Health Advocacy in Emergency Medicine

Quick Answer

One-liner: Health advocacy in emergency medicine is the systematic identification and mitigation of barriers to optimal patient care through individual, institutional, and systemic action.

Health advocacy is a core competency of emergency physicians requiring proactive identification of social determinants of health, cultural safety needs, and system-level barriers. Effective advocacy operates at three levels: individual (patient-specific interventions), institutional (hospital policy and resource allocation), and systemic (population health policy and legislation). Emergency physicians must balance immediate patient care with longer-term advocacy to improve health equity, particularly for vulnerable populations including Aboriginal and Torres Strait Islander peoples, Māori, rural/remote communities, socioeconomically disadvantaged individuals, and those with mental health or substance use disorders.

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ACEM Exam Focus

Primary Exam Relevance

• Health Law: Duty of care, professional obligations
• Public Health: Social determinants, health equity principles
• Medical Ethics: Justice, beneficence, non-maleficence

Fellowship Exam Relevance

• Written: SAQs on advocacy frameworks, barriers, and strategies
• OSCE: Communication stations advocating for patients, challenging system barriers
• Key domains tested: Health Advocate, Professional, Communicator

High-Yield Written Exam Points:

• Three levels of advocacy (individual, institutional, systemic)
• Social determinants of health in emergency presentations
• Indigenous health disparities and cultural safety
• Speaking up culture and patient safety
• ACEM advocacy positions and policy work

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Key Points

The 5 things you MUST know:

1. Three advocacy levels: Individual (patient-specific), Institutional (hospital policy), Systemic (population health/policy)
2. Social determinants account for 30-40% of health outcomes - screening in ED identifies actionable barriers [1]
3. Indigenous health gap: Aboriginal and Torres Strait Islander peoples experience 2-3× higher mortality across most conditions [2]
4. Speaking up saves lives: 60-80% of sentinel events have identifiable warning signs unreported [3]
5. ACEM advocacy framework: Evidence-based policy positions on access, equity, and system reform [4]

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Epidemiology

Health Equity Indicators in Emergency Medicine

Australian/NZ Specific

• Aboriginal and Torres Strait Islander peoples: 2.3× higher ED presentation rate, 1.8× higher admission rate [6]
• Māori: 1.6× higher ED utilization, 2.1× higher mental health presentations [10]
• Rural/remote: 1.4-2.3× higher ED utilization per capita, longer wait times for specialist care [11]
• Socioeconomic gradient: Lowest quintile has 1.9× higher ED presentation rate, 2.4× higher preventable admissions [5]

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Pathophysiology

Social Determinants of Health Framework

Health outcomes are determined by:

Individual Behaviours (30%)
    ↓
Social and Community Networks (10%)
    ↓
Socioeconomic Conditions (40%) ← KEY TARGET FOR ADVOCACY
    ↓
Cultural and Environmental Factors (20%)

Why Advocacy Matters Clinically

• Barriers to care: Transport, cost, language, health literacy, cultural safety
• Unmet social needs: Housing instability, food insecurity, domestic violence, substance use
• System-level inequities: Distribution of services, resource allocation, policy gaps
• Healthcare system barriers: Wait times, access to specialists, insurance coverage

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Clinical Approach

Recognition of Advocacy Needs

Trigger situations requiring advocacy:

• Frequent ED presenters with social determinants
• Discharge barriers due to housing, transport, or social support
• Language barriers or cultural safety concerns
• Insurance/medicare issues affecting care
• System delays or resource constraints causing harm
• Vulnerable populations (elderly, children, mental health, disability)

Initial Assessment

Social Determinants Screening

Cultural Safety Assessment

• Language preference and interpreter need
• Cultural health beliefs and practices
• Trust in healthcare system
• Previous discrimination experiences
• Family/community decision-making preferences

Advocacy Framework Application

Level 1: Individual Advocacy

• Direct patient advocacy during ED encounter
• Navigation assistance for referrals, appointments, medications
• Social work referral
• Patient education at appropriate health literacy level
• Cultural liaison engagement

Level 2: Institutional Advocacy

• Hospital policy development
• Resource allocation advocacy (e.g., interpreter services, social work)
• Quality improvement initiatives
• Debriefing and clinical review of system failures
• Staff education on advocacy and cultural safety

Level 3: Systemic Advocacy

• Policy advocacy at regional/national level
• Media engagement on health equity issues
• Professional body advocacy (ACEM positions)
• Research and publication on health inequities
• Community partnerships and public health initiatives

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Management

Immediate Management (Individual Advocacy)

1. Identify barrier → 2. Assess impact → 3. Determine advocacy level → 4. Take action → 5. Document

Common Barriers and Interventions

Institutional Advocacy Strategies

Quality Improvement

• Root cause analysis of system failures
• Clinical pathway development addressing equity
• Discharge planning optimization
• Interpreter service access improvement
• Social work integration in ED workflow

Resource Advocacy

• Justify staffing needs with data
• Advocate for interpreter services funding
• Support for social worker positions
• Telehealth infrastructure for remote communities
• Cultural liaison staff positions

Systemic Advocacy Approaches

Policy Development

• ACEM position statements
• Government submissions on health reform
• Media commentary on ED access issues
• Parliamentary inquiries and consultations
• Research publication on inequities

Community Engagement

• Public health education campaigns
• Partnerships with community organizations
• Advocacy for vulnerable populations
• Support for preventive health initiatives
• Emergency department outreach programs

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Disposition

Advocacy in Disposition Planning

Admission Advocacy

• Advocate for admission when discharge unsafe due to social determinants
• Ensure cultural safety in ward placement
• Request specialist review when barriers exist
• Facilitate interhospital transfer for needed services

Discharge Advocacy

• Ensure safe discharge plan addresses social needs
• Provide transport and follow-up arrangements
• Supply medications and equipment
• Arrange community health support
• Document barriers and advocacy actions

Follow-up

• Social worker follow-up for complex cases
• GP communication about social barriers
• Referral to community services (housing, financial, support)
• Cultural health service engagement
• Case conference for complex patients

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Special Populations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations:

Health Disparities (2-3× across most conditions) [2]:

• Life expectancy: 8-10 years less than non-Indigenous Australians
• Chronic disease prevalence: 2-3× higher diabetes, CVD, renal disease
• ED presentation rates: 1.8× higher, higher acuity presentations
• Preventable hospitalizations: 2.4× higher

Cultural Safety Requirements:

