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doi:10.1111/jpc.12756
ORIGINAL ARTICLE
Improving delivery of health care to Aboriginal and Torres Strait Islander children Lucy Attwood,1 Sarah Rodrigues,3 Josephine Winsor,2 Shirley Warren,2 Lyn Biviano2 and Hasantha Gunasekera1,2 1
Sydney Medical Program, 2Sydney Children’s Hospitals Network (Westmead), Sydney, New South Wales, Australia and 3Department of Paediatrics, University College London, London, United Kingdom
Aim: To identify opportunities to improve health-care delivery for urban Aboriginal and Torres Strait Islander children requiring hospital admission and to determine their characteristics. Methods: We analysed all documentation of admissions of Aboriginal and/or Torres Strait Islander children to a tertiary paediatric hospital in 2010. We reviewed the medical records to determine whether the Aboriginal status of patients was known, whether Aboriginal and/or Torres Strait Islander children and their families were reviewed by Aboriginal staff during admission and whether basic health-care quality indicators were met, including documentation of anthropometry, ear examination findings, immunisation status and catch-up immunisation delivery. Results: In 2010, 543 (2%) patients admitted to the institution were identified as Aboriginal and/or Torres Strait Islander: 140/538 (26.0%) were from the first decile (most disadvantaged) on Socio-Economic Indexes for Areas index. Of all admitted children, 148/543 (27.3%) were referred to Aboriginal health professionals during admission, more when length of stay was greater than 7 days (61% vs. 23%, P < 0.001). There was documentation of weight in 533/543 (98.2%), ear examinations in 64/543 (11.8%), immunisations being not up to date in 126/543 (23%), catch-up immunisation given in 7/126 (5.6%), Aboriginal and/or Torres Strait Islander status in 8/543 (1.5%) medical and 1/543 (0.2%) nursing discharge summaries. Conclusions: We have identified several opportunities to improve culturally appropriate health-care delivery for Aboriginal and Torres Strait Islander children admitted to hospital, including improved recognition of Aboriginal and/or Torres Strait Islander status of patients, improved access to Aboriginal health professionals and increased performance and documentation of basic anthropometry, ear examination and immunisation catch-up. Key words:
cultural competency; delivery of health care; immunisation; indigenous; paediatric.
What is already known on this topic
What this paper adds
1 Aboriginal and Torres Strait Islander children demonstrate poor health outcomes compared with the Australian population. 2 The majority of Aboriginal and Torres Strait Islander people live in major cities, inner regional areas and outer regional areas yet the majority of research is focused on remote Aboriginal health. 3 Aboriginal health workers are an important component of effective health-care delivery to Aboriginal patients.
1 Aboriginal and Torres Strait Islander status is poorly documented in medical or nursing notes. 2 There are opportunities to improve health-care delivery for Aboriginal children in an urban health-care setting such as improved catch-up immunisation delivery and ear examinations. 3 Many Aboriginal children are not receiving support from Aboriginal health professionals when admitted to a tertiary paediatric institution.
Despite decades of research demonstrating poor health outcomes in Aboriginal and Torres Strait Islander children,1–3 there are scant data on the quality of the health care actually provided to them. A better understanding of how health care is delivered is an essential first step to improve it. The health of urban Aboriginal and Torres Strait Islander children, in particular, Correspondence: Dr Hasantha Gunasekera, General Medicine, The Children’s Hospital at Westmead, Hawkesbury Road, Westmead, 2145, Sydney, NSW, Australia. Fax: +02 9845 3432; email: hasantha.gunasekera@health .nsw.gov.au Conflict of interest: The authors report no conflicts of interest. Accepted for publication 12 September 2014.
534
needs specific focus. Although only 25% of Australian Aboriginal and Torres Strait Islander people live in remote areas, these regions are over-represented in publications, with only 11% from urban areas.1,4 This population also has a young skew (37% < 15 years).1 Therefore, improved health-care delivery for children in urban settings is essential to improve long-term health outcomes for Australian Aboriginal and Torres Strait Islanders. In 2007, the Australian Medical Association (AMA) called for an assessment of service delivery to Aboriginal and Torres Strait patients to bridge the gap.2 The 2010–2011 Aboriginal and Torres Strait Islander Health Report Card5 called for an increased focus on the type and quality of health care available for Aboriginal people.
