[Series] Out-of-hospital cardiac arrest: prehospital management

Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services’ staff.

[Correspondence] Safe travels during hurricanes

On the evening of Sept 10, 2017, in Miami (FL, USA), at a time when Hurricane Irma had reached category 4 status, a 91-year-old woman had a stroke. As per local hurricane protocol, emergency medical services are halted when storm winds reach category 3 status or higher. With no viable alternative transportation to navigate through strong winds and the substantial storm surge (appendix), the patient was brought to the emergency room in the backseat of her granddaughter’s car.

AMA Federal Council formally condemns Bupa move

The AMA Federal Council has passed two motions against private health insurer Bupa over plans to change to its policies and coverage.

Meeting in Canberra on Friday March 16, the Federal Council held lengthy discussions about Bupa’s recent announcement to rework its medical gap scheme.

A third of Bupa’s Australian customers were told their cover for a range of procedures will change from a minimal benefit to total exclusion.

And patients would only qualify for gap cover if treated in Bupa-approved facilities.

Bupa softened its position slightly after the AMA sharply condemned the announcement, but the AMA believes the move is still far too harsh and is heading towards a US-style managed care system.

It formally rebuked the private insurer with the following two motions:

“Federal Council expresses its concern at recent changes to health insurance products announced by Bupa. These changes threaten member choice and access to health care. Federal Council calls on Bupa to reconsider these changes and to act in the interests of its members and the broader Australian community.”
“That Federal Council recommends that the AMA advises Australian citizens how they can change their private health insurance.”

The AMA has already forced an investigation into Bupa, after AMA President Dr Michael Gannon called on the Government to look into the legality of the private insurer’s move.

Federal Health Minster Greg Hunt subsequently ordered the Private Health Insurance Ombudsman to do exactly that.

The punitive changes were announced just weeks after Mr Hunt approved a 3.95 per cent increase to private health insurance premiums.

“The fact that the change has occurred straight after a premium increase, straight after agreement was made to retain second tier rates for non-contracted facilities, and straight after an announcement by Government to work collaboratively with the sector on the issue of out-of-pocket costs, is unconscionable,” Dr Gannon said.

“The AMA will not stand by and let Bupa, or any insurer, take this big leap towards US-style managed care.

“The care that Australian patients receive will not be dictated by a big multinational with a plan for vertical integration.”

The affected procedures include hip and knee replacements, IVF services, cataract and lens procedures, and renal dialysis.

Bupa made the announcement initially via letter to medical practices, suggesting to them that: “Prior to the commencement of any treatment, patients should be encouraged to contact Bupa directly to confirm their cover entitlements, and any possible out-of-pocket expenses that may be applicable.”

Bupa’s Head of Medical Benefits Andrew Ashcroft also wrote: “Customers affected by these changes will be given an opportunity to upgrade their cover should they wish to receive full coverage for services that were previously only restricted cover.”

Dr Gannon said customers were right to be concerned with the new list of exclusions, but that there was even more bad news hidden in the fine print of Bupa’s new business plan.

“From 1 August 2018, no-gap and known gap rates will now only be paid to the practitioner if the facility in which the procedure takes place also has an agreement with Bupa,” he said.

“Medical benefit rates outside those facilities will now only be paid at the minimum rate that the insurers are required to pay – that is, 25 per cent of the MBS.”

Dr Gannon has written to all AMA members to explain the changes and why they are bad for patients and the medical profession (the full letter can be viewed at ausmed/bupa-decision-bad-news-patients-and-profession).

CHRIS JOHNSON

PICTURE: AMA Federal Council passing motions condemning the Bupa changes.

New vaccines for improved coverage against flu in Australia

Two new ground-breaking flu vaccines will be given to more than three million Australians.

The Federal Government recently said it will provide the new vaccines to those Australians aged 65 years and over who want them.

In making the announcement, Health Minister Greg Hunt said: “This is a direct response to last year’s horrific flu season, which had a devastating impact around the world, and aimed squarely at saving lives.”

More than 90 per cent of the 1,100 flu related deaths in 2017 were of people aged over 65 years of age. While less than one to two per cent of people who get influenza will end up with a complication from it, it is the elderly who seem hardest hit.

“The medical advice, both from the vaccine producers, the World Health Organisation and the Chief Medical Officer is that the mutation which occurred last year in many countries will be specifically addressed by these new vaccines,” Mr Hunt said.

The new vaccines – Fluad® and Fluzone High Dose® – were registered in Australia to specifically provide increased protection for people aged 65 years and older.

