Stay'n Deadly & Stay'n In: Reducing Incomplete Treatment

Stay'n Deadly & Stay'n In is providing Aboriginal patients with quick and timely access to treatment whilst allowing them to engage in further treatment that is convenient for them, if they are required to leave. It is important that they feel well supported in the Emergency Department by the Aboriginal Health Unit and have a positive experience when engaged with all staff.

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Aim

To reduce the rate of incomplete treatment (Did Not Wait and Left At Own Risk) in the Emergency Department from 19.5% to 5% by December 2020

Benefits

• Improve acute health outcomes for Aboriginal patients.
• Improve management of chronic conditions for Aboriginal patients.
• Improve patient satisfaction and quality of care.
• Improve staff satisfaction with complete treatment.
• Improve staff skills for cultural sensitivity.
• Increase culturally safe and appropriate care.
• Reduce the financial burden on St Vincent's Emergency Department.
• Reduce rate of readmissions.

Background

The project focuses on incomplete treatment of Aboriginal patients who present to St Vincent's Health Network Sydney (SVHNS) - Emergency Department (ED). Incomplete treatment includes those patients who have commenced their treatment but 'Left At Own Risk' (LAOR) prior to completion, and patients who 'Did Not Wait' (DNW) after being triaged by nursing staff without intervention by a clinician.

Prior to the project, there were 1,760 Aboriginal patients presented to SVHNS-ED in the financial year of 2018-2019. Out of these, 343 (19%) of them did not complete their treatment, which was sub-categorised into 150 (8%) 'Left At Own Risk' (LAOR) and 193 {11%) ' Did Not Wait' (DNW) for treatment. To provide a perspective on the performance or ability to treat Aboriginal patients in a NSW public hospital, the Ministry of Health set a target for this at 5%, with the state average for 2019 at 8.6%.

After consulting with both patients and staff this has become a catalyst for the organisation to undertake a clinical redesign project, not only to improve patient satisfaction and quality of care, but also to improve staff satisfaction and decrease hospital expenditure associated with this significant clinical safety issue (NSW Aboriginal Health Dashboard 2018).

Implementation

Three key solutions aimed at reducing high incomplete treatment rates are outlined below:

Solution 1: Flexi-Clinic development with Dr Paul Preisz

The Flexi-Clinic is a flexible clinic which allows Aboriginal patients who present to Emergency Department to be seen by a staff specialist upon presentation. One of the aims of the clinic is to reduce the amount of time the patient spends in Emergency Department. By being seen by a staff specialist the treatment and diagnosis time is reduced due to experience and ability by the staff specialist to make decisions without supervision. The Flexi-Clinic also allows patients who have been triaged and had immediate treatment to represent at a convenient time to finalise results or plan further treatment. The Flexi-Clinic operates 24 hours, 7 days per week by a rostered doctor, responsible for all Aboriginal patients. The flexi doctor and Aboriginal Health Unit (AHU) are both notified by text message which is generated from the COREPAS/EDIS system when the patient is being entered into the system. Wait times have been reduced from pre-implementation times of 56 minutes to 13 minutes currently.

Solution 2: Aboriginal Health Unit after hours with Pauline Deweerd

The Aboriginal Health Unit (AHU) has changed its service delivery times to 8am to 9pm, Monday to Friday, and to 1pm to 9pm on Saturday. Statistics showed during this process that the main presentation time for Aboriginal patients was between 4pm-8pm with Friday, Saturday and Monday being our busiest days. The Saturday shift has only been a recent addition to the Aboriginal Health Unit (AHU) as a majority of the remaining and incomplete treatments, post -implementation, have occurred on Saturday evenings.

Solution 3: Training package with multiple stakeholders

A training package has been developed for Junior Medical Officers (JMOs) prior to working in the Emergency Department, as well as for all current medical staff, to provide and support the necessary skills to engage and treat Aboriginal patients. 'Respecting the Difference' training has become mandatory for all doctors in the hospital, in particular the Emergency Department. St Vincent's Network Sydney has become the first hospital to take 'Respecting the Difference' virtual, facilitating the continued training and learning for staff.

