Towards The Four-Hour Rule: Impact of Observation Units and Emergency Medicine Specialists in an Indonesian Tertiary Hospital

Emergency Department (ED) overcrowding is a global challenge. In response, the government of Indonesia mandates an ED Length of Stay (LOS) of ≤4 hours. This study aims to evaluate the impact of implementing an Emergency Department Observation Unit (EDOU) combined with an Emergency Medicine (EM) specialist-led disposition process on ED LOS at a national referral hospital in Indonesia. This was a retrospective, pre-post analysis comparing all ED visits in 2023 (pre-intervention, n = 26,282) with all visits in 2024 (post-intervention, n = 31,483). The primary outcome was the proportion of patients with an ED LOS ≤4 hours. Secondary outcomes included median ED LOS and the odds ratios (OR) for yellow zone patients achieving the ≤4-hour target based on the intervention period and the deciding physician's specialty. Following the intervention, the median ED LOS decreased from 16.4 hours to 8.0 hours (p-value = <0.05). Yellow zone patients in the post-intervention period had 6.37 times the odds of achieving a ≤4-hour LOS compared to the pre-intervention period (95% CI [5.72–7.09]). When the decision to admit to the EDOU was made by an EM specialist, the odds of achieving the target were 1.86 times higher than for other specialists (95% CI [1.43–2.42]). The combined implementation of an EDOU and EM specialists-led disposition significantly reduced ED LOS and dramatically increased the odds of meeting national performance targets. The success was driven by both increased downstream bed capacity and streamlined, specialist-led disposition processes.