NEAT a yardstick not a hammer for EDs

THE National Emergency Access Target (NEAT) has been praised as a “good start” in relieving pressure on emergency departments (EDs), but it is essential that the target is effectively integrated with other systems and quality measures, say Australian experts.

Professor Gordian Fulde, director of emergency medicine at St Vincent’s Hospital Sydney, told MJA InSight that the NEAT 4-hour rule must be applied as a hospital-wide response to avoid placing additional pressure on ED staff.

“If the pressure of NEAT rests only on the ED, then that’s wrong. But if all the parts of the hospital are involved, then the patients get a better deal.”

Professor Fulde was commenting on research published in the MJA which examined the relationship between NEAT and in-hospital mortality of patients admitted to EDs.

The aim of NEAT was to ensure that by 2015, 90% of ED patients were being admitted, discharged or transferred within 4 hours.

• Related: MJA — The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target
• Related: MJA — The National Emergency Access Target (NEAT): can quality go with timeliness?

The authors looked at episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals from 2010 to 2014. Primary measures included emergency hospital standardised mortality ratio and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT). During the study period, ED and inpatient data was aggregated for 12.5 million ED episodes of care, and 11.6 million inpatient episodes of care.

The authors found that there was a highly significant, inverse relationship between in-hospital mortality and each of the total and admitted NEAT compliance rates. However, this relationship was lost once the total and admitted NEAT compliance rates rose above 83% and 65% respectively.

“The inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care,” the authors wrote.

Professor Fulde said that while there had been some initial reluctance in Australia towards adopting NEAT, “nobody who has the 4-hour rule now would go back”.

“It really has helped those hospitals where the acutely ill patient is seen as a burden by the rest of the hospital,” he said.

Co-author of the research and deputy director of emergency medicine at Princess Alexandra Hospital in Brisbane, Dr Andrew Staib, told MJA InSight that “previous studies had suggested an association between 4-hour performance improvements and in-hospital mortality, but never on this scale”.

When it came to viewing NEAT as an appropriate measure of ED efficacy, “clinicians are more interested in patient outcomes than in process measures such as NEAT”.

“Monitoring both may help engage clinicians and hospitals to improve the quality and efficiency of care,” Dr Staib said.

Gerard FitzGerald, professor of public health at Queensland University of Technology and former commissioner of the Queensland Ambulance Service, told MJA InSight that compliance with NEAT was plateauing and “unless we do something about capacity, like getting more beds, this will continue”.

Specialist emergency physician, Dr Sue Ieraci, added that NEAT was strongly influenced by the ability to move patients to the next phase of care, whether that be hospital wards or the intensive care unit.

“If ward beds are not available, treated patients can be stuck in the ED [which prevents] other patients entering the ED,” she told MJA InSight.

Professor FitzGerald said it was important to recognise that NEAT did have a role to play as a process measure. “These types of measures are important. We know that patients don’t want to be hanging around in the ED.

“However, we need a balanced scorecard of performance – a suite of measures,” he said.

This scorecard would include quality measures, alongside patient and staff satisfaction. “To be blunt, we have to think about costs as well, because we don’t have spare resources.”

Professor FitzGerald said that when it was developed, a key condition of the 4-hour rule was to apply it “where clinically appropriate”.

The importance of this is clear, he said, as a patient with multiple, complex problems is going to be safer in the ED than being moved to a quiet room on the ward.

“But we are missing the ‘where appropriate’ part in NEAT, because it’s not a balanced scorecard,” Professor FitzGerald said.

Dr Ieraci added that there had always been acceptance that for clinical reasons, not all patients will be optimally treated by moving them out of the ED within 4 hours.

“That’s why the target should never be 100% – clinical priorities must prevail.”

Regarding whether the 4-hour time limit was optimal, Professor FitzGerald said that there was “no magic logic behind it”.

“There’s nothing that says if a patient is in the ED for more than 4 hours, then there will be rapid deterioration.”

Professor Fulde agreed, adding that while Australia had the 4-hour rule, New Zealand had chosen a goal of 6 hours.

“It is a guesstimate, but like with everything, you’ve got to have a yardstick. Just as long as the yardstick isn’t being use to hit staff over the head.”