Journal of Paediatrics and Child Health 51 (2015) 534–540 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
L Attwood et al.
Improved identification of Aboriginal and Torres Strait Islander status is required to ensure culturally competent health-care delivery.6,7 Aboriginal status is consistently underreported in the health-care setting,7,8 despite documentation being a requirement for all patients presenting to New South Wales (NSW) health facilities.9 The AMA called for the federal government to co-ordinate national improvements in data management to ensure that comprehensive information is recorded and available regarding Aboriginal identification and health.10 Identification of the Aboriginal status of both parents/ carers is crucial in paediatrics. A study of Aboriginal children in an urban setting found that the majority had only one Aboriginal parent and that unless information on the Aboriginal status of both parents were sought, Aboriginality was underestimated.6 Better identification could improve linkage of Aboriginal and Torres Strait Islander patients with Aboriginal health-care services (e.g., Aboriginal health workers). Indigenous health workers, world-wide, have been shown to facilitate progression through the health-care journey, as well as promote understanding of cultural differences, aiding effective health-care delivery.5,7,11,12 Ongoing evaluation and re-evaluation of service delivery models is required to close the gap in health inequity for Aboriginal and Torres Strait Islander populations.5 We sought to evaluate health-care delivery for Aboriginal and Torres Strait Islander children admitted to an urban tertiary paediatric teaching hospital to determine opportunities for improvement.
Methods All patients presenting to emergency departments or admitted to wards in NSW Health facilities are asked whether they are Aboriginal, Torres Strait Islander or both. We used a list of every admission to Sydney Children’s Hospitals Network (Westmead) between 1 January and 31 December 2010 of children who were recorded on their inpatient identification form as being Aboriginal and/or Torres Strait Islander. We extracted the medical records of all these patients and one author (LA) read them in full, from presentation to discharge, while a second reviewer validated a subset (SR).
Data collection All medical records at our institution are stored electronically with paper notes scanned and included in the electronic record. We reviewed all of these electronic records from the day of admission to the day of discharge, including emergency department notes, progress notes, consultation reports, NSW inpatient identification sheets, request for elective admission notes, growth charts, and medication charts and medical and nursing discharge summaries. We looked for any reference to the patient’s Aboriginal and/or Torres Strait Islander status anywhere in the admission notes as well as any documentation of referral to and consultation with Aboriginal health-care professionals. Our institution had an Aboriginal Health Education Officer and an Aboriginal Manager. Data were collected on characteristics of the child, including age, sex and whether they were local or out of area. Our institution’s outpatient department uses a list of postcodes to
Aboriginal children admitted to hospital
determine ‘local’ children, and we used this same list. We noted characteristics of the admission, including whether it was an emergency or booked admission, whether it was a medical or surgical admission based on the department of the child’s consultant, length of stay in nights, carer on admission (mother, father, foster parent) and whether the mother or father were documented as being Aboriginal and/or Torres Strait Islander. Then we extracted data on the following markers of health-care delivery quality: whether there was documentation of the child’s weight, height and head circumference; immunisation status; catch-up immunisations based on medication chart review; and middle ear examination. We also noted whether the child’s Aboriginal and/or Torres Strait Islander status was included in medical and/or nursing discharge summaries and whether they had visits documented by an Aboriginal staff member or social worker. Correct identification is important to ensure access to Aboriginal staff during the admission, as well as immunisation and Closing the Gap pharmaceutical schemes. We extracted growth parameters from either the progress notes or growth charts and used World Health Organization centiles.