From April 2018, both vaccines will be available through the National Immunisation Program following a recommendation from the Pharmaceutical Benefits Advisory Committee.

“Annual vaccination is the most important measure for preventing influenza and its complications and we encourage all Australians to get vaccinated. We encourage all Australians aged over six months old to get a flu vaccination this year before the peak season starts in June” Mr Hunt said.

The Chief Medical Officer, Professor Brendan Murphy, believes the new ‘enhanced’ vaccines will be more effective.

However, Professor Murphy said: “No flu vaccine is complete protection, the standard vaccine seems to protect well in younger people, but we are confident this will give better protection for the elderly.”

The Department of Health believes the new trivalent (three strain) vaccines work in over 65s by generating a strong immune response and are more effective for this age group in protecting against influenza.

There is now a mandated requirement for residential aged care providers to provide a seasonal influenza vaccination program to all staff as well as the Aged Care Quality Agency continuing a review of the infection control practices of aged care services across the country.

Under the National Immunisation Program, those eligible for a free flu shot include people aged 65 years and over, pregnant women, most Aboriginal and Torres Strait Islander people, and those who suffer from chronic conditions.

The following four strains will be contained within this year’s Southern Hemisphere vaccines:

A(H1N1): an A/Michigan/45/2015(H1N1) pdm09 like virus;
A(H3N2): an A/Singapore/INFIMH-16-0019/2016(H3N2) like virus;
B: a B/Phuket/3073/2013 like virus; and
B: a B/Brisbane/60/2008 like virus.

Allen Cheng, Professor in Infectious Diseases Epidemiology at Monash University, has warned: “Despite the common perception that the flu is mild illness, it causes a significant number of deaths worldwide. To make an impact on this, we need better vaccines, better access to vaccines worldwide and new strategies, such as increasing the rate of vaccination in childhood.”

AMA President Dr Michael Gannon welcomed the Government’s announcement because it was targeting vaccine coverage for “a particularly vulnerable group”.

MEREDITH HORNE

Right to put the spotlight on private health insurance

The news about Bupa is timely. With large numbers of people discontinuing their private health insurance, the AMA and consumer advocate organisations, such as CHOICE, should be revealing that companies such as Bupa and Medibank Private have shareholders, who receive a dividend each year, and they sponsor major sports such as tennis, cricket and golf. Such activities use large amounts of members’ contributions, which could be used to provide more comprehensive cover for their health needs.

It is time for the AMA and other consumer advocate organisations to point out that non-profit health insurers provide much better value, and the federal government should be urged to make all health insurers non-profit.

Some 40-50 years ago health insurers were branches of church and community groups such as lodges – IOOF, Hibernian, etc. – and other societies and employers which were non-profit. The Doctors’ Health Fund is a good example of such an insurer. A return to non-profit status would reduce the current trend to ‘Americanise’ our health services.

Dr John A. Crowhurst B.Pharm., MB BS, Dip.(Obst.)RCOG, FANZCA, FRCA.
Consultant Anaesthetist (Ret.)
Linden Park, SA

Is it ever OK to recreate medical records?

Keeping accurate medical records is the responsibility of every doctor for the continuing good care of patients. Sometimes when a doctor looks at their records after the event, for example when a complaint is made, they may feel that their previously recorded notes are inaccurate or incomplete, and may be tempted to correct them, or even rewrite them.

A recently reported court case involving a General Practitioner (GP), highlights the importance of accurate, contemporaneous notes and why rewriting medical records, especially with dishonest intentions, is unethical.

Doctor presents recreated notes as contemporaneous

The case involved a GP with a special interest in skin cancer who had completed a Primary Certificate in Skin Cancer Medicine. Complaints were made to AHPRA at various times relating to four patients. Two involved complaints of boundary violations and two regarded complaints of a failure to perform an adequate skin check and failure to make adequate notes.

At various times during the complaints process and with the intention of misleading AHPRA’s investigation into the complaints, the GP deleted the original, brief notes he had made during his consultation with three of the patients, and replaced them with a more comprehensive version. The doctor sent the new version of the notes to AHPRA, claiming them to be contemporaneous.

Falsifying records constitutes professional misconduct

The doctor claimed that the recreated notes accurately recorded what had occurred, however the Tribunal determined that this was not the case.

In reaching its decision, the Tribunal said the doctor’s reliance on the recreated medical notes to assist their case reflected poorly on their character. The doctor’s insistence that the new notes were an accurate depiction of what had occurred during the consultation suggested to the Tribunal the doctor had little insight into the serious nature of their misconduct.

