Academic journal article Australian Health Review

Report on the 4-H Rule and National Emergency Access Target (NEAT) in Australia: Time to Review

Academic journal article Australian Health Review

Report on the 4-H Rule and National Emergency Access Target (NEAT) in Australia: Time to Review

Article excerpt


The National Emergency Access Target (NEAT), introduced into Australian hospitals in2011, stipulatesthata certain proportion of patients will be discharged, admitted to hospital or transferred within 4 h of arrival in the emergency department (ED), hence the term the '4-h rule.' This reform, designed to improve access to emergency care and reduce ED overcrowding, evoked considerable anxiety about the possible consequences of lower-quality care resulting from a time-based target being used to drive delivery of emergency care.1,2

A re-examination of the 4-h rule, the evidence underpinning its introduction and its benefits and risks to patients has been prompted by the recent dissolution of the Australian National Partnership Agreement, which provided hospitals with financial incentives for achieving certain NEAT compliance rates, and the current downward revision of compliance rates in the UK amid reports of poor-quality care in EDs.

As a means of informing future policy decisions around the most appropriate NEAT compliance targets, the Queensland Department of Health commissioned a systematic review of existing literature pertaining to NEAT and its implementation in Australia and the UK. This article provides an executive summary of the key findings of that review; the full review, in the form of a monograph, is available as Supplementary Material to this paper.


A systematic review of published literature was undertaken using specific search terms, snowballing techniques applied to retrieved references and Google searches. Results are presented as a narrative synthesis given the heterogeneity of included studies. More detail as to exact methods are published in the full monograph.

Results and Discussion

ED overcrowding

ED overcrowding was initially measured in terms of 'access block' (defined as the percentage of admitted patients remaining intheEDformorethan8 h).In2011,thiswasreplacedbyaNEAT compliance rate (the percentage of all patients leaving the ED within 4 h of presentation). This more stringent time window was aimed at reducing ED overcrowding and improving access to emergency care in all Australian hospitals.3,4 As detailed in the Supplementary Material, this was a political directive at the Federal level that was agreed to by the States and Territories and supported by financial incentives to individual hospitals.

Introduction of NEAT was spurred by Australian research showing direct correlations between longer stays in the ED and both longer in-patient stays and higher in-hospital mortality. Richardson5 and Sprivulus et al.6 were the first to show that overcrowding in EDs was associated with prolonged ED length of stay (LOS) and increased mortality for patients admitted acutely via the ED. Liew et al.7 and Richardson8 also highlighted the positive relationship between LOS in ED and an increased inpatient LOS, with the former study quantifying the increased inpatient LOS for increasing ED LOS (Table 1).

Benefits of NEAT

Recent research suggests that, in general, the introduction of NEAT and the ensuing system of care redesign has led to a reduction in ED overcrowding in many centres in association with improved outcomes for patients seeking emergency care.

Improvement in timeliness of accessing emergency care

Access to emergency care in some states has improved significantly, as measured by waiting time by triage category, ambulance off-stretcher times, ambulance redirection, average ED LOS and access block.9 This improved access has been achieved despite an average growth in ED presentations nationally of 5% per annum over the past 4 years, which has been disproportionate to the rate of population growth.

Kelly et al.10 highlight that a 10-min reduction in total treatment time in the ED may not seem important to an individual patient. However, when achieved for 40 patients per day, it adds up to 400 min (i.e. >6 h) of additional cubicle availability within the ED. …

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