Data analysis and validation Two reviewers (LA and SR) independently evaluated the first 70 admissions and compared extracted data. Any disagreements were resolved through consensus, re-examination of the medical record if needed and final arbitration by a third reviewer (HG). To validate the capture of all Aboriginal and Torres Strait Islander children admitted in this target period, we also interrogated the separate list of children seen by the Aboriginal health education officer in 2010. This list was compared with our list of children in order to determine if any Aboriginal and/or Torres Strait Islander children had been miscoded on the admission records. We also looked at the socio-economic demographics of children admitted using the Australian Bureau of Statistics Censusbased Socio-Economic Indexes for Areas (SEIFA) scores based on the postcode of their stated address. We used Microsoft Office Excel 2007 and SPSS version 19 (SPSS, Inc., Chicago, IL, USA) for statistical analysis. We calculated crude odds ratios (ORs) and 95% confidence intervals (CIs) using chi-squared analysis for comparing dichotomous proportions and Fisher’s exact test when counts were less than 5.
Ethics approval We obtained quality improvement ethics approval (QIE-201012-09) from Sydney Children’s Hospitals Network (Westmead) via the Clinical Governance Unit.
Results Between 1 January and 31 December 2010, there were 543 admissions of 542 children who identified at admission as being Aboriginal and/or Torres Strait Islander (one child admitted twice). Table 1 shows the demographic characteristics of these children and their parents. The mother’s Aboriginal and/or Torres Strait Islander status was recorded in 20 (3.6%)
Journal of Paediatrics and Child Health 51 (2015) 534–540 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
535
Aboriginal children admitted to hospital
L Attwood et al.
Table 1 Characteristics of Aboriginal and Torres Strait Islander children admitted in 2010 Demographic
Gender Male Female Child’s Aboriginal status recorded on admission Aboriginal not Torres Strait Islander Torres Strait Islander not Aboriginal Aboriginal and Torres Strait Islander Neither Aboriginal or Torres Strait Islander Not stated Mother’s Aboriginal status recorded Aboriginal and/or Torres Strait Islander Neither Aboriginal or Torres Strait Islander Not stated Father’s Aboriginal status recorded Aboriginal and/or Torres Strait Islander Neither Aboriginal or Torres Strait Islander Not stated Child’s age (years) 0 to
doi:10.1111/jpc.12756
ORIGINAL ARTICLE
Improving delivery of health care to Aboriginal and Torres Strait Islander children Lucy Attwood,1 Sarah Rodrigues,3 Josephine Winsor,2 Shirley Warren,2 Lyn Biviano2 and Hasantha Gunasekera1,2 1
Sydney Medical Program, 2Sydney Children’s Hospitals Network (Westmead), Sydney, New South Wales, Australia and 3Department of Paediatrics, University College London, London, United Kingdom
Aim: To identify opportunities to improve health-care delivery for urban Aboriginal and Torres Strait Islander children requiring hospital admission and to determine their characteristics. Methods: We analysed all documentation of admissions of Aboriginal and/or Torres Strait Islander children to a tertiary paediatric hospital in 2010. We reviewed the medical records to determine whether the Aboriginal status of patients was known, whether Aboriginal and/or Torres Strait Islander children and their families were reviewed by Aboriginal staff during admission and whether basic health-care quality indicators were met, including documentation of anthropometry, ear examination findings, immunisation status and catch-up immunisation delivery. Results: In 2010, 543 (2%) patients admitted to the institution were identified as Aboriginal and/or Torres Strait Islander: 140/538 (26.0%) were from the first decile (most disadvantaged) on Socio-Economic Indexes for Areas index. Of all admitted children, 148/543 (27.3%) were referred to Aboriginal health professionals during admission, more when length of stay was greater than 7 days (61% vs. 23%, P < 0.001). There was documentation of weight in 533/543 (98.2%), ear examinations in 64/543 (11.8%), immunisations being not up to date in 126/543 (23%), catch-up immunisation given in 7/126 (5.6%), Aboriginal and/or Torres Strait Islander status in 8/543 (1.5%) medical and 1/543 (0.2%) nursing discharge summaries. Conclusions: We have identified several opportunities to improve culturally appropriate health-care delivery for Aboriginal and Torres Strait Islander children admitted to hospital, including improved recognition of Aboriginal and/or Torres Strait Islander status of patients, improved access to Aboriginal health professionals and increased performance and documentation of basic anthropometry, ear examination and immunisation catch-up. Key words:
cultural competency; delivery of health care; immunisation; indigenous; paediatric.
