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. 2018 Mar 14;13(3):e0193902.
doi: 10.1371/journal.pone.0193902. eCollection 2018.

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013

Hanh Ngo  1 , Roberto Forero  2   3 , David Mountain  1   4   5 , Daniel Fatovich  5   6   7 , Wing Nicola Man  2   3 , Peter Sprivulis  1   5 , Mohammed Mohsin  8   9 , Sam Toloo  10 , Antonio Celenza  1   5 , Gerard Fitzgerald  5   10 , Sally McCarthy  5   11   12 , Ken Hillman  2   3 ; Four-Hour Rule Partnership Grant
Affiliations

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013

Hanh Ngo et al. PLoS One. .

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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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1
ITS analysis for rate of ED attendance across WA hospitals (A to E). Estimated trend lines for Without FHR (broken line) and With FHR (solid line). Series with markers represent actual data.
Fig 2
Fig 2. Results of ITS analysis for rate of ED re-attendance across hospitals: Estimated trend lines for Without FHR (broken line) and with FHR (solid line).
Series with markers represent actual data.
Fig 3
Fig 3. ITS analysis for median length of stay in ED (measured in hours): Estimated trend lines for Without FHR (broken line) and with FHR (solid line).
Series with markers represent actual data.
Fig 4
Fig 4. Results of ITS analysis for mean ED occupancy rate: Estimated trend lines for Without FHR (broken line) and with FHR (solid line).
Series with markers represent actual data.
Fig 5
Fig 5. Results of ITS analysis for rate of access block: Estimated trend lines for Without FHR (broken line) and with FHR (solid line).
Series with markers represent actual data.
See this image and copyright information in PMC

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