title: The 'four-hour target' and the impact on Australian metropolitan acute surgical services.
abstract: BACKGROUND
  The National Emergency Access Targets (NEAT), introduced in 2012, guides the clearance of emergency department (ED) presentations within 4 h of initial presentation. We aim to assess the impact of NEAT on acute surgical services at a large metropolitan centre.
  
  
  METHODS
  A retrospective cohort study was performed and data were collected from electronic patient management systems. The control group was represented by ED presentations between June and September 2011, 1 year prior to the introduction of NEAT. The two study groups consisted of ED presentations between June and September 2012 and 2013 respectively. Outcome measures included time to appendicectomy and cholecystectomy, inpatient length of stay (IPLOS) (for operative and non-operative cases), out-of-hours operating and hospital mortality rates.
  
  
  RESULTS
  In total, 2619 inpatient episodes were included, with a trend showing increasing admissions throughout the study periods (P < 0.001). Time to surgical review and ED length of stay decreased significantly (P < 0.001). Time from emergency presentation to emergency appendicectomy and cholecystectomy remained unchanged and procedures performed out-of-hours increased significantly from 20.9% to 42.9% (P < 0.001). Median IPLOS for operative and non-operative patients was reduced during the study from 2.05 to 1.84 days (P < 0.001). Inter-unit transfers within 48 h of presentation increased significantly from 5.3% to 14.7% (P < 0.001).
  
  
  CONCLUSIONS
  The early results following the implementation of NEAT have been correlated with increased efficiency in ED clearance and increased burden on surgical operative and inpatient outcomes. While improvements in IPLOS were observed, they must be considered in the context of increased lower-acuity admissions and out-of-hours operating.
authors.affiliation: Department of Surgery, Western Health, Melbourne, Victoria, Australia.|School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Marlon L
authors.initials: ML
authors.lastname: Perera
authors.affiliation: Department of Surgery, Western Health, Melbourne, Victoria, Australia.
authors.forename: Neiraja
authors.initials: N
authors.lastname: Gnaneswaran
authors.affiliation: School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Roberts
authors.affiliation: Department of Surgery, Western Health, Melbourne, Victoria, Australia.
authors.forename: Marian
authors.initials: M
authors.lastname: Giles
authors.affiliation: Department of Statistics, Western Health, Melbourne, Victoria, Australia.
authors.forename: Danny
authors.initials: D
authors.lastname: Liew
authors.affiliation: Emergency Department, Western Health, Melbourne, Victoria, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Ritchie
authors.affiliation: Department of Surgery, Western Health, Melbourne, Victoria, Australia.|Academic Surgery, The University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Steven T F
authors.initials: ST
authors.lastname: Chan
mesh_terms: D000328:Adult; D001315:Australia / Q000453:epidemiology; D004630:Emergencies / Q000453:epidemiology*; D004636:Emergency Service, Hospital / Q000331:legislation & jurisprudence / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005260:Female; D006284:Health Plan Implementation / Q000379:methods; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*
keywords: crowding; emergency; length of stay; surgery