First Nations patients were less likely to be prioritized for the most urgent treatment than others with the same ultimate diagnosis at emergency departments in Alberta, according to a study published today in the Canadian Medical Association Journal.
“We were surprised to see differences for things like long bone fractures, which seem pretty obvious. You would expect that if someone's got a broken forearm or broken femur, that would result in the same kinds of triage,” said lead investigator Patrick McLane, adjunct associate professor in the University of Alberta’s Faculty of Medicine & Dentistry and assistant scientific director of Alberta Health Services’ Emergency Strategic Clinical Network.
The researchers looked at records for more than 11 million emergency department visits in Alberta from 2012 to 2017 to determine the correlation between First Nations status and triage scores, the priority rating (on a scale of one to five) that is given to each patient based on their symptoms and a brief medical history. They focused on five disease categories (trauma and injury, infection, mental health, obstetrics and gynecology, substance use) and five specific diagnoses (long bone fracture, acute upper respiratory infection, anxiety disorder, spontaneous abortion, and opioid-related substance use), chosen in consultation with an advisory panel of Elders.
Patients with First Nations status had lower odds of receiving an acute triage score compared with non-First Nations patients, they found, with lower odds of being rated as needing the most urgent care for all five disease categories and for three of the five diagnoses.
The findings are consistent with those of other studies on triage and ethnicity, which have shown that patients belonging to non-white racial groups receive lower acute triage scores than white patients.
“Systemic racism, stereotyping and differential access to health-care resources (especially primary care), as well as factors such as communication and level of patient trust in the health-care system, may all contribute to differences in triage scores between First Nations and non-First Nations patients,” the authors noted in the study.
The research was carried out by a partnership between the U of A and the Alberta First Nations Information Governance Centre, which promotes appropriate use of data about First Nations peoples. It was funded by the Canadian Institutes of Health Research and supported by Alberta Health Services.
The study's co-authors include Lea Bill, who is a registered nurse, Indigenous Knowledge Holder and executive director of the Alberta First Nations Information Governance Centre, and Bonnie Healy from the Kainai Nation (Blood Tribe) in southern Alberta, who is health director with the Blackfoot Confederacy. Eunice Louis with Maskwacis Health Services, Anne Bird with the Yellowhead Tribal Council and Kris Janvier with Treaty 8 First Nations of Alberta are also co-authors. Statistical analysis was led by Rhonda Rosychuk through her Biostatistics Consulting Group at the U of A.
Physical and mental health impacts
The research team began its work in 2016 and has published other studies, including qualitative data on what it’s like to go to emergency as a First Nations person and a report showing that, due to a lack of primary care on reserves, First Nations people visit emergency three times as often as non-First Nations Albertans. First Nations people end up leaving without completing treatment nearly twice as often.
Waiting longer for treatment, or not getting treatment at all, can have serious health consequences, McLane said.
“First Nations people see that they're being made to wait longer, that they're not being taken seriously, that something other than health status is driving their treatment — and that can have really negative mental health consequences as well.”
Improved training, partnerships with First Nations could help
The research team is now working on a new report on what physicians and nurses in emergency departments have to say about the care they deliver for First Nations patients, with a focus on best practices.
McLane said he would like to see emergency department-specific anti-racism training for staff and quality improvement partnerships established between individual First Nations and the emergency departments that serve them.
“We know that working in emergency departments is a difficult job, especially during the pandemic, so we need to support health-care providers to give the high-quality care for everyone that they aspire to give,” McLane said. “It really is about helping the health system improve by supporting physicians and nurses to provide culturally safe care.”
In the meantime, McLane stressed that he doesn’t want to discourage anyone from visiting the emergency room when they need it.
“Emergency departments are unique in the health system in that the doors are always open to everyone,” he said. “Things are going to get better, and I hope this research is part of driving that.”
