Volume 196 - Issue 8
Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia
Authors: Biswadev Mitra and Peter A Cameron
Med J Aust 2012; 196 (8): 499. || doi: 10.5694/mja12.10315
Published online: 7 May 2012
Published online: 7 May 2012
To the Editor: We would like to congratulate Geelhoed and de Klerk1 for reporting the expected decreases in emergency department (ED) overcrowding following introduction of the 4-hour rule in Western Australia. Their study highlighted potential adverse effects and inflated demand across hospital systems - specifically, concerns regarding patient safety
and junior medical staff training; significantly ...
To the Editor: We would like to congratulate Geelhoed and de Klerk1 for reporting the expected decreases in emergency department (ED) overcrowding following introduction of the 4-hour rule in Western Australia. Their study highlighted potential adverse effects and inflated demand across hospital systems — specifically, concerns regarding patient safety and junior medical staff training; significantly higher proportions of admitted patients (39.6% to 49.1%); and incomplete assessment and management in EDs, underscored by “more . . . investigations occurring on the wards”.
However, we found it difficult to appreciate the relevance of inhospital mortality rates with increased denominators. It may be argued that a stretched primary care system, with little increase in resources to cater for population growth2 and combined with worsening economic conditions, led to a disproportionate increase in numbers of relatively well patients, thus diluting the mortality rate among patients presenting to hospital in 2010–11. There was also more variation in the raw mortality over the preceding years, with a possible aberrant rise in 2009–10, which was used as the reference year to calculate the statistically significant 13% reduction in 2010–11.
The vast majority of hospital deaths are inevitable and unlikely to change with changes to patient flow. Hospital-wide reforms focusing on earlier discharge from EDs and wards further challenge the relevance of inhospital mortality. In advanced health systems, outcome measures should focus on risk of unexpected death,3 or, at least, risk of death adjusted for major predictor variables. The question of whether the 4 hour rule is affecting outcomes in ED patients remains unanswered. The National Emergency Access Targets have been aptly termed a “natural experiment” in health policy,4 and Geelhoed and de Klerk’s analysis provides little more than exploratory data on changes in patient outcomes.
Competing interests
No relevant disclosures.
References
- Geelhoed GC, de Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust 2012; 196: 122-126. 1
- Primary Health Care Research and Information Service. General practice size in Western Australia, 2005–06 to 2009–10. http://www.phcris.org.au/fastfacts/fact.php?id=4982 (accessed Feb 2012).
- Mitra B, Cameron PA, Archer P, et al. The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients. Intern Med J 2012; 42: 444-450. 0_i1142865
- Richardson DB. Emergency department targets: a watershed for outcomes research? Med J Aust 2012; 196: 126-127. 0_i1142867