• Recognize impact of intergenerational trauma and colonization
• Use Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs)
• Respect family/community decision-making structures
• Understand "Sorry Business" (cultural protocols around death)
• Avoid assumptions about traditional medicine vs western medicine
• Consider gender-specific health services (men's/women's business)

Communication Considerations:

• Use plain language, avoid medical jargon
• Allow storytelling and indirect communication
• Extended time for family discussions
• Eye contact and physical touch preferences vary
• Interpreter services for language needs

Systemic Advocacy Priorities:

• Closing the Gap initiatives
• Cultural safety training for all ED staff
• AHW/ALO employment in EDs
• Culturally appropriate clinical pathways
• Access to specialist services for remote communities
• Addressing racism and discrimination in healthcare

Key Resources:

• National Aboriginal and Torres Strait Islander Health Plan
• Australian Indigenous Doctors' Association (AIDA)
• Aboriginal Medical Services Alliance Northern Territory (AMSANT)
• State Aboriginal health policies

Māori Health

Māori Health Considerations (Aotearoa New Zealand):

Health Disparities [10]:

• Life expectancy: 7-8 years less than non-Māori
• Chronic disease: 2-3× higher diabetes, CVD, respiratory disease
• ED utilization: 1.6× higher, higher acuity, longer stays
• Mental health: 2.1× higher ED presentations for self-harm

Tikanga and Cultural Safety:

• Whānau (family) involvement in all aspects of care
• Manaakitanga (hospitality, care, respect) in interactions
• Tapu (sacred) considerations around body parts and medical procedures
• Concept of wairua (spirituality) in health and illness
• Use of Māori Health Workers and cultural advisors
• Respect for kaumātua (elders) and whakapapa (genealogy)

Te Whare Tapa Whā (Māori Health Model):

• Taha tinana (physical health)
• Taha hinengaro (mental health)
• Taha whānau (family health)
• Taha wairua (spiritual health)
• Whenua (land/ connection to environment)

Systemic Advocacy Priorities:

• Te Tiriti o Waitangi obligations in healthcare
• Māori health workforce development
• Culturally safe ED environments
• Access to kaupapa Māori health services
• Reducing institutional racism in healthcare
• Addressing social determinants (housing, poverty, education)

Key Resources:

• Ministry of Health Māori Health Directorate
• Te Aka Māori Dictionary (for correct terminology)
• Māori Health Providers and organizations
• He Korowai Oranga (Māori Health Strategy)

Rural and Remote Communities

Rural and Remote Emergency Medicine Advocacy:

Access Challenges [11]:

• RFDS retrieval: 1800 625 800 (24/7 emergency retrieval)
• 30-40% longer travel times to tertiary care
• Limited specialist access (telemedicine)
• Workforce shortages (higher doctor turnover)
• Fewer diagnostic resources (no CT/MRI in many sites)

Health Disparities:

• 1.4-2.3× higher ED utilization per capita
• Higher rates of preventable hospitalizations
• Worse outcomes for time-sensitive conditions (stroke, trauma, sepsis)
• Higher mortality from injury and poisoning
• Limited access to follow-up care and specialist services

Resource Limitations:

• Limited diagnostic imaging (ultrasound only, no CT/MRI)
• No on-site specialists (generalist physicians)
• Limited ICU capabilities
• Medication stock limitations
• Fewer allied health professionals

Advocacy Strategies:

• Telemedicine integration with tertiary centers
• RFDS advocacy for timely retrieval
• Equipment and resource allocation advocacy
• Generalist training and support
• Emergency retrieval service optimization
• Indigenous health service partnerships

Key Resources:

• RFDS (Royal Flying Doctor Service): 1800 625 800
• Rural Doctors Association of Australia (RDAA)
• Australian College of Rural and Remote Medicine (ACRRM)
• State rural health policies
• CRANAplus (rural and remote health organization)

Socioeconomic Disadvantage

Socioeconomic Disadvantage in ED:

Key Issues [5]:

• Lowest SES quintile: 1.9× higher ED presentation rate
• Medication non-adherence due to cost (up to 25%)
• Transport barriers to follow-up care
• Housing instability and homelessness
• Food insecurity and malnutrition
• Health literacy challenges

Advocacy Interventions:

• Supply discharge medications in ED
• Arrange transport and appointment scheduling
• Provide interpreter services
• Financial assistance navigation (Medicare, social security)
• Social work referral for housing and income support
• Health literacy-appropriate discharge education

Systemic Advocacy:

• Pharmaceutical Benefits Scheme (PBS) advocacy
• Public hospital funding advocacy
• Social housing and support services
• Community health center development
• Preventive health program funding

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Pitfalls & Pearls

Clinical Pearls for Health Advocacy:

• Screen for social determinants systematically: Use validated tools (e.g., Accountable Health Communities screening tool) [12]
• Always use professional interpreters: Family interpreters violate confidentiality and may misinterpret medical information
• Document advocacy actions: Clear documentation supports continuity of care and demonstrates advocacy impact
• Build relationships with community services: Direct contact improves referral success and patient outcomes
• Start with individual advocacy: Personal patient advocacy builds skills for institutional and systemic work
• Use data to drive advocacy: Collect local data to support institutional and systemic change proposals
• Involve patients in advocacy: Patients are powerful advocates for their own care and system reform

Pitfalls to Avoid:

• Cultural stereotyping: Assuming all patients from a cultural group have the same beliefs or needs
• Family as interpreters: Using family members as interpreters violates confidentiality and risks medical errors
• Blaming patients: Framing social needs as "non-compliance" rather than system failures
• One-off advocacy actions: Without addressing underlying system causes, problems recur
• Advocating without evidence: Policy and systemic advocacy needs data and evidence to be effective
• Ignoring institutional constraints: Realistic advocacy works within existing systems and resources
• Burnout from emotional advocacy: Balance individual patient advocacy with systemic solutions for sustainability

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Viva Practice

Scenario 1: Individual Advocacy for Homeless Patient Stem: A 45-year-old homeless man presents with cellulitis of his right lower leg. He was discharged yesterday from another hospital with oral antibiotics but has not taken them because he has no food and the medication causes nausea when taken on an empty stomach. He has no GP and no regular income.

Opening Question: How would you approach this patient's care considering the social determinants affecting his health?

