Volume 194 - Issue 5
Lessons from the 4-hour standard in England for Australia
Authors: Roberto Forero, Geoff D McDonnell, Sally M McCarthy, Peter Nugus, Jeffrey Braithwaite, Kenneth M Hillman, Daniel M Fatovich, David Mountain, Frank F Daly, Gerard J Fitzgerald and Drew B Richardson
Med J Aust 2011; 194 (5): 268. || doi: 10.5694/j.1326-5377.2011.tb02964.x
Published online: 7 March 2011
Published online: 7 March 2011
To the Editor: Australia is in the process of making the most important change to its health care system since the implementation of Medicare.1 We agree with Cameron and Cooke that there are important lessons for Australia from the implementation of the 4-hour rule in the United Kingdom.2 As in Robert Zemeckis’s 1985 movie classic, Back to the future, the old question of “If I had the opportunity to do something again, what would I have done differently?” applies.
We challenge the assumption that Australia is embarking on something that the UK has recently abandoned. The UK has not actually abandoned the 4-hour rule but expanded it into a suite of eight indicators that include three time-based measures, including total time in the emergency department (ED).3
Our concerns are about how the lessons learned by the UK can be applied in Australia in 2011 and beyond. Cameron and Cooke state that “Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway”.2 The systems we have are neither universal nor integrated across the country. We need substantial data infrastructure, including comparable data linkage services across states. Of all the states, Western Australia has the most advanced national data linkage system. Yet even with the most sophisticated data systems in the world, proper impact assessment studies are required. Australia’s evaluation of the changes being made to rules and systems is neither systematic nor well standardised — to be safe and effective, innovation needs to be evaluated in coordinated and systematic ways.4
We also need systems-thinking approaches and simulation technologies to avoid repeating past mistakes. It is important to link theory and data to learn about the complex dynamics of ED patient flow and safety, and understand the consequences of our interventions.5
As suggested by Cameron and Cooke,2 we should focus on real-time, clinically relevant, consistent and comparable quantitative and qualitative data about patients, staff, processes, outcomes and facilities. We must learn to improve daily performance rather than sanction variable outliers.
In conclusion, the lessons learned from the 4-hour target are relevant and appropriate for Australia. Cameron and Cooke have highlighted some of the dangers, including those of inadequate measurement.2 We need timely, integrated and linked data and an explicit theory of performance. We should aim to manage the risks by appropriately funded research and implementation strategies to improve this significant policy intervention while maintaining patients’ outcomes, experience and safety, and the timeliness of instigating their care.
Competing interests
David Mountain has received a $10 000 grant from the Department of Health of WA to research a management pathway for chest pain to shorten patient length of stay in the ED. Frank Daly is employed by the Department of Health of WA in the role of Executive Clinical Lead for the WA Four Hour Rule Program. Drew Richardson has received grants from the Australasian College for Emergency Medicine to research crowding of EDs. He has received funding and travel expenses from the Australian Department of Health and Ageing for his participation in the National Emergency Department Project Advisory Committee.
References
- Kirby T. Moving Australia’s health-care system into the 21st century. Lancet 2010; 376: 219-220.
- Cameron PA, Cooke MW. Lessons from the 4-hour standard in England for Australia [editorial]. Med J Aust 2011; 194: 4-5. 0_i1095876
- United Kingdom Department of Health Urgent and Emergency Care. A&E clinical quality indicators. Data definitions. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122892.pdf (accessed Feb 2011).
- Forero R, Hillman KM, McCarthy SM, et al. Access block and ED overcrowding. Emerg Med Australas 2010; 22: 119-135. 0_i1095880
- Paul SA, Reddy MC, DeFlitch CJ. A systematic review of simulation studies investigating emergency department overcrowding. Simulation 2010; 86: 559-571. 0_i1095882