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Barriers to the 4-h rule: What causes delays for gynaecology patients in the emergency department?

Authors

  • Sahar Pakmehr,

    1. Department of Obstetrics and Gynaecology, Joondalup Health Campus, Joondalup, Western Australia, Australia
    2. Edith Cowan University, Perth, Western Australia, Australia
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  • Rodney W. Petersen,

    1. Department of Obstetrics and Gynaecology, Joondalup Health Campus, Joondalup, Western Australia, Australia
    2. Edith Cowan University, Perth, Western Australia, Australia
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  • Julie A. Quinlivan

    Corresponding author
    1. University of Notre Dame Australia, Fremantle
    2. Women's and Children's Health Research Institute, University of Adelaide, Adelaide, South Australia, Australia
    • Department of Obstetrics and Gynaecology, Joondalup Health Campus, Joondalup, Western Australia, Australia
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Correspondence: Prof Julie A. Quinlivan, Suite 106 Private Consulting Rooms, Joondalup Health Campus, Joondalup, WA 6027 Australia. Email: quinlivanj@ramsayhealth.com.au

Abstract

Objectives

To explore factors that led to noncompliance with the 4-h rule for gynaecology patients in a general emergency department.

Methods

A cross-sectional cohort study was performed at a general emergency department. The files of all female patients aged from birth to 100 years presenting from 1 January 2009 to 31 December 2010 were screened. Those patient's files where a coded gynaecological diagnosis was made were reviewed. A time flow analysis was then undertaken of 580 consecutive files to evaluate barriers to admission or discharge of patients within the 4-h period. A further 300 files were audited to determine whether suboptimal management by emergency department staff contributed towards delays.

Results

There were 134 438 presentations to the emergency department, of which 2968 were gynaecology presentations (2.2%). The overall compliance with the 4-h rule was 66%. Patients with acute triage status, who were pregnant or who were eventually admitted, were more likely to be managed in compliance with the 4-h rule. The main barriers to compliance were incomplete examinations by emergency department staff; waiting for ultrasound examinations and blood test results; delays waiting for specialty review; and delays caused by initial review by surgical teams.

Conclusion

Specific barriers to compliance with the 4-h rule can be identified in gynaecology patients. Strategies specific to overcome these barriers can be developed to improve compliance.

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