Model Answer: This case highlights the critical intersection of clinical care and social determinants of health. My approach would be:

1. Clinical assessment: Treat the cellulitis appropriately - assess severity, consider IV antibiotics given oral treatment failure

2. Social determinants screening: Systematically assess:

   • Housing: Currently homeless, sleeping rough or in shelter?
   • Nutrition: Food insecurity, meal access
   • Income: Social security benefits, eligibility for support
   • Support: Family, social services involvement
   • Health literacy: Understanding of condition and treatment

3. Immediate advocacy interventions:

   • Admit for IV antibiotics given oral treatment failure and inability to take oral medications
   • Arrange discharge medications from hospital (eliminate cost/access barrier)
   • Social work urgent referral for housing assessment
   • Arrange nutrition support during admission
   • Consider discharge to hostel or supported accommodation rather than back to street

4. Documentation: Clearly document all social barriers identified and advocacy actions taken

5. System-level consideration: This is the 6th ED presentation this month for similar issues - indicates system failure. Consider institutional advocacy for homeless health pathway development

Follow-up Questions:

1. What specific questions would you ask to assess his social needs?

   • Answer: I would use a systematic approach:
     • Housing: "Where did you sleep last night?" "Do you have stable accommodation?"
     • Food: "When was the last time you ate?" "Do you have regular access to meals?"
     • Income: "Are you receiving any benefits or support payments?" "Do you have any income?"
     • Support: "Is there anyone who helps you or checks on you?" "Do you have case manager or support worker?"
     • Health: "Do you have a regular doctor or healthcare provider?" "Are you taking any regular medications?"

2. The social worker says there are no available beds in homeless shelters. What would you advocate for?

   • Answer: I would advocate at multiple levels:
     • Individual: Extended observation unit stay while social worker advocates for emergency accommodation
     • Institutional: Speak with hospital administration about emergency discharge accommodation options
     • Systemic: Contact local homelessness services directly to advocate for priority placement given medical needs
     • Documentation: Clearly document that safe discharge is impossible due to lack of accommodation

3. How would you approach discharge planning to prevent early readmission?

   • Answer:
     • Ensure infection improved before discharge (clinical stability)
     • Supply full course of antibiotics from hospital pharmacy
     • Arrange transport to accommodation
     • Provide written instructions at appropriate health literacy level
     • Ensure follow-up appointment scheduled and transport arranged
     • Social work referral for ongoing case management
     • Contact GP or primary health service to arrange continuity of care
     • Consider OPAL (Outpatient Parenteral Antibiotic Therapy) if available for continued IV antibiotics

Discussion Points:

• Homelessness is associated with 3-6× higher ED utilization [13]
• 25-30% of homeless presentations are potentially preventable with primary care access
• Mortality for homeless individuals is 3-4× higher than general population
• Advocacy must balance immediate clinical care with longer-term system solutions

Scenario 2: Indigenous Health and Cultural Safety Advocacy Stem: A 62-year-old Aboriginal woman presents with chest pain. She has a history of diabetes and hypertension. She is accompanied by several family members who want to be involved in all discussions. She initially refused to call an ambulance when the pain started due to previous bad experiences in hospital.

Opening Question: What are the key considerations in managing this patient from a health advocacy perspective?

Model Answer: This case highlights critical cultural safety and advocacy issues for Aboriginal patients:

1. Immediate clinical care: Standard ACS workup - ECG, troponin, chest pain protocol. Do not delay clinical care for cultural considerations, but integrate them

2. Cultural safety assessment:

   • Acknowledge family presence as strength, not barrier
   • Understand previous bad experiences in hospital (discrimination, cultural insensitivity)
   • Ask about cultural preferences for communication and decision-making
   • Identify if Aboriginal Health Worker or ALO available

3. Immediate advocacy actions:

   • Welcome family and involve them in discussions (with patient permission)
   • Request Aboriginal Health Worker/ALO support if available
   • Explain procedures and tests in plain language
   • Acknowledge and address previous negative experiences
   • Ensure all staff treat patient with respect and cultural sensitivity

4. System-level advocacy:

   • This patient's delayed presentation due to distrust is predictable and preventable
   • Advocate for cultural safety training for ED staff
   • Ensure AHW/ALO availability in ED (if not present)
   • Develop culturally safe cardiac pathways for Aboriginal patients

Follow-up Questions:

1. The family insists on speaking with the doctor together rather than the nurse. How do you respond?

   • Answer: I would:
     • Respect the family's request for direct doctor communication
     • Speak with family together, not separately
     • Allow family members to support patient and contribute to history
     • Use plain language, avoid medical jargon
     • Allocate adequate time for discussion
     • Be prepared for storytelling approach rather than direct questioning
     • Check understanding by asking them to explain back

2. The patient is admitted for NSTEMI. What advocacy considerations apply for her ward stay?

   • Answer:
     • Advocate for culturally safe ward placement if possible (Aboriginal-specific ward or female-only ward)
     • Ensure AHW/ALO continues to be involved in care
     • Facilitate family visiting (more flexible visiting policies may apply)
     • Ensure discharge planning includes family and community supports
     • Consider cultural needs around food, privacy, and spiritual practices
     • Document cultural safety considerations for continuity

3. How would you address her fear of hospitals and prevent delayed presentation in future?

   • Answer:
     • Acknowledge her previous experiences and apologize for past discrimination
     • Explain current hospital's commitment to cultural safety
     • Provide information about Aboriginal Liaison Services
     • Ensure positive experiences during this admission (staff education, cultural respect)
     • Discharge with clear plan and cultural support services referral
     • Arrange cardiac rehabilitation that is culturally appropriate
     • Consider Aboriginal Medical Service involvement for follow-up

Discussion Points:

• Aboriginal patients have 2-3× higher cardiovascular mortality [2]
• Median time to presentation for ACS is 2-3× longer for Aboriginal patients
• 30-40% of Aboriginal patients report discrimination in healthcare settings
• Family involvement is a cultural strength that improves outcomes when supported
• AHW/ALO involvement reduces length of stay and readmission rates

Scenario 3: Systemic Advocacy - ED Overcrowding and Access Block Stem: Your ED has experienced 30% increase in presentations over the past year. Access block (patients waiting greater than 8 hours for admission) is now 25% of admissions. Today, an 80-year-old with pneumonia has been in ED for 36 hours waiting for a ward bed. Her condition is deteriorating but no beds are available.

Opening Question: As the FACEM on shift, how would you advocate for this patient and address the systemic issues?

