The Board of St Vincent’s Hospital in inner Sydney monitors a number of indicators of quality of care for Aboriginal and Torres Strait Islander people, including rates of incomplete treatment in the Emergency Department (ED). Incomplete treatment includes patients who leave the ED before the medical team recommends discharge, those who are not present when called to be seen by a doctor and those who attended ED and did not wait to complete treatment - collectively known as leave events.

Incomplete treatment is associated with an increased risk of readmission and death.¹ The NSW Ministry of Health has identified the high rate of incomplete treatment in EDs among Aboriginal and Torres Strait Islander patients compared to other patients (8.6% and 6.1%, respectively, nationally, 2019)² as a priority issue.³

The hospital Board requested that the ED department work to reduce the rate of incomplete treatment among Aboriginal and Torres Strait Islander patients.

Dr Paul Preisz, Director of ED at St Vincent’s Hospital, did not need to create any additional data collection for the project, as data on incomplete ED attendances are routinely collected as part of the Emergency Department Data Collection. A policy of asking all patients whether they identify as Aboriginal or Torres Strait Islander when they arrive at the ED was also already in place. The quarterly Aboriginal Health Dashboard reports, sent to Local Health Districts and other Health Service Networks in NSW, allows health services to see their own rates, as well as the state average.

The ED at St Vincent’s hospital, Sydney, had a rate of incomplete ED attendance of 19.5% among the 1,760 Aboriginal and Torres Strait Islander patients who presented in 2018-2019⁴ - over double the national average (8.6% in 2019).²

Dr Paul Preisz, Director of ED, St Vincent’s Hospital

‘Amongst the thousand other things that come across your desk during the day, that really got our attention. We started laying out some plans for what to do about it, and we chose a different path than most’

A team made up of Aboriginal Health Unit staff, an ED staff specialist, nursing staff, members of the hospital executive and Dr Preisz, explored the underlying reasons for the high rate of incomplete treatment among Aboriginal and Torres Strait Islander patients. Staff time was covered by a grant from the hospital board.

Through discussions and a literature review, the team found that possible contributors included:

• Long waiting times
• Distrust of the health system
• Miscommunication
• Prioritisation of family and social obligations
• Isolation and loneliness within the ED
• Lack of understanding of the treatment being given
• Feeling that treatment was complete when it was not
• Racism or a feeling of being judged and lack of respect.

The ED team and staff from the Aboriginal Health Unit of the hospital co-designed a ‘Flexi Clinic’ that would address the major factors contributing to incomplete treatment. The approach was underpinned by seven core values that promote cultural sensitivity and humility⁵:

1. Holding shared information as sacred, demonstrating respect and trust, and not judging
2. Seeking a common interest or path, or seeking permission while weighing the importance of an issue
3. Listening deeply, and allowing silence (regarded not as uncomfortable, but as inherent to respect)
4. Asking for clarification on issues, having humility and not acting as the keeper of all knowledge
5. Awareness of endemic power differences in medicine and sensitively ameliorating their effects
6. Sharing of resources and helping those in need
7. Extending benefits garnered for the individual for the good of the community.

Kieran Costigan, Acting Executive Director Aboriginal Health, St Vincent’s Health Network, Sydney

‘Designing, implementing and working in the Flexi Clinic has been a positive experience for the Aboriginal staff involved, and it’s given them a sense of pride and satisfaction that they are supporting their communities and contributing to better health outcomes for our people.’

A dedicated system was set up so that all Aboriginal and Torres Strait Islander patients presenting to the ED, and categorised as triage category 3, 4 or 5, were directly referred to the designated team (all category 1 and 2 patients are seen immediately, or within 10 minutes, respectively). The team was made up of the rostered ED senior clinician and an Aboriginal Health Worker.

The system is managed by an ED staff specialist during the day and an ED registrar overnight, in conjunction with their other duties. A referral from triage is sent as a text message to the ED clinician and to the Aboriginal Health Unit and the patient is seen by both as soon as possible, while balancing the needs of other patients. The Aboriginal Health Unit operates 8 am to 9.30 pm, Monday to Friday. Fast-track systems for imaging and for dispensing medications to take home were also put in place, as these were found to be major roadblocks.

The patient may choose to leave the ED at any point. If they choose to leave, a card is provided with a summary of the current plan. On return, the card is presented at triage and the patient’s management will continue where it left off. Patients are followed up by telephone within 48 hours of leaving ED to check on their health, check whether they are linked with appropriate community-based health services and to ask for feedback on their experience in the ED.

All medical staff in the ED were required to complete the ‘Respecting the Difference’ training package about treating, and engaging with, Aboriginal and Torres Strait Islander patients. A number of discussion sessions for staff with an ethicist were also held before the program was introduced.

Dr Paul Preisz, Director of ED, St Vincent’s Hospital, Sydney

‘It was important to think about the ethics of what we were doing, because I did not want people doing this grudgingly. We had a number of discussion sessions for staff with an ethicist, and these included nurses, doctors, administration staff and executives. Most of the staff were already on board, but the ethicist discussions cemented the middle group and brought on board the sceptics – and it is critical to bring them along.

Many people hold the belief that the fairest system is to be the same for everybody – and that sounds superficially like it’s right, but actually it’s not. We looked at historical harms as well as outcome measures…and concluded that if every other category 3, 4 and 5 patient had to wait one minute longer, that would be a reasonable trade-off for getting better outcomes for this group who were faring so badly. But that trade-off we were prepared to wear didn’t happen in the end’

In the three months following the introduction of the Flexi Clinic system, the rate of incomplete treatment among Aboriginal and Torres Strait Islander patients fell from 19.5% to 5.2% of presentations - a five-fold decrease. No decrease in benchmarked provision of care levels for non-Aboriginal patients was seen after the implementation.

Dr Paul Preisz, Director of ED, St Vincent’s Hospital, Sydney

‘No other group was adversely affected, in fact waiting times for everyone improved. It was an example of when one part of the engine’s not working, and you fix that, the whole thing works better. We had fewer patients having aggressive interactions, fewer patients having to have their treatment start right at the beginning again, which took up time, and fewer patients coming back a short time later much sicker than they were.’

Kieran Costigan, Acting Executive Director Aboriginal Health, St Vincent’s Health Network, Sydney

‘The Flexi Clinic has had a positive impact on Aboriginal and Torres Strait Islander patients by creating safe, culturally appropriate spaces for consumers to access care, and, more importantly complete their care. The flexibility of the service allows consumers to complete their treatment at a time that suits them (depending on presentation, triage category and that a staff specialist has medically cleared them to leave and return). The presence of Aboriginal Health Workers also creates an element of safety for consumers, and communities have responded well with reduced rates of incomplete treatments and better connected care to local AMSs, community services and GP’s.’

Since the initial implementation in 2020, Dr Preisz and the board have continued to monitor rates of incomplete treatment in the ED. A monthly review meeting with all stakeholders, including medical, nursing and Aboriginal Health Unit staff, is also held to review all cases of incomplete treatment for Aboriginal and Torres Strait Islander patients. The feasibility of the system and acceptability by staff are also reviewed regularly, as well as patient feedback from the 48-hour follow-up calls.

Dr Paul Preisz, Director of ED, St Vincent’s Hospital, Sydney

‘For anyone else trying to do something similar, I’d say do some background reading on the issues and then do local work on what your roadblocks are. For us it was imaging and pharmacy; it might be pathology or something else for another hospital.’

Further reading: 'Dalarinji': A flexible clinic, belonging to and for the Aboriginal people, in an Australian emergency department⁵