The emergency room four hour wait rule explained or How history teaches us that history teaches us nothing.

Now I have worked in a lot of different health care jurisdictions and this gives me a different outlook on our system than someone who has only worked in one place, seen things done only one way.  The ridiculous concept which has followed me around the globe is the idea of a rule that governments (who have little idea about how to run a health care system, but a pretty good idea of how to get elected) always seem to trot out around election times.  That is the concept that somehow, their government is going to, or has already, dramatically reduced emergency room waiting times.  That and operating room wait lists are the two health care election items they know, or think they know, will get peoples’ attention.  You want that sound bite that is going to hit home.  The problem of emergency department (ED) wait times is a complex problem,  and you are welcome to refer back to my blog on “Why you need a family doctor.” to examine one of the main causes of inappropriate ED use which is that a lot of people don’t have access to a family doctor.  Of course ED’s will always be needed for car crashes, heart attacks, perforated bowels, appendicitis,  burns, broken legs and so on, and if all they saw was stuff that was ED appropriate, I’m sure my emergency room colleagues would be pretty happy.  But you can’t send everybody to medical or nursing school, or teach everyone how a health care system should be used appropriately.  EDs are overrun with ingrown toenails, narcotic seekers, people seeking work notes, colds, prescription refills other stuff that really should be dealt with anywhere but an ED.   The four hour rule (called pay-for-results in Ontario) is a band aid approach to the much deeper problem of why there is SO MUCH inappropriate use of emergency rooms.  People in our society do not want to wait, for anything, be it their appropriately named fast food, or their health care.  But do you really want a fast food approach to health care? One could argue that one way to discourage people from being in EDs inappropriately is to have long wait times, but there are problems with that for sure.

My son was once being admitted to hospital, but we remained in an ED bed, as no ward beds were available.  We had arrived in the ED, having driven from another smaller hospital, around 930 pm.  The ED waiting room was packed, with people hanging off the rafters.  Our son was quite sick and we were almost immediately assigned an ED bed, but not before noticing the people around us in the waiting room.  At 8 am, a parent and child I recognized from the waiting room (who had registered  before us and therefore had been waiting a minimum of 10 ½ hours) were led into the stretcher beside us.  The kid had something in his ear. I didn’t see what happened, but they were in the bed for about 3 seconds and on their way out the door after a nurse or doctor scooped out whatever was causing the problem.   I do feel sorry for anyone waiting overnight in an ED to be seen for such a minor complaint which was so easily fixable, but at the same time I think we can all agree that patients with more serious problems should be seen and treated first.  Did the parents think whatever was in there was going to damage his hearing?  Or erode into his brain?  Did they not have a family doctor? Or couldn’t access their family doctor?  Were they immigrants who didn’t know about walk in clinics? Or Telehealth? I don’t know what the thinking was, the kid certainly didn’t look distressed, but one family now has a horror story of an ED wait, and therefore any election propaganda which involves reducing ED wait times will likely hit home with them.

Enter the four hour rule (or eight hour rule, or six hour rule, depending on what country or province you are in at any given time.)  This is a rule that states from the time a patient gets into a bed (NOT the time they present to the ED, the time their bum hits the stretcher) or sometimes from the time of their first interaction with an ED physician, they must either be discharged home, transferred to another hospital,  or admitted within four, six, or eight hours, depending on where the dart landed while the administrators were thinking up this rule.  The number of hours chosen is random and not based on any science or studies.  It is a number based on what politicians hope will get them elected.  If it was the 8 hour rule last election, it’s the six hour rule now, and now we have, you guessed it, the four hour rule.  Some of the funding for emergency departments  in Ontario is now punitively based on the percentage of patients who are seen and allocated under the set time.  Meaning emergency departments who are performingly poorly get LESS funding than those performing well.  Kind of like giving the kid who is already getting A’s in school the extra tutoring, instead of the kid who is failing.  More than a little backward, but that’s the approach.  The idea that extra staffing (which would mean extra beds) would help to ease the problem has not been put forward as a solution, not surprisingly, as this would cost money.  The idea that a hospital does not have a bed is occasionally true.  More often though, there are beds which are not funded to be open because of the cost to staff them with nurses.  It would be more accurate to say- “There’s no funding for nurses,” instead of “there is no bed.” Basically this is the government saying, do more with the same or less resources, or we will make it harder for you.  This will be an ongoing theme in healthcare in the years to come.

The idea that a certain percentage of patients presenting to the ED should be seen and a definitive decision made as to what should happen to them sounds good on paper, and that would be fine for a trial run in Ontario if this approach had not failed so abysmally when tried in multiple other countries with socialized health care in the past.  I admit that I like the idea that everything should be just done quicker when I use an emergency room.   But, remember the kid waiting 10 ½ hours?  He would qualify as someone seen and treated in an acceptable length of time, in spite of the fact that he waited over 10 hours just to be seen.  He would be a success story by this measure.  Remember, the clock doesn’t start until you are in a bed, and he wasn’t in a bed for very long- he was in the appropriately named waiting room.  We now have our emergency departments twisting themselves in knots to keep as many patients under the guideline as possible.  Is this good care?  I would say no.  Is faster care good care when it comes to emergency departments?  Sometimes,  but not necessarily.  A lot of unnecessary testing and admissions could be avoided if watchful waiting was allowed to be employed as a strategy.  Maybe the kidney stone will pass, the ventolin will kick in, or the abdominal pain will resolve on its own (meaning it is unlikely to be appendicitis) as three quick examples.