Model Answer: This scenario requires advocacy at multiple levels:

1. Immediate patient advocacy:

   • Escalate patient's deteriorating condition to hospital administration
   • Request emergency bed creation (ward, discharge lounge, or ward overflow)
   • Consider ICU/HDU admission if clinically indicated for higher level of care
   • Ensure nursing care and monitoring appropriate for deteriorating patient
   • Document clinical status, delays, and advocacy actions clearly

2. Institutional advocacy:

   • Raise at daily hospital executive meeting
   • Request bed management review and optimization
   • Advocate for ED-in-charge bed management authority
   • Propose short-term solutions (ward overflow beds, discharge lounge)
   • Request data on access block trends and outcomes

3. Systemic advocacy:

   • Collect and present data on access block impact (patient harm, length of stay)
   • Prepare submission to regional health department for additional resources
   • Consider media advocacy (with hospital approval) if patient safety at risk
   • Work with ACEM on broader advocacy for access block solutions
   • Collaborate with other FACEMs for coordinated advocacy

Follow-up Questions:

1. The hospital administration says "that's just how it is" and nothing can be done. How do you respond?

   • Answer:
     • Present data on patient harm from access block (mortality, morbidity studies)
     • Cite ACEM position statements on access block and patient safety
     • Request formal risk assessment of current conditions
     • Propose specific, cost-effective solutions (not just problems)
     • If no response, escalate to regional health department with clinical safety concerns
     • Document all advocacy efforts and lack of response

2. You're asked to present a business case for additional resources. What data would you include?

   • Answer:
     • Current access block rates (25%) and trends (30% increase in presentations)
     • Length of stay data compared to benchmarks
     • Deterioration incidents and adverse events linked to access block
     • Staffing costs (overtime, agency staff) due to inefficiencies
     • Patient satisfaction scores related to wait times
     • Peer comparison data with similar hospitals
     • Cost-benefit analysis of additional beds vs current costs (adverse events, inefficiency)
     • ACEM recommendations on ED staffing and bed ratios

3. How would you use ACEM's advocacy framework to support your case?

   • Answer:
     • Cite ACEM position statements on access block and ED overcrowding
     • Reference ACEM standards for ED design and capacity
     • Use ACEM data on national access block trends
     • Request ACEM support for regional advocacy
     • Participate in ACEM advocacy campaigns on ED funding
     • Consider presenting case study at ACEM scientific meeting
     • Collaborate with ACEM policy department for broader advocacy

Discussion Points:

• Access block is associated with 30-40% higher mortality for admitted patients [14]
• ED overcrowding increases length of stay, adverse events, and ambulance diversion
• Cost of access block (overtime, agency staff, adverse events) often exceeds cost of additional beds
• Effective advocacy requires data, persistence, and multi-level approach
• ACEM provides resources and support for FACEM advocacy on system issues
• Media advocacy can be powerful but must be coordinated and evidence-based

Scenario 4: Speaking Up - Patient Safety Culture Stem: You notice a colleague repeatedly fails to perform time-out checks before procedures. When you raise concerns privately, they dismiss it saying "I've never had a problem." Yesterday, you saw them almost perform a procedure on the wrong patient but caught it before harm occurred.

Opening Question: What are your professional obligations and how would you advocate for patient safety in this situation?

Model Answer: This scenario involves critical patient safety advocacy obligations:

1. Immediate actions:

   • No harm occurred in yesterday's incident, but it was a near-miss
   • Document the near-miss in incident reporting system
   • Discuss with colleague again (debrief) emphasizing patient safety
   • Monitor colleague's practice for further incidents

2. Professional obligations:

   • Duty to speak up when patient safety at risk (AHPRA Code of Conduct)
   • Obligation to report near-misses and adverse events
   • Professional responsibility to address colleague impairment or incompetence
   • Advocacy for patient safety over collegial relationships

3. Advocacy escalation pathway:

   • Level 1: Direct conversation with colleague (already attempted, ineffective)
   • Level 2: Discuss with ED Director or Clinical Director (escalation required)
   • Level 3: Report to hospital patient safety committee / clinical governance
   • Level 4: If ongoing risk, report to AHPRA (professional regulator)
   • Throughout: Document all actions and concerns

Follow-up Questions:

1. The ED Director says "we don't want to create trouble, it's a senior doctor." How do you respond?

   • Answer:
     • Emphasize patient safety is paramount, overrides seniority or collegiality
     • Present evidence: 60-80% of sentinel events have prior unreported warning signs [3]
     • Cite professional obligations (AHPRA Code of Conduct, ACEM Code of Professional Practice)
     • Note that failing to act is itself a professional lapse
     • Request formal risk assessment and performance monitoring
     • If no action, consider reporting to hospital governance or AHPRA (with legal advice)
     • Document all advocacy efforts and responses

2. What evidence would you use to support your advocacy for improved time-out compliance?

   • Answer:
     • WHO Surgical Safety Checklist evidence (mortality reduction, complication reduction) [15]
     • Wrong-site surgery statistics (still occurs despite checklists)
     • Australian Commission on Safety and Quality in Healthcare standards
     • Hospital's own near-miss and adverse event data
     • Literature on speaking up culture and patient safety
     • ACEM patient safety standards and guidelines

3. How would you advocate for a stronger speaking up culture in the ED?

   • Answer:
     • Model speaking up behavior (demonstrate it's safe and expected)
     • Praise colleagues who speak up about safety concerns
     • Advocate for formal debriefing after near-misses and adverse events
     • Request training on just culture and speaking up
     • Support establishment of safety huddles and safety walkrounds
     • Advocate for psychological safety in team culture
     • Contribute to hospital patient safety committee
     • Publish or present on safety culture improvement

Discussion Points:

• Speaking up prevents 50-70% of adverse events when warnings are heeded [3]
• Hierarchical culture is a major barrier to speaking up in healthcare
• "Just culture" balances individual accountability with system learning
• Whistleblower protections exist but require careful navigation
• Professional obligation to speak up overrides collegial loyalty
• 60-80% of healthcare professionals have observed errors they did not report
• Effective speaking up requires training, psychological safety, and leadership support

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OSCE Scenarios

Station 1: Health Advocacy - Individual Patient Level

Format: Communication / Clinical Reasoning Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the FACEM in a metropolitan ED. A 28-year-old woman presents with abdominal pain. She has no Medicare card (recently arrived from overseas on student visa), has no GP, and is concerned about the cost of investigations. She is considering leaving the ED without treatment.

Examiner Instructions: The candidate should demonstrate:

• Systematic assessment of clinical and social needs
• Individual-level advocacy to address cost barriers
• Knowledge of Medicare and health system for overseas visitors
• Effective communication and patient education
• Discharge planning addressing social determinants

Actor/Patient Brief: You are a 28-year-old international student from India. You have had intermittent abdominal pain for 2 weeks, worse today. You have no Medicare because you just arrived on a student visa 3 months ago. You are worried ED investigations will be very expensive and you can't afford them. You have no GP and don't know how to find one. You are considering leaving the ED because you're scared of the cost.

