South West Sydney Clinical Campuses

Validation and Impact of the four-hour rule in the Emergency Department : A large data linkage study

Project Main Description

Access block and Emergency Department (ED) overcrowding have been described as the most serious issues confronting EDs in the developed world, as these problems compromise the quality and timeliness of patient care. There is an urgent need to understand if the four hour rule was effective in reducing access block and overcrowding, and how patients were affected. The four-hour policy, where most patients must spend less than 4-hours in ED from arrival to admission, transfer or discharge was implemented in WA in 2009, which was followed across Australia in 2012 by the “National Emergency Access Target” policy. We need to find out if the policy has been effective in reducing access block and ED overcrowding.

The main purpose was to validate the impact of the intervention in WA and compare it with similar hospitals in NSW, QLD and ACT using data linkage capability. To assess the impact of the policy, this study used a reference point retrospective data linkage study in WA and conduct comparisons across states on admitted adult patients before and during the implementation of the WA intervention. This is from 2005-2013, from 16 of the busiest hospitals in Australia. Data linkage techniques were used to explore patient as well as hospital key performance indicators. We also use a multilevel analysis approach to assess some of the hospital characteristics.

The findings of this mixed methods study will enable us to assess the effectiveness of policy interventions and translate the recommended evidence based changes into policy and clinical service delivery.

Quantitative Component: Data Linkage data from WA, NSW, QLD and ACT.

Qualitattive component: 119 semistructured interviews across participating hospitals.



This partnership was also a unique opportunity to meet the need for a more effective integration of evidence into health services research policy and service delivery. We expect that our findings will encourage researchers and partner organisations to form alliances of national and international significance to improve the quality of policy interventions and programs.

    To view the 'Conceptual Framework' of the qualitative component of the study, click here.

    To access the detailed version of the 'Codebook' of the qualitative compoent of the project, click here

    To access the detailed version of the 'Study Protocol 4hr rule'. click here.


    We thank all the participants for their contribution in time and information provided together with the other stakeholders across jurisdictions who also provided their time for interviews, data and research advice.
    Research Team
    Dr Roberto Forero, Dr Shizar Nahidi, Dr Hanh Ngo, Dr Wing (Nicola) Man, Prof Daniel Fatovich, Prof David Mountain, Dr Sam Toloo, Prof Gerard FitzGerald, Prof Drew Richardson, Dr Nick Gibson and A/Prof Sally McCarthy. 
    Former staff: Dr Fenglian Xu, Josephine De Costa and Brydan Lenne.
    Project Management Committee 
    Current members:
    Dr Roberto Forero (chair), Prof Kenneth Hillman, Prof Daniel Fatovich, A/Prof David Mountain, Prof Sally McCarthy, Prof Peter Sprivulis, Prof Antonio Celenza, Prof Drew Richardson, Prof Gerard FitzGerald, Dr Mohammed Mohsin, Dr Elizabeth Rohwedder, Dr Patrick Aboaye-Sarfo, Mrs Sarah Marmara (Hoy), Dr John Burke and Dr Paul Tridgell.

    Former members:
    Prof Frank Daly, Mr Kinsley Burton, Ms Sam Green and A/Prof Paul Middleton,.
    Quantitative Data Provision and Support
    We thank the Data Linkage Units from WA (Data Linkage Branch), NSW (CHeReL), QLD (Data Linkage Unit) and all current and former Data Custodians fin each jurisdiction for the Emergency Department Data Collection, Hospital Morbidity Data Collection and Mortality Data Registries. 
    We also thank the Ambulance Data Custodians in WA (St. John’s Ambulance), NSW Ambulance, QLD Ambulance Services (QAS) and ACT Ambulance. In particular late Prof Ian Jacobs, Prof Judy Finch and A/Prof Paul Bailey from St John’s Ambulance; Rosemary Carney and Dr Harry Lai from NSW Ambulance; Emma Bosley from QAS; and Toby Keene from ACT Ambulance for their assistance and support with the availability of the respective ambulance data. 
    Qualitative Component
    We thank all the individuals at the hospital Emergency Departments and site coordinators who provided data for the qualitative component at the request of the research team. 
    Interview team: Dr Roberto Forero, Dr Shizar Nahidi, Brydan Lenne, Karlene Dickens; Dr Cecily Scutt and Tracey Hawkins.
    Site Coordinators: A Prof Anna Holdgate, Dr Michael Golding, Dr Michael Hession, Dr Amith Shetty, A Prof Drew Richardson, Prof Daniel Fatovich, A Prof David Mountain, Dr Sam Toloo, Dr Conrad Loten, Dr John Burke and Mr Vijai Joseph who acted as site contacts on each State/Territory.
    Consultants: Jenine Beekhuyzen, Adroit Research
    Transcription services: Liz Brownlee, Bostock Transcripts services 
    Project Supporters


    1.    National Health and Medical Research Council Partnership Grant No, APP1029492.
    2.    Cash contributions from the following organizations:

    - Department of Health of Western Australia.

    - Australasian College for Emergency Medicine (ACEM).

    - Ministry of Health of New South Wales.

    - NSW Agency for Clinical Innovation, Emergency Care Institute.

    - Queensland Emergency Medicine Foundation.


    Project Collaborators: External

    Prof Daniel Fatovich (UWA/ACEM) - CI

    A Prof Sally McCarthy (NSW Health/ACEM) - CI

    A Prof David Mountain (UWA/ACEM) - CI

    Prof Gerry Fitzgerald (QUT/ACEM) - CI

    A Prof Drew Richardson (ANU/ACEM) - CI

    A Prof Peter Sprivulis (UWA/ACEM) - CI

    Prof Frank Daly (WADOH/ACEM) - AI

    Dr Mohammed Mohsin (UNSW/SWSLHD LIberpool Hospital) - AI - Partner representative

    Dr Paul Tridgell - Private consultant, AI

    Dr Nick Gibson (ECU) - AI

    Prof Tony Celenza (UWA/ACEM) - Partner representative

    Dr Elizabeth Rohwedder (WADOH) - Partner representative

    Dr Patrick Aboagye-Sarfo (WADOH) - Partner representative

    Ms Sarah Marmara (NSW Health) - Partner representative


    Project Status
    Project Members
    Senior Research Fellow and Post Graduate Coordinator SWS Clinical School
    Ph 02 8738 9369

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