughes A B D , C. J. Cabilan A and Andrew Staib A CA Emergency Department, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. Email: carajoyce.cabilan@health.qld.gov.au; andrew.staib@health.qld.gov.au
B School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan, Qld 4111, Australia.
C School of Medicine, The University of Queensland, St Lucia, Qld 4072, Australia.
D Corresponding author. Email: james.hughes@health.qld.gov.au
Australian Health Review 41(2) 185-191 https://doi.org/10.1071/AH16025
Submitted: 14 September 2015 Accepted: 14 April 2016 Published: 2 June 2016
Abstract
Objectives The aim of the present study was to assess the relationship between and the effect of the 4-h target or National Emergency Access Target (NEAT) on the time-to-analgesia (TTA), as well as the provision of analgesia in an adult emergency department (ED).
Methods The present study was a pilot descriptive explorative retrospective cohort study conducted in a public metropolitan ED. Eligible presentations for analysis were adults presenting with a documented pain score of ≥4 out of 10 between 1 and 14 September 2014. Triage Category 1, pregnant, chest pain and major trauma cases were excluded from the study. As a result, data for 260 patients were analysed.
Results Of 260 patients, 176 had analgesia with a median TTA of 49 min. Increased NEAT compliance did not significantly decrease TTA. However, when the factors that affected the provision of analgesia were analysed, an association was demonstrated between Admitted and Short Stay NEAT performance and the provision of analgesia. The likelihood of receiving analgesia at all increased as Admitted and Short Stay NEAT compliance improved.
Conclusion NEAT is a significant health policy initiative with little clinical evidence supporting its implementation. However, as the Admitted NEAT compliance increases, the probability of receiving analgesia increases, demonstrating a possible link between hospital function and clinical care provision that needs to be explored further.
What is known about the topic? The 4-h target or NEAT is a widely used initiative in EDs to allay crowding and access block. However, little is known of its impact on clinical endpoints, such as TTA.
What does this paper add? TTA was not significantly reduced as NEAT compliance increased. However, when the focus was on the probability of receiving analgesia, the results demonstrated that an improvement in Admitted and Short Stay NEAT compliance was associated with an increase in the likelihood of patients receiving analgesia.
What are the implications for practitioners? NEAT is a relatively recent initiative, hence evidence of its effect on clinically orientated outcomes is limited. Nevertheless, evidence of safety and effectiveness is emerging. The results of the present pilot study provide preliminary data on the timeliness of patient-centred care as demonstrated by TTA and administration of analgesia when required. Further, the results would seem to suggest that the provision of analgesia is affected by how timely patients are moved out of the ED to the in-patient setting. As for future investigations on TTA as a result of NEAT, a wider time period should be considered so that the accurate effect of compliance thresholds (e.g. ≥90%, 81–89%, ≤80%) of NEAT can be explored.
Additional keywords: 4-h rule.
References
[1] Australasian College for Emergency Medicine (ACEM). Access block and overcrowding in emergency departments. Melbourne: ACEM; 2004.[2] Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, McConnell KJ, Pines JM, Rathlev N, Schafermeyer R, Zwemer F, Shcull M, Asplin BR, Society for Academic Emergency Medicine Emergency Department Crowding Task Force 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 |
[3] Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008; 52 126–36.e1.
| Systematic review of emergency department crowding: causes, effects, and solutions.Crossref | GoogleScholarGoogle Scholar | 18433933PubMed |
[4] Commission for Healthcare Audit and Inspection. Investigation into Mid Staffordshire NHS Foundation Trust March 2009. London: Commission for Healthcare Audit and Inspection; 2009.
[5] Lansley A. Abolition of the four-hour waiting standard in accident and emergency. London: Department of Health; 2010. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213836/dh_116917.pdf [verified 29 June 2015].
[6] Maumill L, Zic M, Esson AA, Geelhoed GC, Borland MM, Johnson C, Aylward P, Martine 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 |
[7] Council of Australian Governments (COAG). The National Health Reform Agreement–National Partnership Agreement on Improving Public Hospital Services. Canberra: COAG; 2011.
