The Four Hour Rule comes to Australia

WA health has taken another bold step in its continued quest to drive ‘long term system wide reform’ and implement strategies which will enhance the patient experience and ‘flow’ through the turbulent waters of ‘unscheduled care’. WA health has acknowledged that a radical change and expansion of improvement measures is required to have a significant impact on the increasing demand for emergency services in Western Australia.

As part of devising a solution to this problem, a group of clinicians from WA Health visited 12 hospital sites in the United Kingdom in November 2008 to look at the model used by the National Health Service (NHS). The model used in ‘most’ of the UK has been branded the ‘Four Hour Rule

Definition of the Four Hour Rule:

98% of patients arriving at the emergency department are to be seen and either admitted, discharged or transferred within four-hours from the time of triage.

Four Hour Rule Implementation in Western Australia:

The four-hour rule will be implemented in three stages, starting with adult tertiary hospitals (such as Sir Charles Gairdner Hospital (SCGH) and Royal Perth Hospital (RPH)) and Princess Margaret Hospital (PMH), then other metropolitan sites and finally, regional hospitals. Hospitals will have two years to ensure at least 98 per cent of their emergency patients either get a hospital bed or are discharged within four hours. The state’s tertiary hospitals and PMH will start phasing in the rule from April 14 2009.

The Intent of Implementation

The aim of this new program is to improve patient experiences by reducing delays in emergency departments (ED) and inpatient areas by streamlining processes for admission and discharge.

This is a serious reform of the way our hospitals operate and will take time to get right, but this is not simply about announcing a target – Dr Kim Hames

Contextualizing the Four Hour Rule

Implementing the four-hour rule will not just shake up the way emergency departments function, it will require a radical change to the way hospitals operate in general. A ‘localized version’ of the UK Four Hour Rule is essential, and it appears that the clinicians in the steering committee [Dr Frank Daly and Dr Robyn Lawrence] are looking closely at options to ‘skim the cream’ from the UK strategy to provide maximal benefit to the WA health system. The ability to observe the positive and negative aspects of the Four Hour Rule should provide a great platform from which to develop the most effective strategy for the WA hospital system.

The UK system will serve as a basis for the WA program, but the State Government will be refining the model to suit local conditions and community needs – Dr Kim Hames

Strategic options that could be reviewed include

  • Review and overhaul of the 5-tier Australasian Triage Scale (ATS) [triage system used to determine the priority for treating emergency patients]. Strategic implementation of a two-tier system [‘majors’ and ‘minors’] or a three-tier system [category 1, category 2 and category 3-4-5]
  • Enhanced use of discharge lounges
  • Increasing 24 hour coverage [Dr Daly stated that ‘hospital staff could be expected to work more night shifts and weekends under a patient-focused health service’]
  • Earlier consultant/senior registrar review at triage
  • Increased use of GPs in Emergency Departments
  • Enhanced roles for nurses with more ‘defined’ nurse practitioner roles
  • Focused utilization of allied health services within the framework of the emergency department – incorporating such as physiotherapy, occupational therapy, social work, psychiatric liaison, community health, HITH and


Potential Positive Outcomes:

  • The current problem of ‘access block’ will be formally addressed. [Access Block occurs if the time from a patients presentation to their admission to an inpatient hospital bed exceeds 8 hours]. The current burden of access block rests with the emergency departments and has a significant impact on patient care.
  • The new ‘access block’ standard will be four hours not eight hours – with ‘enforced’ high level compliance. This paradigm shift from ‘eight hours’ to ‘four hours’ would potentially solve the access block problem – if achieved.
  • Implementation of the Four Hour Rule would force hospital administration to take responsibility for the problem of access block. The ramifications of poor patient flow would become a ‘hospital wide issue’ rather than purely an ED problem
  • The Four Hour Rule focuses staff on the assessment and management of patients at an early stage – enhancing the use clinical judgment rather than waiting for the results of diagnostic tests.

