Emergency time reduced by 4 hours could save 80 lives a year: Study

By Dr. Ananya Mandal, MDFeb 6 2012

A new Australian study shows that reducing emergency department waiting times to less than four hours saves lives. All Australian hospitals will need to admit or refer emergency department patients within four hours under new federal benchmarks to be phased in from 2012. The research draws a direct link between decreased overcrowding as a result of the initiative requiring 85 per cent of emergency department presentations to be finalized within four hours, and lower mortality rates.

The purely-statistical study analyzed data on emergency department activity and death rates at Princes Margaret Hospital for Children, Fremantle Hospital and Royal Perth and Sir Charles Gairdner hospitals. In the study of Western Australian hospitals, which adopted the four hour rule in 2009, it was seen that it reduced death rates by 13 per cent. Approximately 80 lives were saved across three hospitals in one year.

In a separate study, Monash University Centre of Research Excellence in Patient Safety's Judy Lowthain said the whole emergency health care system would need to be redesigned in order to meet the four hour target. She found Melbourne emergency departments had a 55 per cent rise in the number of people attending EDs in the decade to 2009. It also showed that in the 2008-2009 year 61 per cent of people were discharged from EDs within four hours.

Retired neurosurgeon Bryant Stokes recommended scrapping the name of the program, because it focused “on the clock instead of patient safety and quality”. Hospitals across the country will be progressively required to implement the four-hour rule as part of the National Emergency Access Targets.

“There is no reason to suspect that other Australian health systems should far differently if their hospitals similarly commit to whole-of-hospital reform,” wrote the study's authors, Princess Margaret Hospital for Children emergency department director Professor Gary Geelhoed, and head of biostatistics and bioinformatics at the University of WA Centre for Child Health Research, Nicholas de Klerk.

They found the four-hour rule had led to a whole-of-hospital approach that appeared to have encouraged better communication between the emergency departments and wards, “with an increased appreciation of each other's problems”. “Clearly, exposure of EDs to unlimited numbers of patients - while inpatient wards are protected with “quotas” and have no responsibility for overcrowding in EDs - is unsustainable, dangerous for patients and illogical,” the report says.

Industry colleagues praised the research as a good starting point, suggesting deeper analysis was still required. Professor Drew Richardson, from the Australian National University Medical School, said the number of lives saved under WA's four-hour rule represented half the state's road toll and could have significant public health implications across the nation. However, he said it was yet to be seen whether external factors, such as age, influenced the reported changes in mortality. “The number of admissions [to WA emergency departments] increased by 46 per cent over four years, despite little change in inpatient bed numbers in WA,” Professor Richardson said. “Thus, the average length of admission episodes must have decreased by at least 40 per cent. This raises the possibility that some of this was achieved by alterations in recording practice, such as increased use of ‘statistical discharges’, which occur when a patient who was admitted through the ED begins a new episode of care without changing beds. If such a patient dies, his or her death may not be recorded as being linked to an episode that began in the ED,” he explained.

Victorian chair of the Australasian College for Emergency Medicine Simon Judkins said for the reform to work, Victorian hospitals needed adequate senior staffing levels and enough hospital beds. According to Southern Health Director of Emergency Medicine George Braitberg, the research published in the Medical Journal of Australia, showed structural change of an overburdened system reduced access blocks, ED length of stay and mortality rates, despite an increase in the number of patients. Judkins said otherwise it could become a number-crunching exercise where patients are moved out of ED for the sake of meeting a benchmark.

Braitberg in an accompanying editorial criticized the study for excluding information on how the changes were achieved or whether there were any unanticipated consequences for patients. “The stories of staff and patients are yet to be fully told,” he wrote. “We must interpret this research cautiously, and encourage appraisal and debate.”

Health Minister Kim Hames said the research dispelled many myths around the four-hour rule and proved the program had led to “huge” improvements in WA hospitals. “This has positioned WA ahead of other states as this program is rolled out nationally,” he said.

Opposition health spokesman Roger Cook said the four-hour rule had helped to improve clinical processes, but some of the improvements had since tapered off. Princess Margaret is now the only hospital to achieve the 85 per cent target. “The time factor is just one aspect in terms of improving overall hospital service,” Mr Cook said.

The results were published in the Medical Journal of Australia.