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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.
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Thankyou for taking time to leave comments. Please be assured that like other doctors I am finding public A&E still responding well this week. However, I am trying to think proactively about how our health system will be operating in the next weeks to months if the pandemic trajectory continues. Please read the latest MJA articles on ‘COVID 19: public health, health systems and palliative planning’, and ‘A model for the number of ICU beds during the COVID 19 pandemic’ in the latest edition. I certainly hope that these projections will not become our reality. However in case they do, we will do well to be proactive about anticipating barriers to access rather than reactive. Very pleased to hear others’ views.
If the public and private system cannot manage a strangulated hernia or a penetrating eye injury, it’s gross negligence. Most hospitals are currently well below the level of saturation predicted (to date). Are all the surgeons working in emergency and ICU?
If private and public gynaecologists cannot assist, at the very least with expert advice regarding immune suppressed patient with acute pain, I would be surprised.
I can treat Harry and his injuries myself in my GP practice and under my other hat at the Private Fracture Clinic. No problem. That reduces the case load by 25%.
We all have skills. We just don’t use them effectively. Lots of useful medical staff are currently locked up waiting for the wave to crash. Looking for old codgers to sacrifice is missing the point.
All of these patients have acute issues that will need hospital intervention. Harry does need sorting out from a geriatric perspective-what caused his fall and how do we prevent the next one if possible? He also needs some acute surgical intervention ideally with aged care support. Although Covid is around, my hospital service is improving its ability to streamline those with Covid, those that might have it and those unlikely to. At this point in time I am still confident that you could safely request the assistance of our A and E services or direct contact the relevant specialties for assistance. The reduction in usual volumes of sport, work and vehicle related injuries with everyone in self isolation has at this stage freed up a lot of staff in A and E to work better. Likewise at this stage our wards are working more efficiently as we are not as yet overrun and so many non urgent meetings and lower priority surgery ops have been cancelled. If we can keep the curve flat and avoid what we are seeing overseas we may actually have the opportunity to see how much better our hospital systems can run when they are not filled to overflowing. Please don’t deny the patients the care they need for acute issues at this stage and even with further escalation of the crisis. I also suspect that we are flattening the curve for influenza with everyone improving their hygiene and reducing public exposure.
Leanne, I would strongly recommend to people to contact the doctors they normally would have in the days before COVID-19. Presumably you normally refer to somebody sensible, who knows about the relevant condition, and can make good decisions. If that person is still around and is not self isolating or otherwise out of action, they can take things from there.
As a hand surgeon, I would normally see a patient like Harry in my rooms, if he is ambulant, and arrange closed or open reduction of his radius, and if necessary a shoulder surgeon to have a look at the shoulder, and a plastic surgeon to fix the face at the same operation. If he is non-ambulant, I would arrange him to be admitted to the relevant hospital, so he would not wait around in the ED, but go straight to a surgical ward.
Today the decision would be more complex, and as a board member of the Australian Hand Surgery Society we have been wrestling with the difficult concepts of accepting suboptimal treatments for some conditions, to minimise risks. Harry’s distal radius fracture carries significant risks of disability, and if he is self caring and driving to the shops from the aged care facility, I would discuss with him the benefits of internal fixation as a day stay procedure, which can be performed under regional anaesthesia. In and out of preferably a small hospital with no ED, the current experience from Singapore (https://journals.lww.com/jbjsjournal/Documents/Novel%20Coronavirus%20and%20Orthopaedic%20Surgery.pdf) is that even an overnight stay carries minimal additional risks.
The advantage of internal fixation with modern plates is that the fracture can basically be ignored, so Harry can do simple self catering, like microwaving a frozen meal the following day. That means he does not need multiple visits from people to provide him with meals, assist with dressing etc.
If Harry is demented and unable to comply for local anaesthetic, general anaesthetic carries more complex risks in the COVID-19 era. Droplet precautions mean the entire surgical team has to leave the theatre during and for 15 minutes after intubation or laryngeal mask insertion, whereas we normally prep the arm and closed-reduce the fracture in that period, as well as doing the instrument set up. This would commit him to an extra perhaps half hour of anaesthesia.
It may be in Harry’s best interests for the carer to bring him across to the rooms, have a waterproof cast or splint applied, with or without a reduction under local anaesthetic and panadol, and maybe some Steri-Strips to his facial laceration. This still avoids the ED, and the worse acute pain, permanently impaired hand function and facial cosmesis may be a reasonable trade-off. Some public hospitals will direct him via a fracture clinic, but ultimately he is still lower priority than David, Carmen, and Jo. Hopefully, state governments are smart enough (Ruby Princess notwithstanding) to have respiratory EDs separate from rest-of-body EDs.
Not too sure if fancy telehealth helps any of your 4 patients, as all except possibly Carmen need surgery urgently, and she needs an abdominal/gynae surgeon to clinically assess her (ruptured caecal cancer or ectopic, or endometriosis?).
As a profession, we must address new inequities in the health system and any maldistribution of medical and surgical workload. Many GPs and other specialists have suddenly found they are either underutilised or cannot keep up with the high demand for their services. How can we best address this imbalance?
A&E DEPARTMENTS……….
The doctors over 65 may be at higher risk of dying but young health providers are also dying. Each person needs to be able to use PPE correctly and make the decision for themselves.
I am currently in the under utilised category and want to know how my experience and time could help.