Potential Negative Outcomes:

  • Increased stress. Increased after hour shifts, weekend shifts and potentially 24 hour ED consultant cover to address the surges in patient presentations
  • The setting of ‘targets’ with or without punitive penalties may lead to ‘gaming’ of the facts, the figures and the flow e.g. admitting patients to a ward to wait for test results, admitting patients who have yet to be seen or just ‘doctoring’ the figures.
  • Reduction in the standard of emergency care delivered. Currently the Australian Emergency Department model emphasizes early patient care, diagnostic investigation and procedural intervention. This model has been shown to reduce the overall patient length of stay (LOS) and increase discharge rates. Stringent time-capped pressure may denude the emergency physician of clinical autonomy and impact negatively on patient outcomes.
  • Increased propensity for adverse patient outcomes and the risk of early discharge from the ED without a definitive diagnosis or appropriate treatment plan in place.
  • ‘Emergency care’ may be reduced to ‘early referral and flow management’ heralding a return to the perception of EDs as ‘patient portals with advanced severity-filtering criteria‘ akin to the ‘Casualty Departments’ of the 1950s and 1960s.
  • Clinical Flow in the ED will become the ‘Gold Standard’. Excellence in flow will be rewarded and necessarily be given higher priority than patient care

Four Hour Rule – Success?

  • Fundamental concerns still exist with the time and percentages of the ‘Four Hour Rule’. The College of Emergency Medicine in the UK has suggested that ‘a 95% six hour target would be more sustainable, and cost effective.’
  • WA will be a test case for the rest of Australasia. It will be difficult to turn the clock back or implement later change if this model proves incorrect or harmful to patients.
  • Reduced relevance of Emergency Medicine as a profession. This will lead to a further deterioration in recruitment and retention of trainees and specialists in Western Australia. Rapid patient processing, reduced diagnostic evaluation and procedural intervention will impact heavily on the learning experience of emergency personnel.
  • ED Clinical Care will be capped at four hours from presentation for 95-98% of ED presentations. This may lead to a culture of ‘time-capped clinical concern’ for patients.

Patients are no longer known by their names or by their conditions, they’re not even known by a number…patients are referred to by their time. By this I mean how long they’ve been in the department…as soon as a patient ticks past 3 hours their name lights up like a Christmas tree…If their stay approaches 3 hours 30… the managers start to appear… they don’t actually care…about Mr Jones who is having a heart attack…he’s got to go, wherever it may be, as long as its not ED…[UK Medical Student 2008]

It is paramount that before we undertake a complete paradigm shift in the structure and function of our emergency departments and the way in which we evaluate and treat patients presenting with acute medical conditions – that we fully evaluate the positive and negative aspects of the Four Hour Rule implementation in the UK. CHKS [a UK organization providing independent analytical benchmarking to the NHS] has published an audit of acute admissions.

Over the past five years, approximately two million extra patients were admitted to hospital through emergency departments (ED) in England, an increase not seen in Scotland and Northern Ireland, which do not have the four-hour target. In Wales, which implemented the target later, the rise was delayed but appeared in 2005. More than 25% of emergency admissions are discharged the same day, most being patients admitted through the ED; same day discharges after ED admission rose by 65% between 2001 and 2005, when the four-hour target was introduced in England.

CHKS states “there is no obvious clinical reason why growth in emergency admissions should differ between UK countries… the 4-hour target in England has clearly had an impact and potentially cost the taxpayer more than £2 billion… primary care trusts pay as much as £1,000 per admission, compared with about £100 for an ED treated patient. Other possible explanations include changes to out-of-hours care and NHS Direct but most of the increase must be due to the target… an example of how targets that are good in principle can have unexpected effects.” A spokesman for CHKS says that it is unlikely (but cannot rule it out) that the increase in admission through the ED is because hospital finances benefit; with payment by results they earn much more. An erudite summary from a nursing perspective is also worthy of consumption.

I am in favour of enforced targets for admission times. Like many of my colleagues I believe that a fundamental overhaul of the process by which we facilitate the emergency management of patients will ultimately provide better patient outcomes. However, I believe the exact process required to achieve such altruistic gains has yet to be determined.

Responses in the news:

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  1. cps says

    compliance with 4 hour rule may have unintended consequences of cutting corners, reduced quality, burnout of FACEM (who become bed managers), increased admisssion rate & therefore increased cost.
    Paul Gaudry