COVID-19: Where do I refer my patients with acute surgical needs?

Harry*, an 82-year-old in an aged care facility with a comminuted fracture of his right radius, severe right shoulder pain and a deep facial laceration after a fall.

David*, a 50-year-old with diabetes and cardiovascular disease with severe groin pain due to a strangulated hernia.

Carmen*, a 45-year-old immunosuppressed woman with severe pain in her right iliac fossa and abnormal vaginal bleeding.

Jo*, an Indigenous child with a penetrating eye injury.

* Not their real names

WHAT patients like Harry, David, Carmen and Jo have in common is they require rapid surgical triage, to avoid prolonged waiting times in accident and emergency departments and contact with COVID-19 in hospitals.

Within a few weeks, the Australian public and private health systems and our referral pathways have been disrupted. In the next few weeks, it has been predicted that many Australians may not be able to access ICU and other hospital beds if the current pandemic trajectory continues.

In response, governments have moved quickly to contract private hospital intensive care and other beds. Public specialist outpatient clinics and all elective surgery (except for Category 1 and urgent Category 2 procedures) have been cancelled to appropriately divert clinicians and personal protective equipment (PPE).  New Medicare items have been rolled out for telehealth to safeguard doctors and their patients.

As there are dire predictions of health system overload despite community lockdowns, governments in partnership with our medical organisations have appropriately focused on managing COVID-19.

As a profession, we also need to advocate for optimal access for both public and private patients who require acute health care, but do not have COVID-19.

Is there a new health pathway solution for these complex issues?

Triage services currently exist, but will they address the disruption of our referral pathways? Obviously, many GPs already have strong personal referral networks with specialists, national and state nurse call centres provide valuable patient information, and many hospitals have set up separate accident and emergency centres for patients who do not have COVID-19. Throughout the pandemic, will these services have the capacity to consistently respond to the acute (non COVID-19) health needs of our communities?

For our patients like Harry, David, Carmen and Jo, doctors must be able to access coordinated specialised telesurgical triage services.  Using innovative etechnologies, GPs and other specialists could refer directly to available surgeons in accessible operating theatres without delay.

Why are new triage services necessary?

As a profession, we must address new inequities in the health system and any maldistribution of medical and surgical workload. For example, many GPs and other specialists have suddenly found they are either underutilised or cannot keep up with the high demand for their services.

We must also maintain a high standard of quality of care and address the heightened clinical risks associated with recent significant changes in models of clinical care.

While the new national telehealth program will have great benefits, we are aware of the increased risk of clinical error when an appropriate physical examination and specialist assessment are not undertaken in a timely manner. As many GPs and other referrers now consult remotely in virtual clinics across multiple health districts and public and private hospitals, they will quickly need to find new clinical pathways to navigate inevitable waiting times.

Clearly, careful clinical risk assessment is also important postoperatively. During the pandemic, surgical patients (including those requiring high acuity procedures) should be discharged home as soon as practical and appropriate, to help prevent exposure to COVID-19. New models of clinical care involving day and short stay hospitals and virtual hospitals in the home will need to involve GPs and other healthcare providers (i.e. aged care) to make this happen.

In summary

As our traditional referral pathways continue to be disrupted, doctors will be confronted with major inequities in our new health system, particularly for our patients most at risk of COVID-19 – those with chronic disabilities and disease, and those who are elderly, Indigenous or immunosuppressed.

By collaborating throughout the pandemic, GPs and other specialists will make a major contribution to patients, especially those suffering with the deadly combination of pre-existing vulnerability and financial hardship.

While the new national telehealth program for all Australians and their doctors is a welcome initiative, let’s make it work and let’s make it safe.

We need to adapt rapidly and advocate for funding of coordinated and equitable specialised telesurgical triage services to respond quickly to the acute medical and surgical needs of both our public and private patients.

And for our patients like Harry, David, Carmen and Jo, we need to do so now.

Clinical Professor Leanne Rowe AM is a GP, past Chairman of the Royal Australian College of General Practitioners, co-author of ‘Every Doctor: Healthier Doctors=Healthier Patients’ (www.everydoctor.org) and Chairman of Nexus Hospitals.

 

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.