The four hour target to reduce Emergency Department 'waiting time': a systematic review of clinical outcomes

Emerg Med Australas. 2010 Oct;22(5):391-8. doi: 10.1111/j.1742-6723.2010.01330.x. Epub 2010 Sep 29.


Governments in Australasia are introducing emergency department length of stay (EDLOS) time targets similar to the UK 'four hour rule'. There is debate about whether this rule had beneficial effects on health-care outcomes. We sought to determine what effects the four hour time target for EDLOS had on clinically relevant outcomes in the UK by conducting a systematic search for evidence. Articles were screened by both authors independently and assessed for quality using standard tools. Differences in outcomes measured and how they were measured precluded meta-analysis. There were inconsistencies between target achievement reported by Trusts and that reported in the studies, and empirical evidence that the target might be unattainable. National Health Service spending on ED increased £820,000,000.00 (1998-2007) and emergency admissions rose overall by 35% (2002-2006), but not in all hospitals. Time to see a treating clinician and hospital mortality was unchanged. One hospital demonstrated a small reduction in return rate. 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.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Australasia
  • Emergency Service, Hospital / statistics & numerical data*
  • Health Policy*
  • Health Services Accessibility / statistics & numerical data*
  • Health Services Needs and Demand / statistics & numerical data*
  • Hospital Mortality
  • Humans
  • Length of Stay
  • National Health Programs
  • Time Factors
  • Treatment Outcome*
  • Waiting Lists*