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

Document Type

Journal Article


Wiley-Blackwell Publishing Ltd


Faculty of Health, Engineering and Science


School of Medical Sciences




This is the accepted version of the following article: Pakmehr, S. , Petersen, R. W., & Quinlivan, J. (2013). Barriers to the 4-h rule: What causes delays for gynaecology patients in the emergency department?. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53(1), 46-50, which has been published in final form at here


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.