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Emergency Treatment Performance (ETP)

The Emergency Treatment Performance (ETP) target was formerly known as the National Emergency Access Target (NEAT). It is no longer a Commonwealth target, however NSW is still committed to improving access to care and building on the significant improvements already seen using the four-hour target as a driver for change.

ETP - The Basics

What is ETP?

  • ETP stands for Emergency Treatment Performance
  • It was formerly known as the National Emergency Access Target (NEAT). It is no longer a Commonwealth target, but NSW is still committed to using the four-hour target to drive change. It is also a NSW Premier’s priority until 2019.
  • The expectation for ETP is that 81% of all patients presenting to a public hospital Emergency Department ED will, within 4 hours:
    • physically leave the ED for admission to hospital;
    • be referred to another hospital for treatment; or
    • be discharged home
  • The target does not overrule clinical judgement - it is recognised that it is sometimes clinically appropriate for patients to remain in the ED for more than 4 hours
  • All ED patients are included in the target
  • Overcrowding and prolonged LOS in ED for admitted patients is associated with poorer outcomes [1][2][3] . Access block has also resulted in non-admitted patients remaining in ED for longer than necessary reducing access for new patients presenting at the ED, and delayed ambulance offloads.
  • Click here for a PowerPoint presentation on ETP produced on behalf the Ministry of Health

What are the principles of ETP?

  • To drive clinical service redesign
  • It is a whole of hospital change - not just ED
  • It requires Executive engagement and leadership at both hospital and LHD level
  • The majority of process change needs to occur at the ‘back end’ rather than in the ED - EDs have benefited from reviewing existing processes and MOC for efficiency
  • It applies to patients in all triage categories

When does the clock start and stop?

ETP is measured from first patient contact in the ED, and should be recorded by the clinician carrying out the initial triage/assessment or ED reception, whichever is earlier. The clock stops when the patient physically leaves the ED whether they are admitted, transferred, or discharged home.

Triage should occur as soon as possible after a patient presents to an emergency department, but where clerical staff contact comes first this is when the clock starts.

The NSW Ministry of Health have produced a visual ED data points pathway that highlights when the clock starts and stops for NEAT.


Did WA find that patient outcomes were worse with the introduction of the NEAT target?

recent study[5] has found that Introduction of the 4-hour rule in WA in fact led to a reversal of overcrowding in three tertiary hospital EDs that coincided with a significant fall in the overall mortality rate in tertiary hospital data combined and in two of the three individual hospitals.

Why did Australia introduce the ‘4 hour rule’ when the UK abolished it?

The UK has not abolished the 4-hour target, but has reduced the performance threshold from 98% of ED patients to 95% of ED patients, and has introduced a suite of additional clinical quality indicators. There are now 8 clinical quality indicators, a number of which measure the patient’s time in the ED[6].

[1] Richardson DB ‘ Increase in patient mortality at 10 days associated with emergency department overcrowding’. Medical Journal of Australia 2006, 184, 213-216

[2] Sprivulis PC., Da Silva JA., Jacobs IG., Frazer AR., Jelinek GA ‘The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments’. Medical Journal of Australia 2006, 184, 208-212

[3] Forero R., Hillman K., McCarthy S., Fatovich D., Joseph A., Richardson DW ‘Access block and Emergency Department Overcrowding’. Emergency Medicine Australasia 2010, 22, 119-135

[4] Note: Baseline is 2009–10 performance levels, without “exclusions”. The targets increase linearly between the baseline and 2015. Targets are the average performance over the calendar year. Rewards apply to 2012 to 2015. The baseline does not represent similar hospitals in all states and territories as it includes all hospitals that currently report to the Non-Admitted Patient Emergency Department Care National Minimum Dataset—it is assumed to include all Peer Group A and B hospitals with emergency departments and it is noted that additional hospitals may be included over time. Click here for the full guidance.

[5] Geelhoed G. and de Klerk N. ‘Emergency department overcrowding, mortality and the 4-hour rule in Western Australia’ MJA 2012; 196 (2): 122-126

[6] ‘A&E clinical quality indicators: Implementation guidance and data definitions’ Department of Health, UK, Dec 2010 available here.

ETP - Top tips

Although NEAT is no longer an instituted program, many of the strategies and resources developed to support it are still relevant to ETP.