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• Key discriminators:
  • "Pass: Assesses both clinical and social needs, understands Medicare rules, ensures patient receives necessary care regardless of cost"
  • "Fail: Dismisses financial concerns, sends patient away without care, doesn't assess social determinants, provides incorrect information about Medicare"

Model Answer:

Assessment:

• Clinical: Full abdominal pain assessment (history, examination, differential diagnosis)
• Social: Insurance status, financial concerns, GP access, support network

Advocacy Actions:

• Explain that urgent care in ED will not be denied for inability to pay
• Clarify Medicare eligibility (may be eligible after waiting period, or reciprocal agreements)
• Discuss public hospital billing (may be bulk-billed for urgent care)
• Consider necessary investigations for abdominal pain (may be critical to rule out surgical emergency)
• If discharged, supply medications from hospital to reduce cost
• Provide list of bulk-billing GPs in area

Discharge:

• Ensure clinical stability before discharge
• Provide discharge summary and medication
• Register patient with local medical practice (provide resources)
• Explain when to return to ED (red flags)
• Social work referral if ongoing financial hardship

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Station 2: Indigenous Health Advocacy

Format: Communication / Cultural Competence Time: 11 minutes Setting: ED relatives room

Candidate Instructions:

You are the FACEM. An Aboriginal teenager (16 years old) presented with intentional overdose. He is medically stable but requires mental health assessment. The family is concerned about hospital cultural safety and wants to take him home. They report previous bad experiences in the hospital system.

Examiner Instructions: The candidate should demonstrate:

• Cultural safety and understanding of Indigenous health issues
• Family and community engagement
• Advocacy for appropriate mental health care
• Knowledge of mental health legislation and rights
• Collaboration with Aboriginal Health Workers

Actor/Family Brief: You are the auntie of a 16-year-old Aboriginal boy who took some pills. He's okay now medically. You want to take him home to care for him there. You don't trust the hospital staff - last time your nephew was here, the nurses were rude and didn't understand your family. You want to take him to your community's Aboriginal Health Service instead.

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• Key discriminators:
  • "Pass: Engages family respectfully, involves Aboriginal Health Worker, balances clinical safety with cultural safety, finds culturally appropriate solution"
  • "Fail: Dismisses family concerns, threatens mental health act without justification, doesn't involve Aboriginal Health Worker, lacks cultural humility"

Model Answer:

Approach:

• Welcome family and acknowledge their concerns about previous bad experiences
• Apologize for previous experiences and commit to culturally safe care
• Respect family as important support and decision-makers

Clinical Assessment:

• Assess suicide risk (current intent, means, plan, history)
• Evaluate mental state and need for involuntary treatment under Mental Health Act
• Determine if medical stability for discharge

Cultural Safety:

• Request Aboriginal Health Worker or ALO involvement immediately
• Ask about cultural preferences for care and communication
• Respect family's wish for Aboriginal Health Service involvement

Advocacy:

• If low suicide risk and medically stable: Advocate for discharge to Aboriginal Health Service with clear safety plan
• If high suicide risk: Advocate for admission with cultural safety measures (AHW involvement, family visiting, culturally appropriate care)
• Document cultural safety considerations and advocacy actions
• Ensure follow-up with Aboriginal Medical Service

Communication:

• Use plain language, avoid medical jargon
• Allow family time to discuss and ask questions
• Check understanding and agreement with plan

Station 3: Systemic Advocacy - Resource Allocation

Format: Management / Professional Practice Time: 11 minutes Setting: Hospital executive meeting

Candidate Instructions:

You are the FACEM Director presenting to the Hospital Executive. Your ED has no 24-hour interpreter service. Tonight, a patient with limited English suffered a delay in diagnosis and treatment due to communication barriers, resulting in an adverse event. You are advocating for 24-hour interpreter services.

Examiner Instructions: The candidate should demonstrate:

• Effective use of data and evidence to support advocacy
• Understanding of cost-benefit analysis
• Professional communication with executive
• Knowledge of patient safety and legal requirements
• Systemic advocacy skills

Examiner Role: You are the Hospital CEO. You are concerned about budget constraints and need to justify the cost of 24-hour interpreter services. Ask about the adverse event, costs, evidence of benefit, and alternatives.

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• Key discriminators:
  • "Pass: Uses data and evidence effectively, presents clear cost-benefit analysis, understands legal requirements, communicates professionally"
  • "Fail: Relies on anecdote rather than data, unclear on costs, unaware of legal requirements, defensive when questioned"

Model Answer:

Opening Statement: "Tonight's adverse event highlights critical patient safety risks from language barriers. I'm advocating for 24-hour interpreter services based on patient safety, legal requirements, and cost-effectiveness."

Evidence:

• "Our ED serves 25% patients with limited English proficiency (LEP)"
• "Tonight's adverse event is consistent with literature: LEP patients have 2-3× higher risk of adverse events [16]"
• "Diagnostic errors are 2× higher in LEP patients without professional interpreters [17]"
• "Length of stay is 1.5× longer for LEP patients with communication barriers [18]"

Cost Analysis:

• "Cost of tonight's adverse event: $15,000 (additional treatment, extended stay, potential claim)"
• "Annual cost of LEP adverse events in our ED: estimated $250,000 based on published rates"
• "24-hour interpreter service cost: $120,000 annually"
• "Net saving: $130,000 annually, plus improved patient safety"

Legal Requirements:

• "Anti-Discrimination Act requires effective communication for healthcare"
• "Australian Charter of Healthcare Rights includes right to communication"
• "ACHS Standards require interpreter services where needed"
• "Failure to provide interpreters may constitute negligence"

Professional Standards:

• "ACEM Policy: Professional interpreters required for patients with LEP"
• "AHMAC language services policy for public hospitals"
• "Best practice: Family interpreters violate confidentiality and increase error risk"

Alternatives Considered:

• "Video interpreter services: faster deployment, lower cost, less cultural nuance"
• "Phone interpreters: available now, but less effective for complex discussions"
• "Bilingual staff: limited languages, not trained as interpreters"

Closing: "24-hour interpreter services improve patient safety, reduce adverse events, comply with legal requirements, and are cost-effective. The cost of inaction is higher in both financial and human terms."

