EQUIP Emergency: study protocol for an organizational intervention to promote equity in health care

Abstract

Background Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities. Methods EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis. Discussion This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs. Trial registration Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

Review article: Implicit bias towards Aboriginal and Torres Strait Islander patients within Australian emergency departments

“…It fails to recognise individual patient characteristics, dynamic interactions and institutional context factors that may lead a clinician to make certain management decisions. The use of clinical vignettes may not accurately reflect the decisions made in the ED where physician fatigue, patient burden, time pressures and lack of clinical information may result in prejudiced patient management 2,11 . Clinical vignettes may also be prone to response bias, where participants provide a more socially desirable response than what they would do in clinical practice 23 .…”

“…Indigenous communities continue to suffer adverse experiences in healthcare, which can be partly attributed to ongoing institutional racism, 5 and reinforced by structural inequities in housing, education, employment and incarceration 5 . Indigenous peoples are less likely to access appropriate care and often receive lower quality care 2,5 . Although there are currently no existing studies looking at implicit bias of healthcare workers towards Indigenous Australians, one very large study found most Australians carry an implicit bias towards Aboriginal and Torres Strait Islander peoples 33 .…”

“…The ED is often the first interaction that marginalised patient groups have with the healthcare system 1 . This includes those with an insecure living situation, poor mental health, substance use issues and racial or ethnic minority groups 2 . In Australia, Aboriginal and Torres Strait Islander people make up 3.3% of the population 3 but are over‐represented in presentations to the ED, accounting for 6.7% of presentations in 2018 4 .…”

“…Additionally, Indigenous Australians have a reduced life expectancy and Australian Indigenous children have twice the mortality rate of non‐Indigenous children 21 . These disparities indicate the ongoing impacts of colonisation and structural racism 2 …”

Experience of emergency department use among persons with a history of adverse childhood experiences

“…Second, we propose that all ED staff, from leadership to physicians to triage nurses to registration and janitorial staff, be supported in training around the principles of TVIC. TVIC has been demonstrated as having an impact on health outcomes in primary care, and work is currently being done to study this in the ED context [16,36]. Enhancing awareness of all team members of the prevalence of ACEs and trauma, as well as the impact that ACEs may have on patients' presentations, mental health, coping mechanisms and interpersonal interactions, can enhance both provider and patient experience by reducing negative encounters.…”