[8] 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 |
[9] Hughes G. The four hour target; problems ahead. Emerg Med J 2006; 23 2
| The four hour target; problems ahead.Crossref | GoogleScholarGoogle Scholar | 16373794PubMed |
[10] Scott H. BMA claims that patients in A&E are being put at risk. Br J Nurs 2005; 14 305
| BMA claims that patients in A&E are being put at risk.Crossref | GoogleScholarGoogle Scholar | 15902024PubMed |
[11] Mortimore A, Cooper S. The ‘4-hour target’: emergency nurses’ views. Emerg Med J 2007; 24 402–4.
| The ‘4-hour target’: emergency nurses’ views.Crossref | GoogleScholarGoogle Scholar | 17513535PubMed |
[12] British Medical Association (BMA). BMA survey of A&E waiting times. London: BMA; 2005.
[13] Todd KH, Sloan EP, Chen C, Eder S, Wamstad K. Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. Can J Emerg Med 2002; 4 252–6.
[14] Doherty S, Knott J, Bennetts S, Jazayeri M, Huckson S. National project seeking to improve pain management in the emergency department setting: Findings from the NHMRC‐NICS National Pain Management Initiative. Emerg Med Australas 2013; 25 120–6.
| National project seeking to improve pain management in the emergency department setting: Findings from the NHMRC‐NICS National Pain Management Initiative.Crossref | GoogleScholarGoogle Scholar | 23560961PubMed |
[15] National Institute of Clinical Studies (NICS). National emergency department collaborative report. Melbourne: NICS; 2004.
[16] Stang AS, Hartling L, Fera C, Johnson D, Ali S. Quality indicators for the assessment and management of pain in the emergency department: a systematic review. Pain Res Manag 2014; 19 e179–90.
| 25337856PubMed |
[17] Fry M, Ryan J, Alexander N. A prospective study of nurse initiated panadeine forte: expanding pain management in the ED. Accid Emerg Nurs 2004; 12 136–40.
| A prospective study of nurse initiated panadeine forte: expanding pain management in the ED.Crossref | GoogleScholarGoogle Scholar | 15234710PubMed |
[18] Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emerg Med 2002; 14 249–54.
| Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia.Crossref | GoogleScholarGoogle Scholar |
[19] Arendts G, Fry M. Factors associated with delay to opiate analgesia in emergency departments. J Pain 2006; 7 682–6.
| Factors associated with delay to opiate analgesia in emergency departments.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD28XptFCgtrk%3D&md5=e88d395cfa8b5e323f9263c150017902CAS | 16942954PubMed |
[20] Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med 2000; 35 63–8.
| Overcrowding in the nation’s emergency departments: complex causes and disturbing effects.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c%2Fot1OnsQ%3D%3D&md5=223965c6161d52fc1a53bc34b4741562CAS | 10613941PubMed |
[21] Hwang U, Richardson L, Livote E, Harris B, Spencer N, Sean Morrison R. Emergency department crowding and decreased quality of pain care. Acad Emerg Med 2008; 15 1248–55.
| Emergency department crowding and decreased quality of pain care.Crossref | GoogleScholarGoogle Scholar | 18945239PubMed |
[22] Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc 2006; 54 270–5.
| The effect of emergency department crowding on the management of pain in older adults with hip fracture.Crossref | GoogleScholarGoogle Scholar | 16460378PubMed |
[23] Johnson KD, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J 2011; 33 39–54.
| The effect of emergency department crowding on patient outcomes: a literature review.Crossref | GoogleScholarGoogle Scholar | 21317697PubMed |
[24] Mills AM, Shofer FS, Chen EH, Hollander JE, Pines JM. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med 2009; 16 603–8.
| The association between emergency department crowding and analgesia administration in acute abdominal pain patients.Crossref | GoogleScholarGoogle Scholar | 19549018PubMed |
[25] Mitchell R, Kelly AM, Kerr D. Does emergency department workload adversely influence timely analgesia? Emerg Med Australas 2009; 21 52–8.