“The circumstances of the boundary violation, considered separately, would not warrant de-registration nor would the failures to properly carry out skin checks and make adequate notes. These are serious, but they could reasonably be dealt with by imposing conditions as to further training and mentoring,” the Tribunal said.

It was the doctor’s deliberate attempts to deceive that led the Tribunal to cancel the doctor’s registration. The Tribunal found the doctor made four attempts to deceive the AHPRA in order to influence the conduct of the investigations, and that these were inconsistent with the doctor being a fit and proper person to hold registration in the profession.

The Tribunal said, “It is of the utmost importance that practitioners conduct themselves in an ethical manner, especially in matters involving investigations into a practitioner’s conduct, which are necessary for the protection of the public.”

The Tribunal described the doctor’s professional misconduct as serious and unethical, and said there was no evidence to suggest the doctor suffered genuine remorse. The Tribunal decided the doctor had behaved in a way that constituted professional misconduct on four occasions and unsatisfactory professional performance on two occasions and the public would be best protected by cancelling their registration. The doctor was de-registered for three years.

Key lessons

Honesty and integrity are key attributes of being a professional. The Medical Board’s Code of Conduct notes that patients expect that doctors will display qualities such as integrity, truthfulness, dependability and compassion.
It is your professional responsibility to keep accurate up-to-date and legible notes that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners. Records should be made at the time of events, or as soon as possible afterwards.
In this case, the matter for concern is the deliberate attempts to deceive. It is paramount that doctors conduct themselves in an ethical manner, including in matters involving investigations into professional conduct.

This article was originally published by Avant Mutual. You can access the original here.

Bupa in ‘managed care’ blooper

AMA President Dr Michael Gannon has demanded a ‘please explain’ after private health insurer Bupa told a third of its Australian customers their cover for a range of procedures will change from a minimal benefit to total exclusion.

These procedures include knee replacements, pregnancy and renal dialysis.

Bupa made the announcement via letter late in February and suggested to medical practices that: “Prior to the commencement of any treatment, patients should be encouraged to contact Bupa directly to confirm their cover entitlements, and any possible out of pocket expenses that may be applicable.”

The punitive changes were announced just weeks after Federal Health Minister Greg Hunt approved a 3.95 per cent increase to private health insurance premiums.

Dr Gannon told the Minister that the Government should now urgently seek advice from the Health Department and the Private Health Insurance Ombudsman as to the legality of Bupa’s actions.

“The AMA will not stand by and let Bupa, or any insurer, take this big leap towards US-style managed care.

“The care that Australian patients receive will not be dictated by a big multinational with a plan for vertical integration.”

Dr Gannon said customers were right to be concerned with the new list of exclusions, but that there was even more bad news hidden in the fine print of Bupa’s new business plan.

“From 1 August 2018, no-gap and known-gap rates will now only be paid to the practitioner if the facility in which the procedure takes place also has an agreement with Bupa,” he said.

“Medical benefit rates outside those facilities will now only be paid at the minimum rate that the insurers are required to pay – that is, 25 per cent of the MBS.”

“They are bad for the reputation of private health insurance. They are bad news for the contribution that the private system makes to the Australian health care system,” he said.

During a media interview on the subject, Dr Gannon said private health insurance policy holders should start asking questions about whether or not their policies are fit for purpose.

“If it does nothing more than give you treatment in a public hospital, how is that better than relying on the public system?” he said

“If it does nothing more than give you a whole list of exclusions where you can’t access care when you’re sick, when you’re scared, that’s not worth it.

“So, what we’re saying is there needs to be more focus on the value in the policies. We’re worried about the changes in the industry, we’re worried about the junk policies throughout there.

“We do have a Private Health Insurance Ombudsman, and when you look at the complaints there, you get a real feel for the problem. We see a lot of talk in the media about out-of-pocket expenses being the real problem with the value proposition. If you look at the Ombudsman’s report, that’s not the problem.

“Nearly 90 per cent of operations are provided by doctors at no-gap; another five or six per cent at known gap of less than $500.

“We don’t think we’re the problem, but when we see unilateral action like we’ve seen from big insurers like Bupa to say what they won’t be covering, we encourage individual policyholders to ring up, ask, and make sure they’re covered if and when they get sick.”

CHRIS JOHNSON

Trainee doctors impacted by RACP exam fail

The AMA has intervened on behalf of trainee doctors around the country, following the distressing mid-test crash of the computer-based Royal Australasian College of Physicians examination.

