Tempus edax rerum

It was the Roman Poet Ovid (40 B.C) who stated "Tempus edax rerum" - time conquers all..

In the November Annals of Emergency Medicine, is an interesting retrospective data review regarding the 4-hour rule in England, by Prof Mason et al. They found that the UK governments controversial rule that no emergency patient should wait more than 4 hours from their arrival to ED to admission, or discharge, may have improved waiting times, but may not be the best way to overcome ED overcrowding, or be a marker of good quality of care.

They examined waiting times from 2003-2006, which showed that total length of stay actually increased, and activity in the last 20 minutes of the 4 hour period grew every year since the introduction of the rule. 

"The law of unintended consequences seems to be at work, even though the rule came out of a strong intention to improve patient care. We hoped that the target would have led to improved processes leading to shorter wait times in the ED without diminishing time for physician-patient interactions. But we did not observe this pattern." (Professor Mason)

After nearly 6 years in place, the UK government abolished the target in April 2011, and replaced it with quality measures.

Meanwhile, governments in Australasia are introducing similar targets to the UK "four hour rule". A systematic review (by Jones & Schimanski) of clinical outcomes, published in Emergency Medicine Australasia, concluded that "the impact of the introduction of an ED time target and the associated massive financial investment has not resulted in a consistent improvement in care with markedly varying effects being reported between hospitals. Countries seeking to emulate the UK experience should proceed with caution."

In the long term, it remains to be seen whether the implementation of the 4 hour rule in Australasia will actually improve the quality of patient care. Focussing on a time target rather than other quality indicators may have negative implications on education & training, as well as research (see also the letters section in the December issue of EMA). Indeed, the pursuit of such arbitary targets may only serve to focus excessive attention on ED processes, rather than the hospital process as a whole.

COI - I am a refugee of the English "4 hour rule", currently living in Melbourne, Australia, having moved from the UK in 2006 

Time Patients Spend in the ED: England's 4 hour rule -  A Case of Hitting the Target but Missing the Point

The four hour target to reduce emergency department "waiting time" : A systematic review of clinical outcomes.