In 2011 NSW Ministry of Health ran an Emergency Access Target workshop designed to understand the key issues and actions to achieve NEAT.

The key actions were grouped into the following themes:

  • Community and Ambulatory Care based alternatives
  • DIscharge Planning
  • Emergency Department
  • Governance and Quality
  • Inpatient Care / Care Coordination

In addition to these, the following top tips have been pulled together to provide some key areas to focus on. The list is by no means exhaustive but highlights some key ways that have been found to assist:

  • Quality of care should be the driver of change with time as one component. Don’t work to achieve the target, work to improve the patient’s whole experience.
  • At all times patient safety is paramount.
  • The ETP target should be part of a larger quality improvement program.
  • Ensure staff are aware of the performance against what is being measured.
  • Involve patients.
  • The target is a whole hospital initiative, not an Emergency Department (ED) one. It is vital that the whole health care system is considered and any changes result in a whole system improvement and not just a change within one unit, and that such changes are sustainable.
  • Patient flow is crucial. For example, it was found in the UK that the greatest variability in the system is with elective admissions not emergency admissions.
  • Elective and emergency work needs to be planned together, with equal priority. Only by careful planning can delays in exiting the ED be controlled.
  • Accurate system data is vital, to understand patterns of arrival, discharge, when and why waits occur and to reduce system variability. The data support team need access to ALL data eg ED, hospital occupancy, elective waiting lists and outcome data.
  • Identify an executive leadership sponsor as senior engagement is essential from the whole system.
  • Form committees and working parties that reflect whole of hospital ownership of the target i.e. executive, surgery, patient flow, medicine, radiology, pathology ED. Whole system engagement is required and organisational barriers must be minimized.
  • First meetings should:
    • Review current performance of hospital/s with respect to ETP
    • Identify challenging areas in the hospital, the ED and other units e.g. access to surgical consult, diagnostics in ED, access to ICU/high dependency beds, access to beds for ICU discharges, access to imaging within the hospital, quantity and location of unit outlier patients, in-hospital/discharge planning and options for out of hospital care i.e. OPD, Hospital in the Home, enhanced outreach to residential care facilities models of care
    • Determine what information is required to support identification and monitoring of challenges
  • A diagnostic phase is essential to identify the challenges. Risks attached to changes in workflows and clinical care delivery need to be considered in relation to the unique aspects of each hospital.
  • Achievable solutions identified need to be implemented with identified resources and support from hospital executive.
  • Admitted patients from ED may be smaller numbers than those discharged but creating available beds within the hospital within a timely manner is where the greatest challenge lies, to enable improved access to new ED patients.
  • Patient transfers need to be reviewed and streamlined with both the referring and receiving hospitals agreeing process and communication.
  • The role that an MAU, SAU, CDU or CAU can play should be explored to determine if appropriate for the facility as these models can make a huge difference.

ETP - What can the ED do?

ETP is a whole system target and the focus should not be on the Emergency Department (ED) alone to achieve and implement this. It is clear, however, that EDs have a crucial role to play and there will always be scope for improvements within the ED environment. Some, but by no means all, of the key areas that facilities have found it helpful to focus on are:

  • Match staffing levels to arrival times and peak activity.
  • Consider the use of a Navigator Role. An example of a navigator role is here.
  • Involve staff in the process from the outset. Staff input is crucial in identifying how and what can be improved. Consider asking staff the top 3 barriers for patients moving through the ED and listen to their suggestions.
  • Carefully consider the ordering of diagnostic test to ensure they are always appropriate.
  • If a result is not vital to a decision being made, why wait for it?
  • Have agreed turnaround times for investigations, tests and pathology to reflect clinical urgency.
  • Consider exploring enhanced access to radiology and pathology, including point of care testing with agreement on who can request according to protocols.
  • Investigate admitting rights for designated medical staff in the ED.
  • Utilize Models of Care that are appropriate for case mix, complexity and activity in your department, such as Fast Track, Early Treatment Zone, Senior Assessment.
  • The Emergency Department should focus on the identified delays in the patient journey in the ED and use a patient journey template to assist this:
    • Waiting to be seen
    • Waiting for diagnostics and procedures
    • Waiting for specialist review
    • Waiting for senior clinical decision making and a plan of care
    • Other delays relating to clerical and domestic roles may also impact on time
    • Existing models of care should be reviewed for efficiency
    • Are there ways to avoid admission and attendance at the ED
    • Issues around workforce skills mix and capacity need also be noted
  • Have a balanced scorecard to help monitor progress that includes KPIs for whole hospital e.g. discharges before 11am, length of stay etc.
  • Have staged targets within the 4 hours to help with the whole system to respond in a timely manner, such as referring the patient to the inpatient team at X hours.
  • Determine how referrals to the admitting team work and the process after acceptance to ensure timely departure from the ED. Audit and feedback on this.
  • Maximize the use of all clinicians in the ED looking at skill mix and task allocation so that all providers are working according to the top of their scope of practice.
  • Introduce support roles in ED to transfer non-clinical tasks from clinicians as appropriate.