| Does emergency department workload adversely influence timely analgesia?Crossref | GoogleScholarGoogle Scholar | 19254313PubMed |
[26] Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med 2008; 51 1–5.
| Emergency department crowding is associated with poor care for patients with severe pain.Crossref | GoogleScholarGoogle Scholar | 17913299PubMed |
[27] Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med 2010; 17 276–83.
| The effect of emergency department crowding on analgesia in patients with back pain in two hospitals.Crossref | GoogleScholarGoogle Scholar | 20370760PubMed |
[28] Chu K, Brown A. Association between access block and time to parenteral opioid analgesia in renal colic: a pilot study. Emerg Med Australas 2009; 21 38–42.
| Association between access block and time to parenteral opioid analgesia in renal colic: a pilot study.Crossref | GoogleScholarGoogle Scholar | 19254311PubMed |
[29] Whittingham MJ, Stephens PA, Bradbury RB, Freckleton RP. Why do we still use stepwise modelling in ecology and behaviour? J Anim Ecol 2006; 75 1182–9.
| Why do we still use stepwise modelling in ecology and behaviour?Crossref | GoogleScholarGoogle Scholar | 16922854PubMed |
[30] Tibshirani R. Regression shrinkage and selection via the lasso. J R Stat Soc B 1996; 58 267–88.
[31] Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: Institute of Medicine; 2001.
[32] 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 |
[33] 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 |
[34] 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 |
[35] Henneman PL, Nathanson BH, Li H, Smithline HA, Blank FS, Santoro JP, Maynard AM, Provost DA, Hennerman EA. Emergency department patients who stay more than 6 hours contribute to crowding. J Emerg Med 2010; 39 105–12.
| Emergency department patients who stay more than 6 hours contribute to crowding.Crossref | GoogleScholarGoogle Scholar | 19157757PubMed |
[36] White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med 2013; 44 230–5.
| Boarding inpatients in the emergency department increases discharged patient length of stay.Crossref | GoogleScholarGoogle Scholar | 22766404PubMed |
[37] Dunn R. Reduced access block causes shorter emergency department waiting times: an historical control observational study. Emerg Med 2003; 15 232–8.
| Reduced access block causes shorter emergency department waiting times: an historical control observational study.Crossref | GoogleScholarGoogle Scholar |
[38] Falvo T, Grove L, Stachura R, Vega D, Stike R, Schlenker M, Zirkin W. The opportunity loss of boarding admitted patients in the emergency department. Acad Emerg Med 2007; 14 332–7.
| The opportunity loss of boarding admitted patients in the emergency department.Crossref | GoogleScholarGoogle Scholar | 17331916PubMed |
[39] Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA. A conceptual model of emergency department crowding. Ann Emerg Med 2003; 42 173–80.
| A conceptual model of emergency department crowding.Crossref | GoogleScholarGoogle Scholar | 12883504PubMed |
[40] Staib A, Sullivan C, Griffin B, Bell A, Scott I. Report on the 4-h rule and National Emergency Access Target (NEAT) in Australia: time to review. Aust Health Rev 2015;
| Report on the 4-h rule and National Emergency Access Target (NEAT) in Australia: time to review.Crossref | GoogleScholarGoogle Scholar | 26433943PubMed |
[41] Drummond AJ. No room at the inn: overcrowding in Ontario’s emergency departments. Can J Emerg Med 2002; 4 91–7.
[42] Lawrence S, Spencer LM, Sinnott M, Eley R. It takes two to tango: improving patient referrals from the emergency department to inpatient clinicians. Ochsner J 2015; 15 149–53.
| 26130977PubMed |
[43] Stokes B. Four hour rule program progress and issues review. Perth: Government of Western Australia, Department of Health; 2011.
[44] Gregory KE, Radovinsky L. Research strategies that result in optimal data collection from the patient medical record. Appl Nurs Res 2012; 25 108–16.
| Research strategies that result in optimal data collection from the patient medical record.Crossref | GoogleScholarGoogle Scholar | 20974093PubMed |