What is already known on this topic
What this paper adds
1 Aboriginal and Torres Strait Islander children demonstrate poor health outcomes compared with the Australian population. 2 The majority of Aboriginal and Torres Strait Islander people live in major cities, inner regional areas and outer regional areas yet the majority of research is focused on remote Aboriginal health. 3 Aboriginal health workers are an important component of effective health-care delivery to Aboriginal patients.
1 Aboriginal and Torres Strait Islander status is poorly documented in medical or nursing notes. 2 There are opportunities to improve health-care delivery for Aboriginal children in an urban health-care setting such as improved catch-up immunisation delivery and ear examinations. 3 Many Aboriginal children are not receiving support from Aboriginal health professionals when admitted to a tertiary paediatric institution.
Despite decades of research demonstrating poor health outcomes in Aboriginal and Torres Strait Islander children,1–3 there are scant data on the quality of the health care actually provided to them. A better understanding of how health care is delivered is an essential first step to improve it. The health of urban Aboriginal and Torres Strait Islander children, in particular, Correspondence: Dr Hasantha Gunasekera, General Medicine, The Children’s Hospital at Westmead, Hawkesbury Road, Westmead, 2145, Sydney, NSW, Australia. Fax: +02 9845 3432; email: hasantha.gunasekera@health .nsw.gov.au Conflict of interest: The authors report no conflicts of interest. Accepted for publication 12 September 2014.
534
needs specific focus. Although only 25% of Australian Aboriginal and Torres Strait Islander people live in remote areas, these regions are over-represented in publications, with only 11% from urban areas.1,4 This population also has a young skew (37% < 15 years).1 Therefore, improved health-care delivery for children in urban settings is essential to improve long-term health outcomes for Australian Aboriginal and Torres Strait Islanders. In 2007, the Australian Medical Association (AMA) called for an assessment of service delivery to Aboriginal and Torres Strait patients to bridge the gap.2 The 2010–2011 Aboriginal and Torres Strait Islander Health Report Card5 called for an increased focus on the type and quality of health care available for Aboriginal people.
Journal of Paediatrics and Child Health 51 (2015) 534–540 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
L Attwood et al.
Improved identification of Aboriginal and Torres Strait Islander status is required to ensure culturally competent health-care delivery.6,7 Aboriginal status is consistently underreported in the health-care setting,7,8 despite documentation being a requirement for all patients presenting to New South Wales (NSW) health facilities.9 The AMA called for the federal government to co-ordinate national improvements in data management to ensure that comprehensive information is recorded and available regarding Aboriginal identification and health.10 Identification of the Aboriginal status of both parents/ carers is crucial in paediatrics. A study of Aboriginal children in an urban setting found that the majority had only one Aboriginal parent and that unless information on the Aboriginal status of both parents were sought, Aboriginality was underestimated.6 Better identification could improve linkage of Aboriginal and Torres Strait Islander patients with Aboriginal health-care services (e.g., Aboriginal health workers). Indigenous health workers, world-wide, have been shown to facilitate progression through the health-care journey, as well as promote understanding of cultural differences, aiding effective health-care delivery.5,7,11,12 Ongoing evaluation and re-evaluation of service delivery models is required to close the gap in health inequity for Aboriginal and Torres Strait Islander populations.5 We sought to evaluate health-care delivery for Aboriginal and Torres Strait Islander children admitted to an urban tertiary paediatric teaching hospital to determine opportunities for improvement.
Methods All patients presenting to emergency departments or admitted to wards in NSW Health facilities are asked whether they are Aboriginal, Torres Strait Islander or both. We used a list of every admission to Sydney Children’s Hospitals Network (Westmead) between 1 January and 31 December 2010 of children who were recorded on their inpatient identification form as being Aboriginal and/or Torres Strait Islander. We extracted the medical records of all these patients and one author (LA) read them in full, from presentation to discharge, while a second reviewer validated a subset (SR).
