South Western Sydney Clinical School

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.


    Further Information

    About Research Team

      Current staff:

      • Dr Roberto Forero, Senior Research Fellow, UNSW SCHSR (CIA).
      • Dr Wing (Nicola) Man, Research Fellow, UNSW SCHSR.
      • Dr Shizar Nahidi, Project Officer, UNSW SCHSR.
      • Dr Hanh Ngo, Research Fellow, UWA, Emergency Medicine.
      • Dr Sam Toloo, Research Fellow, QUT, SPHSW.


      Former staff:

      • Dr Fenglian Xu, Research Fellow.
      • Josephine De Costa, Research Assistant.
      • Brydan Lenne, Research Officer.



      • Jenine Beekhuyzen,CEO Adroit Research, for consultancy and advice on qualitative aspects of the manuscript.
      • Liz Brownlee, owner/manager Bostock Transcripts services for the transcription of the interviews.


      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.



      • We also thank all the participants for their contribution in time and information provided.


      Project Supporters

      NHMRC Partnership Grant No APP1029492


      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

      A Prof Paul Middleton (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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