Fragmentation of care

More effective collaboration between sectors of health services and professionals are the key to improving quality and safety of discharge care of remote NT mothers and their newborns. By Annie May.

Discharge practices for mothers and newborns from remote areas in the Top End of Australia need to be improved and restructured, with current practices putting both lives at risk, new research reveals.

Examining the transition of care in the postnatal period from a regional hospital to a remote health service, researchers found that poor discharge documentation, communication and co-ordination between hospital and remote health centre staff occurred.

Aboriginal women have been long voicing their concerns about the quality of maternity services and unsafe practices. These concerns have been echoed by policy makers and health providers, however in terms of policy, Dr Sarah Bar-Zeev from the University of Sydney says little has been done.

There is also a lack of published evidence to guide the designing of the transition across service, particularly in remote settings.

"Women from these communities [in remote Northern Territory] have been pushing for change for a long time, and while some improvements have occurred, there is still a long way to go," Bar-Zeev told Nursing Review.

Part of the research team, Bar-Zeev says the study was part of the 1+1 = A Healthy Start to Life project, funded by the National Health and Medical Research Council. A five year project, it is designed to improve maternal and infant health for remote dwelling Aboriginal families in two of the largest communities in the Top End of the NT. It is a three stage baseline, intervention and post-intervention study. Bar-Zeev worked to develop the baseline study. The research was conducted in two remote health centres (HC) and in a 363 bed regional, public hospital in the Top End of Australia's NT.

The NT provides many challenges in providing well co-ordinated, quality maternity care. One is purely a geographic issue. It spans one-sixth of Australia but has only 1 per cent of its population, according to the Australian Bureau of Statistics, so communities can be very isolated. Aboriginal and Torres Strait Islander Australians comprise 30 per cent of the NT population with 80 per cent living in remote locations.

The large number of service providers (Northern Territory Government, Aboriginal Community Controlled and joint national funded services), patient information systems, a high burden of maternal and infant morbidity, a high prevalence of teenage pregnancy and late presentation for antenatal care add to the complexity of providing an effective discharge system, the researchers found.

Current practice in the NT is that remote dwelling women are transferred from their home community to a regional centre at 38 weeks gestation to birth in a hospital.

Transferred women stay in hostel accommodation until the onset of labour and then give birth at the hospital with care providers with whom they are generally unfamiliar.

Women also often find themselves without any family or friends. Bar-Zeev says the Patient Assistance Travel Scheme (PATS) does not support escorts for pregnant women unless they are very young, under 16 years, are women having their first child or cannot speak English.

"If they are having their second or third child, an escort isn't funded and most of these women and their families can't afford the additional costs," she says.

"Most of the time they go unaccompanied, often leaving toddlers at home."

As part of the hospital discharge planning process, mothers are advised to return to their HC for a six week postnatal check or earlier if needed and to take their infant for a visit up on their return home. Some mothers received domiciliary postnatal care in their temporary residence up to day 10 following discharge, although the provision of these visits was inconsistent.

"Reasons described by health providers for this inconsistency included patient mobility following hospital discharge, miscommunication between the health providers and the mothers about the timing and location of the postnatal visit and the perception by health providers that mothers do not value the postnatal visit sufficiently to make it worthwhile for them to undertake," the study said.

Both HC and hospital staff reported significant problems with the postnatal discharge processes.

Most common occurring problems were poor written information transfer, poor verbal communication, lack of coordination between the hospital and the remote health services, lack of clinical governance and leadership and poor knowledge of roles and work practices in HCs by hospital staff.

"The regional hospital policy is for discharge summaries to be completed within 48 hours of discharge. Ideally this occurs prior to discharge and the mother is given her own copy to take home, one copy is to be sent to her GP or HC if she is in a remote community and a third copy to be filed in the hospital medical record."

The practice of mothers being given their own summary upon discharge was also inconsistent.

Reasons given for this by staff were mothers not being provided their own copy was that paperwork was not always complete at the time of discharge, due competing priorities of managing busy and complex patient workloads. Other reasons reported included staff being unable to locate the mother at the time of discharge and "lack of trust by hospital staff that mothers could reliably" take their own summary back to their HC.

Health Centre participants reported receiving hospital summaries "sometimes months after the mother has been discharged or not at all". Eleven per cent of maternal records reviewed at the HCs, did not have a discharge summary for the birth that occurred during 2004-2006.

The most frequently reported consequences of absent or delayed discharge summaries were missed opportunities by HC staff to follow up the mother and infant upon their return to the community and provide postnatal and newborn checks, parenting support, ongoing management of postnatal complications and the failure to have medication regimes implemented or tests administered or pending test results followed up.

Bar-Zeev says as a result of past bad experiences, some mothers avoided going to the hospital to give birth. Instead, she says, they would have no prenatal care and go straight to the HC at the onset of labour. This was worryingly the case for 10 per cent of women.

"I'm not saying that hospital and HC staff isn't trying, but there needs to be a change in practices. In fact, the majority agree with this," she says.

"And there has been change. We report our findings to the NT government, policy advisors and hospitals, so they are well aware of the issues."

The 1+1 = A Healthy Start to Life project is currently in the evaluation phase and will finish next year. The finding of the study, 'From hospital to home: The quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia' was published online in June in Midwifery.

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