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?

    A 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.

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