Volume 196 - Issue 8
Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia
Authors: Dylan J Toh, Campbell H Thompson, Josephine S Thomas and Jeffrey Faunt
Med J Aust 2012; 196 (8): 499-500. || doi: 10.5694/mja12.10304
Published online: 7 May 2012
Published online: 7 May 2012
To the Editor: We read with interest the article by Geelhoed and de Klerk1 regarding the mortality benefits of a policy that ensures high numbers of patients are admitted to hospital within 4 hours of arrival at an emergency department (ED). The proof of improved performance following service intervention within a complex institution requires careful consideration. ...
To the Editor: We read with interest the article by Geelhoed and de Klerk1 regarding the mortality benefits of a policy that ensures high numbers of patients are admitted to hospital within 4 hours of arrival at an emergency department (ED). The proof of improved performance following service intervention within a complex institution requires careful consideration. We offer an alternative interpretation of their data.
The number of patients who presented to the Western Australian tertiary hospitals increased over the 4 years studied, as did the number and the proportion of patients who were admitted. Mortality expressed relative to the number of admissions dropped, assuming that most deaths occurred in admitted patients (Box). We suggest that excessive admission of relatively healthy patients who otherwise would have been released from the ED resulted in this apparent drop in mortality.
Efficiencies in hospital and ED length of stay have been achieved in one tertiary hospital in Adelaide, South Australia, by interposing an acute assessment unit between the ED and the treatment settings in which ongoing care is provided.2 This change was accompanied by a 50.5% increase in admissions to the general medical service2 but only a 10.7% increase in presentations to the hospital ED.3 The Charlson comorbidity score of the admitted patient cohort dropped.
At our hospital, the establishment of an acute medical unit in November 2010 was followed by a 25% increase in workload for the hospital’s inpatient general medical service over the next year, without a significant increase in ED presentations. The proportion of patients presenting to the ED who were admitted increased from 38% to 41%. Mortality among general medical patients fell by 17.5%, with no change in the proportion of patients admitted to a hospital bed within 4 hours.
The nationwide imposition of a 4-hour program may result in the admission of higher numbers of relatively well patients who previously would have been discharged by the ED. This comes at the cost of a rising workload for general physicians, whose established work practices rarely embrace shift work in, or next to, an ED. We believe that the benefit of this new process to community health is still to be established. Ongoing education of physicians and surgeons in the initial assessment of emergency patients may better achieve efficient transit through the ED.
Indiscriminate admission of patients without a diagnosis and of patients who could potentially be released without admission cannot be recommended as a means of facilitating flow through an ED. Measures of inappropriate admission must be considered alongside apparent improvements according to current efficiency measures.
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. 0_CHDDIIHB
- Li JYZ, Yong TY, Bennett DM, et al. Outcomes of establishing an acute assessment unit in the general medical service of a tertiary teaching hospital. Med J Aust 2010; 192: 384-387. 0_i1142909
- Yong TY, Li JY, et al. The selection of acute medical admissions for a short stay unit. Intern Emerg Med 2011: 321-327. 0_i1142911