Reference no: EM133505397

A resident of an Aboriginal aged-care facility sought eye care. She was a senior Elder woman who had been blind for some years and needed eye surgery. In 2017 an enrolled nurse, who had been involved in the Fred Hollows program, began the process. First, a referral was arranged with a doctor in the local Aboriginal health service and an appointment made to see a specialist in the major regional town. After six months, an appointment was available and the woman travelled six hours by road with a carer and a driver. When they arrived, they were informed that the referral was out of date and they would need to get a new referral. They returned home and saw the general practitioner (GP) for a second referral, and waited months for their appointment. Finally, they saw the specialist, who said that her eye condition was beyond his ability and referred her to an Adelaide specialist. After much encouragement and support by aged-care staff, the woman flew to Adelaide for assessment with a mulpa (friend/companion) and the aged-care manager, who interpreted for her. It was determined that one eye could be operated on. They returned home to wait for the surgery date. Two surgery dates were made, and then cancelled, by the hospital in late 2018. The woman was very excited, then very upset, both times. No further surgery date was set. In January 2019, after repeated calls to the city and no positive response, a staff nurse rang the local Member of Parliament and explained the situation. By that afternoon, an appointment was made for five weeks' time. A surgery date was set with pre-admission checks in the same week. The patient would not be able to fly after surgery, and so it was decided to take the agedcare bus with a carer and a driver. A second resident, requiring high levels of disability care, also required surgery the same week. The two patients were related, and could provide family support to each other. The two staff and two patients travelled to Adelaide in one day - a trip that took 12 hours. They were all exhausted when they arrived in the city, only to find that the motel was not suitable for their disability needs and they had to arrange alternative accommodation. There were three pre-admission clinic appointments the next day, which took all day with the patient becoming quite upset. The carer was only able to interpret some of the information provided. The aged-care facility, anticipating difficulties, had arranged for an interpreter already known to the patient to join her and the carer at the hospital. This assisted the process, but it was still a long day. At one stage a repeat ECG (electrocardiogram) was ordered because the copy of the ECG sent did not have a legible date. The patient refused to have the ECG, saying, "I am a Christian woman, I've got Jesus in my heart, there is nothing wrong with my heart". In view of her refusal, the hospital rang the aged-care facility and asked if the date was visible on the original. It was and a second copy of the ECG was faxed with the date clearly showing. The next day the patient returned for X-rays and then went back to the motel to rest. Another carer, with whom the patient was more familiar, and who spoke the same language and was more familiar with the hospital, was called to assist the next day with surgery preparation and postoperative care. The carer had just completed a training course in Adelaide and was about to fly home, but cancelled her flight and moved into the motel with the others. Having a carer familiar with the hospital was reassuring for the patient, but when it came time to get ready for surgery things became difficult. The patient did not understand why she should take her underwear off for eye surgery and was unhappy wearing a gown. At one stage, there were four men (orderlies and nurses) around her, trying to lift her onto the trolley. She couldn't see them, but she could hear them and feel them approaching her. The only thing she knew about white men was that they were not to be trusted. She became more agitated and began to yell at them, to keep them away. The carer had never seen her like this before (she had never been so frightened in aged care). The hospital staff were unable to work with her as they saw her as uncooperative and violent and said that they would have to cancel the surgery. The carer intervened and said that if they would just give the two of them time and space the patient would get ready and get herself on the trolley with the carer's assistance. The carer then drew the curtains and spoke quietly to the woman, reassuring her of the importance of the surgery, and that she would not want to return home without her eyesight. The woman was reassured and got changed and onto the trolley slowly and carefully, with only the carer helping. The carer covered the woman and pulled back the curtains and called the hospital staff back in. The carer said that an anaesthetist, who had watched what was happening, came up quietly and asked the carer if everything was all right. They discussed together the need for something more than local anaesthetic. The carer held the woman's murras (hands) while the anaesthetist put a drip in and the procedure went ahead, with the carer promising to meet the woman in recovery (PACU). After six hours, the patient awoke in recovery with bandaged eyes and called for the carer, who came to her bedside immediately. The carer said that the recovery staff asked her if she was all right being with the woman. She said 'yes, of course" and then saw written on the case notes, 'warning-violent patient'. The carer was shocked. The woman was transferred to a ward and the carer stayed with her. She gave the woman her tablets, with hospital staff recording in the case notes that this had occurred. The carer held the woman's hands, and sang and said evening prayers until she fell asleep. The carer then sat in the chair in the room, having promised to stay all night. This Elder woman was a widow and never slept in a room alone, but always with another woman, as was culturally appropriate. At about 0300 hospital staff brought in a fold-out bed for the carer. The next day, the specialist saw the patient prior to discharge. He took off the bandages and said he wanted to see her again in a week. Ignoring the patient's refusal, he asked the nurse to make the appointment. The carer explained that they came from a remote town and it would take two days to drive home. They could not return so soon; the patient would be exhausted. The doctor shrugged and said he wanted to see her in a week. The patient and her carer collected the discharge drugs and met the aged-care van at the door, and began the two-day trip home. The patient enjoyed being able to see the countryside on the long trip home, and when the van arrived she was happy to be able to see the aged-care staff members clearly for the first time. The hospital appointment card arrived the next week. Fortunately, an outreach ophthalmologist clinic, federally funded and organised through the Aboriginal Health Council of South Australia, happened to be visiting the remote town the following week and the local Aboriginal health service arranged an appointment. This involved a two-minute drive and carer support for half an hour, which was a major saving in time, effort and money for all involved. This woman's life was changed with the surgery and she now has vision in one eye (the other was too badly damaged). She is very social and independent, greeting extended family members who come to visit, and is more involved in cultural and aged-care events.

List three gaps you have identified during your analysis of the patient journey, providing rationales to explain your reasoning. Gaps identified should address key priority areas. (Which are the most important for the Aboriginal Elder and his community?) Identify and discuss strategies you could use to address these gaps. Your strategies may address one or more of your identified gaps. Attention should focus on key priority areas for Aboriginal and Torres Strait Islander peoples. (These relate to the Action items identified in: Australian Commission on Safety and Quality in Health Care [2017]. NSQHS Standards User Guide for Aboriginal and Torres Strait Islander Health) You will need to use current, relevant, reliable and credible sources to support your discussion here.