Data collection All medical records at our institution are stored electronically with paper notes scanned and included in the electronic record. We reviewed all of these electronic records from the day of admission to the day of discharge, including emergency department notes, progress notes, consultation reports, NSW inpatient identification sheets, request for elective admission notes, growth charts, and medication charts and medical and nursing discharge summaries. We looked for any reference to the patient’s Aboriginal and/or Torres Strait Islander status anywhere in the admission notes as well as any documentation of referral to and consultation with Aboriginal health-care professionals. Our institution had an Aboriginal Health Education Officer and an Aboriginal Manager. Data were collected on characteristics of the child, including age, sex and whether they were local or out of area. Our institution’s outpatient department uses a list of postcodes to
Aboriginal children admitted to hospital
determine ‘local’ children, and we used this same list. We noted characteristics of the admission, including whether it was an emergency or booked admission, whether it was a medical or surgical admission based on the department of the child’s consultant, length of stay in nights, carer on admission (mother, father, foster parent) and whether the mother or father were documented as being Aboriginal and/or Torres Strait Islander. Then we extracted data on the following markers of health-care delivery quality: whether there was documentation of the child’s weight, height and head circumference; immunisation status; catch-up immunisations based on medication chart review; and middle ear examination. We also noted whether the child’s Aboriginal and/or Torres Strait Islander status was included in medical and/or nursing discharge summaries and whether they had visits documented by an Aboriginal staff member or social worker. Correct identification is important to ensure access to Aboriginal staff during the admission, as well as immunisation and Closing the Gap pharmaceutical schemes. We extracted growth parameters from either the progress notes or growth charts and used World Health Organization centiles.
Data analysis and validation Two reviewers (LA and SR) independently evaluated the first 70 admissions and compared extracted data. Any disagreements were resolved through consensus, re-examination of the medical record if needed and final arbitration by a third reviewer (HG). To validate the capture of all Aboriginal and Torres Strait Islander children admitted in this target period, we also interrogated the separate list of children seen by the Aboriginal health education officer in 2010. This list was compared with our list of children in order to determine if any Aboriginal and/or Torres Strait Islander children had been miscoded on the admission records. We also looked at the socio-economic demographics of children admitted using the Australian Bureau of Statistics Censusbased Socio-Economic Indexes for Areas (SEIFA) scores based on the postcode of their stated address. We used Microsoft Office Excel 2007 and SPSS version 19 (SPSS, Inc., Chicago, IL, USA) for statistical analysis. We calculated crude odds ratios (ORs) and 95% confidence intervals (CIs) using chi-squared analysis for comparing dichotomous proportions and Fisher’s exact test when counts were less than 5.
Ethics approval We obtained quality improvement ethics approval (QIE-201012-09) from Sydney Children’s Hospitals Network (Westmead) via the Clinical Governance Unit.
Results Between 1 January and 31 December 2010, there were 543 admissions of 542 children who identified at admission as being Aboriginal and/or Torres Strait Islander (one child admitted twice). Table 1 shows the demographic characteristics of these children and their parents. The mother’s Aboriginal and/or Torres Strait Islander status was recorded in 20 (3.6%)
Journal of Paediatrics and Child Health 51 (2015) 534–540 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
535
Aboriginal children admitted to hospital
L Attwood et al.
Table 1 Characteristics of Aboriginal and Torres Strait Islander children admitted in 2010 Demographic
Gender Male Female Child’s Aboriginal status recorded on admission Aboriginal not Torres Strait Islander Torres Strait Islander not Aboriginal Aboriginal and Torres Strait Islander Neither Aboriginal or Torres Strait Islander Not stated Mother’s Aboriginal status recorded Aboriginal and/or Torres Strait Islander Neither Aboriginal or Torres Strait Islander Not stated Father’s Aboriginal status recorded Aboriginal and/or Torres Strait Islander Neither Aboriginal or Torres Strait Islander Not stated Child’s age (years) 0 to
