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

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.