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SAQ Practice

Question 1 (8 marks)

Stem: A 55-year-old man with schizophrenia presents to ED after being found unconscious by police. He is homeless and has not taken his antipsychotic medication for 2 weeks. He has no Medicare card and no regular doctor. He is medically stable but requires psychiatric assessment and housing support.

Question: Outline the health advocacy strategies you would employ for this patient at individual, institutional, and systemic levels.

Model Answer:

• Individual advocacy (3 marks):

  • Immediate clinical care and stabilization
  • Social work urgent referral for housing assessment
  • Arrange psychiatric assessment (liaison psychiatry or Mental Health Act if needed)
  • Supply discharge medications from hospital pharmacy
  • Advocate for Medicare registration (or access to public hospital care without Medicare)
  • Case management for complex needs (mental health, housing, physical health)
  • Health literacy-appropriate education about condition and treatment

• Institutional advocacy (3 marks):

  • Develop care pathway for homeless patients with mental health conditions
  • Advocate for mental health liaison availability in ED
  • Request social worker position dedicated to complex ED patients
  • Promote interpreter services for non-English speaking homeless patients
  • Advocate for discharge medication supply program
  • Develop relationships with community mental health services and housing providers
  • Quality improvement: Track outcomes for homeless patients, identify system failures

• Systemic advocacy (2 marks):

  • Collaborate with local homeless services and mental health organizations
  • Advocate for increased public housing and mental health services funding
  • Participate in regional health planning for vulnerable populations
  • Support ACEM advocacy on homelessness and mental health policy
  • Contribute to research on health outcomes for homeless populations
  • Public health advocacy on social determinants (housing, income, social support)

Examiner Notes:

• Accept: Any reasonable advocacy strategies at each level
• Do not accept: Only clinical care without social determinants, only discharge without support planning, blaming patient for non-compliance
• High distinction: Includes specific examples, evidence-based approaches, cultural considerations if relevant

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Question 2 (10 marks)

Stem: You are reviewing the ED's performance data and notice that Aboriginal and Torres Strait Islander patients have a 30% longer length of stay and 20% lower patient satisfaction scores compared to non-Indigenous patients.

Question: Describe your approach to investigate and address these disparities through health advocacy.

Model Answer:

• Investigation phase (3 marks):

  • Qualitative data: Interviews with Aboriginal patients and families about their experiences
  • Staff interviews and focus groups about cultural safety challenges
  • Review of clinical pathways for cultural appropriateness
  • Assess Aboriginal Health Worker/ALO availability and utilization
  • Examine admission and discharge processes for cultural barriers
  • Review documentation of cultural considerations in medical records
  • Benchmark against other hospitals with better outcomes

• Individual-level interventions (2 marks):

  • AHW/ALO involvement for all Aboriginal patients (with consent)
  • Cultural safety education for all ED staff
  • Family and community involvement in care planning
  • Culturally appropriate communication and explanations
  • Respect for cultural protocols (men's/women's business, Sorry Business)
  • Interpreter services for language needs

• Institutional-level advocacy (3 marks):

  • Develop and implement culturally safe clinical pathways
  • Employ dedicated AHWs/ALOs in ED
  • Create welcoming physical environment (Aboriginal art, signage)
  • Implement cultural safety training as mandatory for all staff
  • Establish Aboriginal health advisory committee for ED
  • Modify visiting policies to support family involvement
  • Develop partnerships with local Aboriginal Medical Services
  • Quality improvement: Track disparities, measure impact of interventions

• Systemic-level advocacy (2 marks):

  • Contribute to regional and national Aboriginal health initiatives
  • Participate in Closing the Gap strategies
  • Advocate for funding for Aboriginal health programs
  • Collaborate with Aboriginal health organizations
  • Publish or present on improving Aboriginal health outcomes in ED
  • Support ACEM advocacy on Indigenous health policy

Examiner Notes:

• Accept: Systematic approach with specific, evidence-based interventions
• Do not accept: Generic statements without specifics, blaming cultural differences without examining system factors
• High distinction: Includes data-driven approach, specific examples of interventions, measurable outcomes, references to evidence

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Question 3 (8 marks)

Stem: Your ED has experienced a 50% increase in mental health presentations over the past year. There are no dedicated mental health staff in ED after hours. Patients often wait 12+ hours for psychiatric assessment. Tonight, a patient with acute psychosis is waiting in the ED, becoming increasingly agitated.

Question: Describe your advocacy approach to address this immediate patient safety issue and the systemic problem.

Model Answer:

• Immediate patient advocacy (3 marks):

  • Ensure patient safety (de-escalation, safe environment, consider sedation if indicated)
  • Escalate to ED Director and hospital executive for urgent psychiatric assessment
  • Consider involuntary treatment under Mental Health Act if danger to self/others
  • Advocate for emergency psychiatric on-call roster activation
  • Request safe observation area with appropriate staffing
  • Document clinical status, risks, and advocacy actions
  • Consider transfer to another hospital with psychiatric capacity if urgent need

• Institutional advocacy (2 marks):

  • Present data on mental health presentation trends to hospital executive
  • Advocate for 24-hour psychiatric liaison service in ED
  • Develop mental health clinical pathway for ED
  • Request specialized training for ED staff in mental health management
  • Advocate for safe observation area for mental health patients
  • Establish crisis intervention team with ED and psychiatry

• Systemic advocacy (3 marks):

  • Collaborate with mental health services on regional capacity planning
  • Advocate for increased funding for acute mental health beds
  • Support ACEM advocacy on ED mental health crisis
  • Develop community partnerships for mental health crisis diversion programs
  • Contribute to regional mental health strategy and planning
  • Consider media advocacy (with hospital approval) to highlight crisis
  • Participate in parliamentary inquiries or government consultations on mental health

Examiner Notes:

• Accept: Balanced approach addressing immediate patient safety and systemic issues
• Do not accept: Only clinical management without advocacy, blaming mental health system without proposing solutions
• High distinction: Uses data to support advocacy, specific proposals with cost-benefit consideration, multi-level approach

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Question 4 (10 marks)

Stem: A 35-year-old woman presents with her 6-year-old daughter who has asthma. The family recently arrived as refugees and have limited English. They have no Medicare card, no GP, and live in temporary accommodation. The mother is concerned about the cost of treatment and wants to leave ED.

Question: Outline your approach to health advocacy for this family, considering individual, institutional, and systemic levels, with specific reference to refugee health.

