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Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study
  1. Nicola Wing Young Man1,2,
  2. Roberto Forero1,3,
  3. Hanh Ngo4,
  4. David Mountain4,5,
  5. Gerard FitzGerald6,
  6. Ghasem (Sam) Toloo6,
  7. Sally McCarthy7,8,
  8. Mohammed Mohsin9,10,
  9. Daniel M Fatovich4,11,
  10. Paul Bailey12,
  11. Emma Bosley13,
  12. Rosemary Carney14,
  13. Harry Man Xiong Lai14,15,
  14. Ken Hillman1,3
  1. 1 Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
  2. 2 National Drug and Alcohol Research Centre, University of New South Wales, Randwick, New South Wales, Australia
  3. 3 Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
  4. 4 Division of Emergency Medicine, Faculty of Health and Medical Services, University of Western Australia, Perth, Western Australia, Australia
  5. 5 Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
  6. 6 School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Queensland, Australia
  7. 7 Emergency Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
  8. 8 Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
  9. 9 Psychiatry Research and Teaching Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
  10. 10 School of Psychiatry, Faculty of Medicine, University of New South Wales, Randwick, New South Wales, Australia
  11. 11 Emergency Medicine, Royal Perth Hospital, Centre for Clinical Research in Emergency Medicine, Perth, Western Australia, Australia
  12. 12 St John Ambulance Western Australia, Perth, Western Australia, Australia
  13. 13 Queensland Ambulance Service, Brisbane, Queensland, Australia
  14. 14 New South Wales Ambulance Service, Rozelle, New South Wales, Australia
  15. 15 Discipline of Psychiatry, University Of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Associate Professor Roberto Forero, Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia; r.forero{at}


Introduction Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays.

Methods EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series ‘Before-and-After’ trend analysis was used for assessing the Policy’s impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes.

Results Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia’s increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall.

Conclusion The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.

  • emergency ambulance systems, systems
  • crowding
  • access to care
  • comparative system research
  • prehospital care, basic ambulance care

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  • Handling editor Edward Carlton

  • Twitter @nic01a

  • Collaborators 4HR/NEAT Partnership Grant members,

  • Contributors RF, DMF, GF, SM and KH were responsible for study concept, grant application and overall coordination and acquisition of the data across all jurisdictions. NWYM, RF, HN, MM, ST, DMF, SM and GF were responsible for study design, analytic strategy and drafting of the study. NWYM, RF, HN, ST and MM had full access to all study data and were responsible for the integrity of the data, ethics application and accuracy of the data analysis. All authors were responsible for critical revision of the manuscript.

  • Funding This work was supported by the National Health and Medical Research Council (NHMRC – Partnership Grant Number 1029492). Cash contributions from the following organisations were also obtained: NSW Ministry of Health, NSW Agency for Clinical Innovation – Emergency Care Institute, Queensland Emergency Medicine Research Foundation and WA Department of Health. Funding organisations were not involved in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review and approval of this manuscript.

  • Competing interests Professor Gerry Fitzgerald is Member of the Editorial Board.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study received ethics approval from the respective Human Research Ethics Committees of the Western Australian Department of Health (201403.07), Cancer Institute New South Wales (HREC/14/CIPHS/30), and Queensland Health (HREC/14/QGC/30), plus governance approval from the 14 hospitals, and the state ambulance services.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Data access is restricted by data custodians.