Following strong interventions from AMA President Michael Gannon and Chair of the AMA Council of Doctors in Training John Zorbas, the RACP has agreed to fully refund the exam fee, to release the questions from the computer-based exam to ensure that no participants were disadvantaged, and to offer a paper-based exam.

Dr Gannon wrote to all State and Territory health departments asking them to accommodate the more than one thousand trainees who had to sit the test again.

“This is a high-stakes examination that trainees spend months preparing for and involves sacrifices in their personal and family lives,” he said.

“The decision by the RACP to call off the exam has caused enormous distress for participating trainees who now face the daunting prospect of having to re-sit the exam.

“While the AMA is very concerned that trainees find themselves in this position and is seeking answers from the College, our main focus at the moment is to ensure that trainees are properly supported and have every chance of participating in and passing the scheduled exam.”

Dr Gannon asked the health departments to allow the trainees extra time for study and revision, and to the sit the rescheduled exam. The dramatic episode had a huge impact on hospital rosters and leave entitlements.

Dr Gannon asked the trainees’ bosses to be understanding of their predicament.

“While some health services may find this challenging, these are unusual circumstances that require a very sympathetic response,” he said.

“I hope you will commit to supporting these trainees, including by directing local health services to do everything possible to help them at this very difficult time.”

About 1200 trainee physicians in Australia and New Zealand had to re-sit the RACP Basic Exam on March 2, after a massive IT failure caused the computer-based written test to be cancelled while they were sitting it last month.

IT company Pearson Vue was employed to conduct the exam on February 19.

A technical fault left a significant number of candidates locked out of the computer based system and unable to complete the second part of the examination after their scheduled break.

Even though some trainees had completed the test, the RACP insisted that all candidates resit the exam and that the cancelled test will not count as an examination attempt.

The Adult Medicine and Paediatric Written Examinations are one exam in two papers. The final score relies on completion of the whole exam, and the complex calculation of pass marks is dependent on this, the College said.

RACP President, Dr Catherine Yelland, apologised to the trainees for the “stress and disruption” caused by the cancellation of the exam and vowed to release findings of an investigation into it.

“We understand that this has been unexpected, stressful and distressing. We have and continue to apologise for this. We encourage all trainees to talk with their supervisors, colleagues, family and friends,” she said.

An RACP panel was established to review the issue, including the technical failure of the exam, the College’s response, and the impact on trainees – including incurred travel costs, cancelled holidays, and other expenses.

“Many of you have had to make other arrangements when you were looking forward to family events, a holiday or a short break from study,” Dr Yelland said.

“We are also aware of the financial implications for trainees.”

Dr Zorbas said the system failure had caused enormous stress throughout the medical profession.

“This is an exam that some people have been studying for years for, and for it to come apart at the last minute because of a technical glitch without a backup system in place is incredibly distressing for these trainees,” he said on the day.

“Any trainee who finds themselves in distress, any doctor who is just not coping with the situation should contact the Doctors’ Help Advisory Service for support.

“And secondly, we want to reassure these doctors that we’re speaking to RACP to find out exactly what’s gone wrong and make sure there’s an open, fair, transparent system in place.”

The exam cost each trainee about $1800. The College vowed none would be financially disadvantaged for travelling to the rescheduled test.

A supplementary examination time was also promised also for those who could not sit the test on March 2.

CHRIS JOHNSON

Campaign for a public health approach to preventing child abuse

Every child in Australia deserves to grow up in a home free from harm. Yet year in, year out, we see an increase in the numbers of substantiated child abuse and neglect cases. In 2016-17, nearly 50, 000 children were found to have been – or were at risk of being – abused, neglected or otherwise harmed. This is unacceptable.

As medical professionals, we are at the forefront of responding to and treating the consequences of child abuse. Doctors see firsthand how the physical and psychological scars of maltreatment and neglect have lifelong negative effects on children and those who love them. They know that the best possible medicine is to stop this trauma occurring in the first place.

The AMA has long advocated for a public health approach to child protection. Just as we know it is a mistake to position the ambulance at the bottom of the cliff, we know we simply can’t wait until problems within families are so severe that the only option is to take children away.

Over the last 20 years, there have been more than 40 inquiries and commissions into the failings of the child protections system. Adopting the principles of a public health model and investing in early intervention and prevention has been a recurring recommendation and repeatedly called for by those of us committed to improving the wellbeing and safety of children.