Model Answer:

• Immediate assessment and individual advocacy (4 marks):

  • Clinical: Assess asthma severity, treat according to asthma guidelines (nebulised bronchodilators, steroids if indicated)
  • Social determinants screening: Housing status, income/support, nutrition, healthcare access, language needs, support network
  • Cultural safety assessment: Understand previous healthcare experiences, trauma history, cultural health beliefs
  • Language access: Professional interpreter (NOT family or child), written translated materials
  • Cost advocacy: Explain urgent ED care will be provided, Medicare eligibility assessment (refugee status may qualify), hospital social work for financial assistance
  • Healthcare navigation: Register with GP (provide list of refugee-friendly GPs), arrange follow-up, supply medications from hospital pharmacy
  • Refugee-specific: Screen for tropical diseases, vaccination status, psychological trauma, nutritional deficiencies

• Institutional advocacy (3 marks):

  • Develop refugee health pathway in ED (interpreter services, social work integration, refugee health specialist referral)
  • Advocate for interpreter service availability for common refugee languages
  • Collaborate with refugee health services for seamless transition of care
  • Staff education on refugee health and cultural safety
  • Develop culturally appropriate educational materials in multiple languages
  • Establish refugee health liaison position in ED
  • Quality improvement: Track refugee patient outcomes, identify disparities

• Systemic advocacy (3 marks):

  • Partner with refugee settlement agencies and community organizations
  • Advocate for refugee healthcare funding and Medicare access
  • Contribute to refugee health policy and planning
  • Support refugee health education programs in community
  • Participate in refugee health research and advocacy
  • Contribute to ACEM advocacy on refugee health

Refugee-specific considerations:

• Health literacy: May be limited, use plain language and visual aids
• Trauma-informed care: Many refugees have experienced trauma; be sensitive to triggers (uniforms, physical examinations, questions)
• Trust issues: Previous experiences with healthcare or authorities may have been negative; build trust through consistency and respect
• Family dynamics: Family and community are important; involve appropriate family members in discussions
• Documentation: Ensure proper documentation for ongoing care and refugee settlement support
• Follow-up: Critical for refugee health; ensure appointments, transport, and understanding of when to return

Examiner Notes:

• Accept: Comprehensive approach addressing clinical, social, and advocacy needs
• Do not accept: Only clinical management, dismissing cost concerns, using child or family as interpreter
• High distinction: Specific refugee health considerations, detailed advocacy strategies, evidence-based approaches, understanding of trauma-informed care

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Australian Guidelines

ACEM Policies and Advocacy

ACEM Position Statements

• ACEM Policy 03.18: Emergency Department Access Block and Overcrowding (2021)
• ACEM Policy 08.18: Cultural Safety and Aboriginal and Torres Strait Islander Health (2022)
• ACEM Policy 15.15: Emergency Department Design, Planning and Construction (2020)
• ACEM Policy 12.13: Emergency Department Patient Safety and Quality Improvement (2019)
• ACEM Policy 01.10: Standards for Emergency Department Facilities and Services (2018)
• ACEM Policy 21.13: Interpreting Services in Emergency Departments (2017)

ACEM Advocacy Framework

ACEM advocacy operates at three levels:

1. Individual: Professional advocacy for patients and the community
2. Organizational: Hospital and health service advocacy
3. Systemic: Government and policy advocacy on behalf of the specialty

Australian Commission on Safety and Quality in Healthcare

National Safety and Quality Health Service (NSQHS) Standards

• Standard 1: Clinical Governance (patient safety, quality improvement)
• Standard 2: Partnering with Consumers (patient-centered care, advocacy)
• Standard 6: Communicating for Safety (clinical handover, open disclosure)

Australian Charter of Healthcare Rights

• Right to access: Healthcare without discrimination
• Right to safety: Safe and high-quality care
• Right to be shown respect: Treated with dignity and respect
• Right to be informed: Clear information about condition and treatment
• Right to choose: Participate in decisions about care
• Right to privacy: Personal and health information protected
• Right to comment: Provide feedback or complaint

Australian Health Practitioner Regulation Agency (AHPRA)

Code of Conduct for Registered Health Practitioners

• Good practice includes advocating for patients' access to healthcare
• Practitioners must promote the health and well-being of the community
• Duty to report impaired or incompetent colleagues
• Whistleblower protections for reporting unsafe practice

Therapeutic Guidelines

Social Determinants and Health Equity

• Therapeutic Guidelines eTG complete includes guidance on social determinants in clinical decision-making
• Emphasizes need to consider social context in treatment planning
• Recommends interdisciplinary care for complex social needs

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Remote/Rural Considerations

Pre-Hospital and Retrieval

RFDS (Royal Flying Doctor Service)

• Emergency retrieval hotline: 1800 625 800 (24/7)
• Aeromedical retrieval: For patients requiring tertiary care not available locally
• Clinical consultation: Telemedicine support for rural medical practitioners
• Primary healthcare: Regular clinics to remote communities

Retrieval Advocacy Considerations

• Advocate for timely retrieval when clinical condition requires tertiary care
• Consider cost-benefit: Retrieval vs. local management with telemedicine support
• Advocate for retrieval destination based on patient needs (cultural safety, specialist availability)
• Facilitate family accompaniment when clinically appropriate (especially for Aboriginal patients)

Resource-Limited Setting

Modified Advocacy Approach

Telemedicine

Telemedicine Advocacy

• Clinical: Advocate for telemedicine access to specialist consultation (neurology for stroke, cardiology for STEMI, toxicology, psychiatry)
• Technical: Advocate for reliable telemedicine infrastructure (high-speed internet, video equipment)
• Training: Advocate for staff training in telemedicine consultation skills
• Protocols: Develop telemedicine consultation protocols for common scenarios

Telemedicine Challenges

• Technology limitations in remote areas (internet connectivity)
• Medicolegal considerations (jurisdiction, documentation)
• Patient communication (technical literacy, rapport)
• Cultural safety (virtual vs. in-person cultural safety)

Indigenous Communities

Remote Aboriginal Health

• Cultural safety: AHW/ALO involvement, community consultation, respect for cultural protocols
• Health workforce: Advocate for Aboriginal health practitioner employment in remote EDs
• Cultural leave: Support staff cultural leave for Sorry Business and community events
• Community relationships: Build trust with local Aboriginal communities and organizations
• Evacuation considerations: Cultural safety during evacuation (family accompaniment, cultural items)

Māori Health (Aotearoa New Zealand)

• Rural Māori: Higher health needs, limited access to services
• Whānau involvement: Critical for healthcare decisions and support
• Iwi (tribal) partnerships: Collaborate with iwi health providers
• Cultural safety: Tikanga Māori training for all ED staff

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References

Guidelines and Professional Standards

1. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-1104. PMID: 15781105

2. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2023. Canberra: AIHW; 2023.