I worked through the introduction of this rule in NSW, Australia and it was a disaster, particularly in the large teaching hospital where I was a consultant surgeon.  The administration was so keen to have as many patients as possible meet this benchmark (KPI or key performance indicator in administrator speak), the emergency physicians were allowed carte blanche to admit any given patient to whatever service (surgery, cardiology, geriatrics etc)  was their best guess (and these patient were so incompletely assessed it really was a guess) as to who could fix whatever ailed the patient .  Not surprisingly, a lot of the time this was the WRONG service. The consultants were furious.  We would arrive in the morning after a night on call with multiple patients under our care we had no idea about.  The rest of the day would then be spent sorting out who needed what, pretty much starting from scratch as if the patients had not even been seen by a physician before.  Length of stay times went up dramatically. There was now no motivation on the part of the ED to come up with a diagnosis or even a treatment plan before the patient left the ED, much less communicate it to anyone. The patients also had not had complete workups, meaning testing like ultrasounds and CT scans, were not done before they went to the ward.  The next day, that patient had to wait in line behind ED patients, who were given priority over ward patients for imaging studies- because of the 8 hour rule.  Again, this extends length of stay and overall cost to the health care system, but the most important point is that it just leads to bad patient care. There has been heavy criticism of this rule from the people actually working in the emergency departments- the doctors and nurses. The irritating thing about the introduction of the rule in Australia was that the approach had already failed in the UK, yet still followed me there, and now has followed me on to Ontario.  Now, one could write a Phd on this topic based on the contradictory numbers and statistics out there surrounding this rule and still not really get anywhere. This blog is my opinion and you can take it or leave it.

There is a lot of cognitive dissonance at work here.  The more something is proven wrong, the more those who promoted it in the first place will dig their heels in to insist it is a good approach. The data which is being collected will always look good.  Isn’t it funny how administrators and politicians usually find what they are looking for when crunching numbers?  Our emergency room healthcare workers will inevitably fatigue of being on this pointless treadmill though (this is what happened in the UK) and hopefully go back to doing what they do best-looking after patients.  As a surgeon, patients and families often ask me “How long will the operation take?”  I do give them a ballpark figure, and then I always tell them- “It takes as long as it takes to do a safe operation.”  It should be the same with an emergency room visit.

Is the 8/6/4 hour rule likely to be repealed?  I hope so, but something tells me no, since there is always an election on the horizon. I’m all for democracy, but the problem with elections every 4-5 years means the long term issues are quite often secondary to doing quick fix, media friendly initiatives which will get the government positive attention.  Our health care system, and our emergency rooms in particular, have some serious challenges and the 4 hour rule isn’t solving any of them.   But then again, nobody’s asking me.


3 thoughts on “The emergency room four hour wait rule explained or How history teaches us that history teaches us nothing.

  1. So dead on. It is drs, like yourself, that should be asked to provide input as to what health care excellence would look like. Politicians and bureaucrats are the last people who should be making these decisions. I think also that all the stakeholders should be involved in how our health care system is set up – doctors, nurses, other support staff. These are the people that work IN the system and can most readily identify what best practices would be. In addition I believe that patients need to be included in discussions. I know there are the ones that want what want when they want it, but there are many who are reasonable, intelligent, articulate and want not only what is best for them, but for the system and all its stakeholders. They can add another level of insight that is also important.


  2. I am a Physician Assistant in an Emergency Department in Ontario and I agree this is a bad marker of performance, but it is only one of many. The Ontario Government also bases funding on wait times and left without being seen rates – these plus other indicators are calculated to give the hospital performance funding. As a result, ERs all across the province have spent precious resources developing fast track or see and treat areas which concentrate on the less urgent patients which improves access for those that, in many cases, should be seen in a less urgent care setting. This encourages people to misuse the ER as it is often faster and more convenient than any other care option. This is the perfect recipe for increasing health care costs by using the most expensive services inappropriately. We need to rationalize Health Care in Ontario by focusing on out of hospital and preventative care. In a well run system the ER should have almost exclusively patients who are acutely injured or are in need of ruling out a serious and imminent medical emergency.


    1. You are exactly right. We are spending money on healthcare and we need to spend smarter, since it is unlikely the pot is going to get any bigger with our provincial government in such debt. Patients have proved not very good at triaging themselves to various problems- ingrown toenails should not be in ED, but I recently had a badly perforated bowel who was seen in a walk in clinic first and should have come straight to emergency.


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