The Four-Hour Rule-Lesson’s Learnt from the WA Experience

Kane Guthrie

Sarah-Louise Moyes

Lisa Gray

Kelly-Ann Hahn

Objectives

Overview of the 4-hour rule in WA Provide tertiary emergency department

experience What we have learnt What the future holds

Why we needed the change

Access block & overcrowding Increase in urgency & acuity Aging population & growth Decreasing inpatient beds ED staff providing 50% of time to inpatient

care Increasing adverse events, morbidity &

mortality

Increase in presentations across all sites

The Four-Hour Rule

All patients will be admitted, discharged or transferred within 4 hours of presenting to an emergency department

Endorsed by WA cabinet January 2008 after study tour to UK in November 2007

Introduced April 2009 to Western Australian tertiary public hospitals

Aim/focus to: Improve quality of care & patient flow within ED Program of clinical service redesign

The Target

Initial targets set at 85% by April 2010 95% by October 2010 98% by April 2011

Re-evaluated target: 85% by April 2011 90% by April 2015

The Review

The Major Findings from the Review

Increased demand in presentations. 2010 - 7.1% increase

2011 - 8.8% increase

2012 – presentations still on the rise (?10%)

With no increase in actual hospital beds!

The 4-hour to discharge/admission achievement so far Percentage of ED attendances with a length of episode less

than or equal to four hours

Access block improvements

The Research

Lesson’s Learnt

“Life can only be understood backwards, but it has to be lived forwards.”

Stuart Connelly

What’s worked

Patient flow/navigators based in ED Over census patients on wards Emergency decision units, better utilisation

of emergency medicine wards Discharge streaming areas More investigations done once admitted Surgical & acute medical assessment units

Factors that impede patient flow

Single room/isolation requirements Delays with ward cleaning/orderly transfers Paperwork requirements Speciality teams wanting to see patients in

ED prior to ward transfer Ramping – the 10am bus arriving Clinical acuity- not every patient is sorted

in 4/24

Some difficulties

Focus on “ED four-hour rule” Assumption issue lies with ED – this is

slowly changing Hospital wide issue

Directive all patients to be seen Dr within 30mins ATS 3,4 & 5- seen in time order ?Achievability

Ongoing challenges

Increasing presentations & acuity Change fatigue The winter epidemic Mental health epidemic Lack of acute medical/mental health beds

The Future

The challenges we face: Sustainability Staff enthusiasm & engagement Staff recruitment & retention Finding new & innovative ways to improve

patient care & flow in the ED

Take Home Points

Reducing overcrowding/access block: Decreases pt morbidity/mortality Improves staff satisfaction

The four rule was a temporary fix

NEAT will need to: Be safe, effective & sustainable Patient focused, without compromising patient

care Value its workforce

Thank you

Be a yardstick of quality.

Some people aren't used to an environment where excellence is

expected.

Steve Jobs

Questions