Status

Implementation – The project has implemented the three above solutions from June 1, 2020.

Sustained - The project team allowed three months of implementation and development of structures to make the solutions part of business as usual. Results for September were maintained with very minimal input from the project team. The Aboriginal Health Unit (AHU) will continue to monitor results and key performance indicators.

Dates

• 1 August 2019 - 31 December 2020.
• The implementation of solutions began on March 1, 2020, but due to COVID and the reallocation of staffing, the solutions were paused. The first two weeks provided positive feedback into issues with solutions as well as a downward trend in data.
• The project solutions then recommenced on June 1, 2020.
• The project moved into the sustainability phase on September 1, 2020.

Implementation sites

St. Vincent's Health Network Sydney

• Emergency Department
• Aboriginal Health Unit
• Mental Health Service
• Alcohol Drug Service
• Social Work Department
• Medical Imagining
• Alcohol and Drug Information Service (ADIS)
• Pharmacy Department

Partnerships

• Centre for Healthcare Redesign
• University of Tasmania

Results

Solution 1 Flexi-Clinic

The Flexi-Clinic was monitored daily in conjunction with the Aboriginal Health Unit (AHU). The following KPl's were reported on daily:

• Number of patients presented.
• Number of incomplete treatments.
• What doctors treated patients per shift (Other than flex-doctor).
• Time to treat.

The Flexi-Clinic has seen a constant and average number of patients compared with pre-implementation. In the four months of the Flexi-Clinic operation, the incomplete treatment rate has reduced to 4.5%, achieving project objectives and NSW Ministry of Health requirements.

Solution 2 Aboriginal Health Unit after hours

The after hour access of the Aboriginal Health Unit (AHU) is monitored on a daily basis. This includes monitored the below:

• Number of patients engaged/seen.
• Number of incomplete treatments.

The Aboriginal Health Unit {AHU) has increased their point of contact with patients in the Emergency Department by 68% by increasing business hours . It has provided patients with a sense of safety, which has been reported by the patients in the 48 hour follow-up.

Solution 3 Training package

The training package is measured routinely with points of reporting below:

• Number of staff attended.
• Percentage of staff trained/attended per department.

The training package will be monitored by learning and development and reported on in a weekly performance review, and monthly to the Aboriginal Health Unit (AHU).

Lessons learnt

• Multiple lessons have been learnt during this process, but nothing more important than project fatigue. Project fatigue along with the current pandemic has placed significant stress on the project team to fulfil and deliver the designated solutions. It is quite important the members of the project had time away from implementing these solutions to gain perspective and clarity on the bigger picture, which includes changing the health outcomes of Aboriginal patients.
• The importance of a global communication system to monitor issues, deliverable outcomes and new developments among key stakeholders.
• The importance of persistence and escalation with resistive staff .

References

1. Aboriginal Health Policy Directorate 2017, Understanding Institutionalised Racism, Western Australia Department of Health, Perth.
2. Department of Prime Minister and Cabinet 2016, Closing the gap: prime minister's report 2016, viewed 10 February 2016.
3. New South Wales (NSW) Ministry of Health 2012, NSW Aboriginal health plan 2013 - 2023, NSW Ministry of Health, Sydney.
4. Wilkinson, R & Marmot, M 9eds) 2003, Social determinants of health: the solid facts, 2nd edn, World Health Organisation, Denmark.
5. New South Wales (NSW) Ministry of Health 2018, NSW Aboriginal Health Dashboard Toolkit, NSW Ministry of Health, Sydney,

Contact

Jamille Torrefranca
Registered Nurse (Project Team Member)
Mental Health Service - St. Vincent's Hospital Sydney
Jamille.torrefranca@svha.org.au

Nioka Tyson
Social Worker (Project Team Member)
Emergency Department and Intensive Care Department
St. Vincent's Hospital Sydney
nioka.tyson@svha.org.au

Sosalim Heng
Registered Nurse (Project Team Member)
Mental Health Service & Aboriginal Health Unit
St. Vincent's Hospital Sydney
sosalim.heng@svha.org.au