We recognise that this is not a comprehensive list and would love to hear about particular initiatives or ways you have found to improve efficiencies within your ED. Please email us with your thoughts and suggestion so that we can include these.

ETP Resources

Emergency Treatment Performance (ETP) Guidance

Quality Resources

The ECI has listed a variety of resources under the following sections that may be of use when ensuring quality remains a key focus of any initiatives or strategies to address ETP and NEAT:

Emergency Care Institute, published November 2013

Reports and Literature

ACI Emergency Care Institute 2013 Stakeholder Survey: Findings of Interest to the NSW Health Whole of Hospital Program Survey

Western Australia: Emergency Access Flow Report

Prof Derek Bell, published September 2013

Western Australia: Day of Care Surveys

Prof Derek Bell, published September 2013

Over-census Strategies

A page developed by the ECI which presents information on over-census strategies along with evidence and papers which may help you engage your hospital in the problems of overcrowding in the ED.

Where do NEAT and patient safety meet?

Dr Sally McCarthy, Medical Director, ECI, May 2013

Brandon Carrus, Stephen Corbett and Deepak Khandelwal, McKinsey, January 2010

Conference Presentations

Access Block Solutions Summit

Australasian College for Emergency Medicine, September 2008

Links to videos of the speakers invovled in this summit on access block.

NEAT: If, when and why it works well

Allan Cumming, General Manager, Southern District Health Board, New Zealand

A talk by Allan Cumming at the ECI Symposium 2012 detailing what works well in achieving NEAT. There is a particular focus on the role of the hospital executive and senior manamgement in leadership and management of timely patient flow.

National Emergency Access Target

Dr Sally McCarthy, Medical Director, ECI, March 2012

Implementation of the Four Hour Program at Royal Perth Hospital

Prof Frank Daly, Executive Director, Royal Perth Group, 2012

Association between reduced overcrowding and decreased mortality for emergency patients following the introduction of the four hour rule in Western Australia

Dr Gary Geelhoed, Director Emergency Department, Princess Margaret Hospital for Children

Demand at the ED front door: Is the 4 hour target the answer?

Judy Lowthian, Doctoral Scholar, Monash University

The great thing about being NEAT

Dr Mark Monaghan, Fremantle Hospital and Western Australia Statewide Rour Hour Rule Clinical Lead

Emergency Physician and Co-Director Fremantle Emergency Department

Member of Expert Panel advising on Emergency Access and Elective Surgery Targets

Increases in patient attendances since the introduction of the Four Hour Rule

  • Dr Yusuf Nagree, Fremantle Hospital and Centre for Clinical Research in Emergency Medicine, Western Australia Institute of Medical Research, University of Western Australia

Low acuity patients do not significantly contribute to ED workload

Dr Yusuf Nagree, Fremantle Hospital and Centre for Clinical Research in Emergency Medicine, Western Australia Institute of Medical Research, University of Western Australia

Growth in Australian ED demand 2004 to 2011

A/Prof Drew Richardson, Australian National University

2011 Australian access block point prevalence survey

A/Prof Drew Richardson, Australian National University

Clinical process redesign for unplanned arrivals in hospitals

Tony J O’Connell, Jane E Bassham, Rod O Bishop, Christopher W Clarke, Carolyn J Hullick, Diane L King, Carmel L Peek, Raj Verma, David I Ben-Tovim and Katherine M McGrath Medical Journal of Australia 2008; 188 (6): 18

Update on Overcapacity Protocols

A/Prof Drew Richardson, Australian National University

Whole of Hospital Program

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