ArticlePloS one2018
Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013.
Article in PloS one, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 14 papers, 2 of them syntheses that pooled it.
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Who cites it
14 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Efficiency measures of emergency departments: an Italian systematic literature review.BMJ open quality · 2021Pooled it
- Emergency department crowding: A systematic review of causes, consequences and solutions.PloS one · 2018Pooled it
- Overcrowding Indicators in Emergency Departments Across Countries: Scoping Review.Interactive journal of medical research · 2026Review
- Western Australia's First and Regional General Practitioner Psychiatry Phone Line to Improve Primary Mental Health Care: Indicators of Effectiveness and Sustainability: A Non-Controlled Population-Based Interventional Study.The Australian journal of rural health · 2025Article
- Policy Spotlight Effects on Critical Time-Sensitive Diseases: Nationwide Retrospective Cohort Study on Taiwan's Hospital Emergency Capability Categorization Policy.Interactive journal of medical research · 2025Article
- Article
- Article
- Impact of the 24-hour time target policy for emergency departments in South Korea: a mixed method study in a single medical center.BMC health services research · 2022Observational
- Pre- and Post-Implementation of One-Hour Rule for the Boarding of Referral of Critically Ill Patients in the Emergency Department.Journal of acute medicine · 2021Article
- "Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing.BMC health services research · 2021Article
- Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study.Medicine · 2021Observational
- Observational
- The goldilocks effect: the rhythms and pace of hospital life.BMC health services research · 2018Article
- The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study.PloS one · 2018Article
Corrections and comments
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Authors and funding
13 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundIn 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning.
methodsA state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique.
findingsThere were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing.
conclusionsThe FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.
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