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Introduction Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays. Methods EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series â € Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes. Results Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall. Conclusion The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.

Objective The implementation of the time target policy (Four‐Hour Rule/National Emergency Access Target [4HR/NEAT]) constituted a major change for ED, and potentially on quality of care. The present study aimed to understand perceptions and experiences of ED staff during 4HR/NEAT implementation. Methods A semi‐structured interview was used to explore views and perceptions of 119 ED staff from 16 EDs in New South Wales, Australian Capital Territory, Queensland and Western Australia. The interviews covered aspects such as perceived changes in quality of clinical care, whether the capacity to deliver education was diminished or enhanced and whether the policy affected access to care. Interviews were transcribed, imported to NVivo 11 and analysed using content and thematic analysis. Results Three themes were identified: quality and safety of care; access block and overcrowding; and medical education and training. Participants described both positive and negative aspects of the policy. Although some reported negative impacts on care quality and access block, more cited overall improvements in these areas. The majority perceived that medical education and training was negatively affected, mainly because of restricted training opportunities and reduced time for procedural skills. Conclusions ED staff perceived important effects on quality and safety of care; access block and overcrowding; and medical education and training. In relation to an optimised ED role, quality of care and access block were overall felt to be improved, while education and training deteriorated. Our study increases understanding of the complexity of policy implementation processes and its impact on staff. Staff perceptions are a valuable measure of system performance and should be incorporated into system change evaluations.

Objective To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. Methods A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi‐level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short‐stay admission (≤24 h), >24 h admissions, unplanned ED re‐attendances within 7 days and ‘left at own risk’ (including ‘did not wait for assessment’). Results Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short‐stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re‐attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). Conclusion ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time‐based measures. Significant increases in short‐stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re‐attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

Objective Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four‐Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. Methods A longitudinal cohort study of a population‐wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2–4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. Results There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age‐standardised mortality was decreasing before the intervention. Post‐intervention, WA had a significant reduction in mortality rate of −0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta‐regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. Conclusions The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long‐term effects of the policy.

Objective It has been 10 years since the ACEM Access Block Solutions Summit and 5 years since the introduction of the Four‐Hour Rule/National Emergency Access Target (4HR/NEAT) policy. The impact of this policy on ED management and on ED staff has been poorly understood. The aim of the present study was to identify changes in ED management resulting from the policy based on ED staff experiences. Methods Semi‐structured interviews were conducted and transcribed, imported to NVivo 11 and analysed using a combination of content, thematic analysis and phenomenological focus within a theoretical framework known as the ‘logic model’. Results One hundred and nineteen ED staff participated in 2015–2016 to assess the impact of the policy implementation. Participants were drawn from 16 EDs in New South Wales, Queensland, Western Australia and Australian Capital Territory. In relation to ED management, three themes were identified: changes in ED management; activities and changes driven by the hospital in relation to 4HR/NEAT; and participant experiences in relation to policy compliance by staff. Conclusions Policy implementation is a complex process that had both positive and negative consequences on how ED staff managed the implementation of the 4HR/NEAT policy and how it changed their work environment. Understanding the perceptions of staff involved in policy implementation has significance for the design of future implementation strategies. The biggest insight from the present study is that ED management is very complex and the policy generated multiple positive and negative changes demonstrating the wide range of processes involved in this area of health services research.

[EN] Increasingly, the higher education sector is driven by sets of standards that describe quality – internal institutional standards that consider curriculum, teaching and delivery to students and external standards from both the sector and the professions that describe expectations, content, skills and attitudes that curricula must address to support graduate outcomes. Quality is the focus of these requirements, and yet quality in higher education remains a messy problem, with no clear framework (Kundu, 2016) and numerous variables that confound the problem. We ask what comes first: the external standards that accredit a university to provide education for a profession, or internal standards that focus on quality teaching and learning opportunities. The paper presents a short case study that highlights the challenge for course leaders pressured to meet industry requirements, and the impact this has on their awareness and capacity to design a transformational curriculum for students. We conclude that it is the difference between an aspirational courses, whereby quality is focussed on the learning design for student experience, and a compliant course, where quality is focussed on meeting static requirements.