The emergency department 4-hour rule: what the clock means for you

The clock on the board

Every ED has a time target, and you’ll see it on the board as a clock beside each patient. It exists because crowding harms patients. It must never drive an unsafe discharge.

It helps to know why the clock runs. The ED is where a struggling health system shows its symptoms. Patients mostly wait in the ED because of problems further along: no inpatient bed, and nowhere to go once they’re ready to leave (an aged care place, for example).

What the 4-hour rule is now

The National Emergency Access Target (NEAT), introduced in 2011, aimed for 90% of patients to leave the ED within four hours. That single national target is history: states now set their own. The Australasian College for Emergency Medicine (ACEM) argues for separate targets for different groups of patients, with nobody staying longer than 12 hours.

What the clock means for you

What the clock means for you is simple. Work each patient up efficiently, make your decisions early, and tell the nurse in charge as soon as you know where a patient is going. A patient waiting for a bed or a transfer still needs your care while they wait: check on them, chase their results, and keep their observations and medicines up to date.

Triage: who is seen first

Triage makes sure the sickest people are seen first, not the people who arrived first.

Australian EDs use the Australasian Triage Scale: five categories, each with a maximum time to medical assessment. Triage nurses often start care before you arrive, using nurse-initiated protocols for things like bloods, an ECG and simple analgesia.

For how a shift runs around the clock, see the emergency medicine survival guide.