Many governments have increasingly adopted public health based polices in relation to child protection, as evidenced by the state and federal collaboration on the National Framework for Protecting Australia’s Children – a national policy premised on a public health model.

Yet in many ways, the mantra that prevention is better than the cure has failed to translate from political rhetoric into meaningful change. This is most clearly seen in budget breakdowns. Significant and sustained funding for prevention and early intervention has yet to become embedded in Federal and State budgets.

Australian service systems continue to remain reactive rather than preventive, with only 16.6 per cent of total child protection expenditure nationally invested in early intervention and prevention.

Nationally in 2015-16, $2.7 billion was spent on out-of-home-care (accounting for 57.4 per cent of all expenditure on child protection services). This amount has continually increased over the last five years.

If we want to see fewer children coming through our hospital doors with injuries no child should experience, we need to stop tinkering at the edges of a broken system. Significant transformation is needed to get families the help they need, quickly and early on, to prevent the worst from happening. To this end, the AMA has been following the development of an ambitious new advocacy campaign to address the persistent barriers to change.

This campaign, initiated by The Benevolent Society in partnership with more than 20 organisations across a range of sectors, aims to put the wellbeing and safety of children on the public and political agenda. The campaign will be calling for greater Government accountability for improved child wellbeing outcomes and will advocate for adequate funding to ensure that families getting the right support at the right time.

While this campaign is still in its early phases – with a public launch forecast for later this year – the AMA is keeping a close eye on its development and providing input into the campaign objectives.

SIMON TATZ
AMA DIRECTOR, PUBLIC HEALTH

Government focus on rheumatic heart disease

Rheumatic heart disease is receiving serious political attention, as the Federal Government makes inroads into addressing and improving the health of Aboriginal Australians.

Indigenous Health Minister Ken Wyatt has convened a roundtable in Darwin to look at charting a comprehensive roadmap to end rheumatic heart disease (RHD).

The roundtable brought together RHD and infectious diseases specialists, health professionals, Indigenous health advocates, philanthropists, service providers and government agencies.

“RHD and acute rheumatic fever take about 100 Aboriginal and Torres Strait Islander lives each year and many of these are young people,” Mr Wyatt said.

“The tragedy is compounded by the fact that RHD is almost entirely preventable, with many organisations, including governments, grappling strongly with pieces of the RHD elimination puzzle.

“Now, through this roadmap we are determined to tackle the whole challenge and eliminate this disease as a significant Indigenous public health problem.”

RHD is a long-term outcome of a condition called acute rheumatic fever (ARF), which typically occurs in childhood. As a result of ARF the affected person develops inflammation of the heart valves with resulting damage and malfunction. ARF typically precedes the RHD by decades.

RHD can be usually resolved if it is detected early, but people are being treated for the condition when it is too late. RHD is most accurately diagnosed using ultrasound.

Indigenous children and young adults in the Northern Territory are estimated to suffer from RHD at more than 100 times the rate of their non-Indigenous counterparts. The Kimberley is also an RHD hotspot, with two-thirds of all Western Australian Indigenous people suffering from RHD living in the region.

The Government has allocated $23.6 million under the Rheumatic Fever Strategy over the next four years. It is also working to address the underlying social and cultural determinants that contribute to RHD, including providing $5.4 billion to States and Territories to help them to provide remote housing, under a national agreement. While the Agreement is due to end on 30 June 2018, the Commonwealth has begun discussions with State and Territory Governments on future funding arrangements.

“While RHD affects children and young adults around the world, in Australia it is a sad reflection of the health gap between Indigenous and non-Indigenous children,” Mr Wyatt said.

“We know this is a disease of poverty, of overcrowding, of difficulty with access to health services.

“The roadmap will acknowledge there is no single silver bullet to eliminate RHD. We are now looking to tackle all the determinants – including environmental health, housing and education – as we work together to help strengthen these communities against this devastating disease.”

AMA President Dr Michael Gannon has repeatedly described the lack of effective action on RHD to date as a national failure; calling for an urgent coordinated approach.

At the launch of the AMA’s 2017 AMA Report Card on Indigenous Health, Dr Gannon said: “Governments must fund health care on the basis of need. There is no doubt whatsoever that funding and resourcing of Indigenous health does not meet the overall burden of illness.”

A copy of the AMA’s 2016 Indigenous Report Card, which focused specifically on RHD, can be found at: article/2016-ama-report-card-indigenous-health-call-action-prevent-new-cases-rheumatic-heart-disease

MEREDITH HORNE