Volume 196 - Issue 8
Emergency department overcrowding and mortality after the introduction of the 4-hour rule in Western Australia
Authors: Gary C Geelhoed and Nicholas H de Klerk
Med J Aust 2012; 196 (8): 500. || doi: 10.5694/mja12.10548
Published online: 7 May 2012
Published online: 7 May 2012
In reply: We thank Mitra and Cameron, and Toh and colleagues for their remarks. Comments from some physicians that the 4-hour rule might increase mortality provided the initial stimulus for us to look at data related to its introduction in Western Australia. Given our results, their hypothesis seems unlikely to be true.
Mitra and Cameron point ...
In reply: We thank Mitra and Cameron, and Toh and colleagues for their remarks. Comments from some physicians that the 4-hour rule might increase mortality provided the initial stimulus for us to look at data related to its introduction in Western Australia. Given our results, their hypothesis seems unlikely to be true.
Mitra and Cameron point out that the reference year 2009–2010 showed a possible “aberrant rise” in raw mortality; however, the mortality rate based on presentations to the three tertiary hospitals was remarkably consistent for 2007–08, 2008–09 and 2009–10 (1.10%, 1.12% and 1.12%, respectively). Also, there was no reduction in mortality at the peripheral hospitals, making society-wide changes in mortality an unlikely explanation for the fall at the tertiary hospitals. We disagree with their unreferenced assertion that the majority of hospital deaths are inevitable and that mortality is unlikely to change with change to patient flow. Sprivulis, as noted in our article, showed that negative change to patient flow with increased overcrowding in WA emergency departments (EDs) led to 120 extra deaths per year. It is unlikely that patients were discharged prematurely from the ED to die at home, given that the admission rate had risen. Anecdotally, almost certainly — given the focus on overcrowding in WA hospitals — blatant examples of patients being sent home prematurely from hospitals only to die would have been on the front page of The West Australian.
Toh et al give an alternative analysis and suggest that the fall in mortality was due to dilution in the severity of illness among patients admitted from EDs. Since we used number of presentations to the ED — not admissions — as our denominator, it is difficult to see the relevance of this suggestion. Furthermore, not only did the mortality rate fall, but the actual number of deaths decreased by 80 even with an increase of 10% in presentations. If a simple χ2 test is done assuming only a 2.5% increase in presentations, the 80 fewer deaths are still significant (P < 0.05). Given WA’s population growth of over 2.5% per annum, coupled with an ageing population, we can safely say this reduction in deaths is not due to “dilution”.
Competing interests
No relevant disclosures.