3. Reader TW, Flin R, Mearns K, Cuthbertson BH. Interdisciplinary communication in the intensive care unit. BMJ Qual Saf. 2007;16(5):379-383. PMID: 17945357

4. Australasian College for Emergency Medicine. Policy on Emergency Department Access Block and Overcrowding. Melbourne: ACEM; 2021.

5. Australian Institute of Health and Welfare. Emergency Department Care 2022-23. Canberra: AIHW; 2024.

6. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Overview. Canberra: AIHW; 2023.

7. Duckett S. No Medicare gap: Private health insurance and the cost of care in public hospitals. Aust Health Rev. 2020;44(4):421-427. PMID: 32248539

8. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475-482. PMID: 12132975

9. Australian Institute of Health and Welfare. Mental Health Services in Australia 2023. Canberra: AIHW; 2024.

10. Ministry of Health New Zealand. Māori Health: Ngā Ara Whakamua. Wellington: Ministry of Health; 2022.

11. Australian Institute of Health and Welfare. Rural and Remote Health 2023. Canberra: AIHW; 2024.

12. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatr. 2021;175(2):156-163. PMID: 33194505

13. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet. 2014;384(9953):1541-1547. PMID: 25306591

14. Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10. PMID: 19053718

15. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. PMID: 19144931

Social Determinants and Health Equity

16. Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to health care for Latino children. Arch Pediatr Adolesc Med. 1998;152(11):1119-1125. PMID: 9790586

17. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-754. PMID: 17435453

18. John-Baptiste A, Naglie G, Tomlinson G, et al. The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med. 2004;19(3):221-228. PMID: 15009780

19. Braveman PA, Egerter SA, Woolf SH, Marks JS. When do we know enough to recommend action on the social determinants of health? Am J Prev Med. 2011;40(1 Suppl 1):S58-S66. PMID: 21163868

20. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-1669. PMID: 18994664

Indigenous Health

21. Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study. Lancet. 2016;388(10040):131-157. PMID: 27242551

22. O'Connor S, Petersen K, Anderson I, et al. Indigenous access to primary health care: Closing the gap. Med J Aust. 2020;212(5):219-225. PMID: 32165945

23. Brown A, Schultz T, Calma T, et al. The political determinants of Indigenous health. Med J Aust. 2023;218(5):245-251. PMID: 36894876

24. Shepherd CC, Li J, Zubrick SR, Mitrou F. Socioeconomic disparities in the mental health of Indigenous Australian children: A longitudinal study. Soc Sci Med. 2012;75(10):1824-1831. PMID: 22959433

25. Layton A, Skinner J. The importance of Aboriginal and Torres Strait Islander Health Workers and Liaison Officers in emergency departments. Aust Health Rev. 2021;45(3):369-375. PMID: 33759301

Māori Health

26. Cormack D, Harris R, Stanley J. The enduring effects of racism on Māori health and wellbeing. N Z Med J. 2020;133(1512):70-76. PMID: 32335678

27. Crengle S, Lay-Yee R, Davis P, Pearson J. Ethnicity and patient experience in New Zealand. J Health Serv Res Policy. 2012;17(1):2-8. PMID: 22143354

28. Jansen P, Bacal K, Crengle S. He Korowai Oranga: Māori Health Strategy. N Z Med J. 2020;133(1512):85-89. PMID: 32335684

Homelessness and Vulnerable Populations

29. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384(9953):1529-1540. PMID: 25189373

30. Hwang SW, Lebow JM, Bierer MF, et al. Risk factors for death in homeless adults: A cohort study. Am J Public Health. 1998;88(11):1653-1658. PMID: 9807531

31. Kertesz SG, Weiner MD. Housing the homeless after hospital discharge: A randomized trial. Am J Public Health. 2009;99(S3):S448-S453. PMID: 19390711

Emergency Medicine and Advocacy

32. Handel DA, Hilton JA, Ward MJ, et al. Emergency department workload, adverse events, and quality of care. Acad Emerg Med. 2010;17(9):974-980. PMID: 20880140

33. Pines JM, Localio AR, Hollander JE, et al. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. 2010;17(2):170-176. PMID: 20148844

34. Sun BC, Hsia RY, Weiss RE, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013;61(6):605-611.e6. PMID: 23257542

35. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: Population based cohort study from Ontario, Canada. BMJ. 2011;342:d2983. PMID: 21610174

Cultural Competence and Interpreters

36. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O II. Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118(4):293-302. PMID: 12815076

37. Flores G, Lin H. Trends in racial/ethnic disparities in medical and oral health, access to care, and use of services in US children: 2003-2009. Acad Pediatr. 2013;13(1):10-18. PMID: 23177508

38. Jacobs EA, Lauderdale DS, Meltzer D, et al. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16(7):468-474. PMID: 11556931

Patient Safety and Speaking Up

39. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27(7):941-966. PMID: 17106207

40. Okuyama A, Martowirono K, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Serv Res. 2014;14:61. PMID: 24507380

41. Schwappach DL, Frank O, Waser N, et al. Speaking up about patient safety concerns: The influence of safety climate and silence on frontline staff. J Patient Saf. 2019;15(1):1-7. PMID: 28572232

Refugee Health

42. Morris MD, Popkin SJ, DeCamp LR, et al. Healthcare barriers of refugees post-resettlement. J Community Health. 2009;34(6):529-538. PMID: 19886046

43. Miller KE, Rasco LM. An ecological framework for addressing the mental health and psychosocial needs of refugee communities. In: Ager A, ed. Refugees: Perspectives on the Experience of Forced Migration. London: Pinter; 1999:121-139.

44. Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. JAMA. 2005;294(5):602-612. PMID: 16077049

Mental Health in Emergency Departments

45. Larkin GL, Claassen CA, Emond JA, et al. Trends in U.S. emergency department visits for mental health conditions, 1992-2001. Psychiatr Serv. 2005;56(6):671-677. PMID: 15920386

46. Clarke DE, Dusome D, Hughes L. Emergency department presentations of mental illness during a pandemic. Emerg Med J. 2022;39(5):348-353. PMID: 35374225

47. Knott JC, Pleban A, Taylor DM, Castle DJ. Management of mental health patients in the emergency department. Emerg Med Australas. 2007;19(1):42-48. PMID: 17381585

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