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Cold and flu centres

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It's essential to make medical centres safe for patients, and not as in Italy places where patients, including the most vulnerable, may pick up Covid-19

We have community transmission, so any patient with a respiratory viral illness could have Covid-19.

Ideally then such patients should be managed in a separate facility, for the sake of all patients.

The aim is:

  1. keep medical centres Covid19-free and safe for patients.
  2. for the facility and staff working there to become experts in Covid19 management protocols and infection control.

The Covid-19 testing centres set up by the government are not set up to see all cold and flu patients. If clinics agree it's best to separate Covid19 patients, it's up to them to make the arrangements;  government support may or may not follow (I am told it is underway in one region, but no official announcement)

This thread is to allow exchange of ideas on how this separation could be implemented. Some ideas posted below start with - these are my thoughts (not the College's), and in some cases are ideas  that clinics have passed on.

Please do add suggestions and your own experience and methods.

David Gollogly

 1.  Set up a regional cold and flu centre

Get together with clinics in your town / suburb and designate one medical centre (or convert other premises, ask the DHB has unused premises) as a regional 'cold and flu centre' (use simple language). Staff it with fit young volunteers, or perhaps in time covid19 immune (seroconverted) staff. Could be from private and public sectors.

 2. Set up a separate cold and flu centre away from the  main clinic

Are there local options for doing this? An unused rear entrance? Nearby empty premises (and a willing owner)? Unused DHB facility? Do you have separate entrances and facilities for UC and GP - could this be rearrranged to C19 and non-C19?

3) Car park and stairwell consults - not ideal but an interim option.

4) Triage nurse at the door - to decide disposition of  patients with viral respiratory illness:

  • Go home and self isolate
  • Go to a Covid testing centre
  • If has to be seen, where?

 

 

 

Thanks David. From my clinic in North Auckland no one has been informed of specific COVID-19 Clinics in the vicinity. The closest thing that has been suggested is a Northcross Drive-through Swabbing Service. Referrers need to call up their reception before referring patients and ensure they are appropriate. If doctors see any Dedicated COVID-19 Clinics go up, can they please let others on the forum know so we use them in the most appropriate way. Kindly.

Thanks David.  As an extension to this, our workload is reasonably split between medical and accident work.  I think there may be room for some clinics to deal with the usual ACC presentations and that the public would rightfully expect that there are safe places for them to attend.  Sitting in a waiting room with people coughing and sneezing is going to become a fairly problematic scenario if community transmission ramps up (hence efforts to control waiting areas / perhaps move to appointments for those that simply must attend).

The advantage of having designated 'accident clinics' within a community would mean that staff who were a little more mature or with milder conditions (falling short of those that probably should not be exposed to patients at all) might be able to make their valued contributions in a 'safer' environment. This might also include those caring for at risk relatives / friends.

Also, I think it is possible to apply things like ottawa rules virtually in certain groups.  I think there is plenty of scope for treatment of minor injuries through virtual consultations, even though we have spent years encouraging people to attend!

 

I think its REALLY important to not allow ANY viral illnesses into the building, and indeed noone should even be meeting them at the door. We have been doing the following process in general practice for the last week:

Essentially:

patients phone in for an appointment -triage question whether viral or not

If viral:  reception put them on a phone triage queue (this means that NO viral illnesses are allowed into the building)

Someone rings and decides from the history whether they need observations, they are then booked into "infectious clinic" -this could run all day -but in our practice its just an hour 1-2pm, -lower risk patients to high risk patients booked in that order in the clinic. They are given an appointment and asked to park in our ambulance bay (we have three parks near the building -but you could run a drive through type clinic as well).

Then a nurse dresses in PPE and goes out to the carpark with HCA with clipboard to write down obs, this might be able to be done on a tablet straight into medtech and put onto the dr video consult as each patient is done.

Patient opens window on their side 10cm, (make sure the wind is blowing away from you -open the other window to create negative breeze) -hand sanitiser applied to patient. obs RR, Temp (flick probe off into patient's car), PR, O2 saturations (use gladwrap over the finger so the Pulse ox is not contaminated -its within 1-2% try it!), are they talking in sentences and do they look sick?

Nurse changes gloves between patients, this is OK as its minimal touch, gear is wiped down between patients.

Then nurse decides which patients get video consult with the doctor from this group and those are put onto another queue. Sick ones -eg RR>24, O2 sats <92% (or whatever cutoff you are thinking of) and febrile etc can be referred to hospital.

and Voila! you have barely touched anyone.

I dont think its worth looking in ears, throats or listening to chests in this environment - all it gives you is a higher risk of infection. In GP we are treating empirically or giving back pocket scripts and our experience is that most can be triaged away with a phone consult and treated empirically and its actually reasonably efficient.

 

As the winter approaches there will be a number of important questions.

What about sick children with URTI/LRTI symptoms?

They will probably all have technically COVID19 symptoms. This is a large proportion of urgent care visits particularly in the ecening and the clinic has to decide about . 1) letting them into the clinic and

2) PPE to be worn, I would suggest mask and gloves are ideal but do we go to gowns and eye protection for all children with symptoms consistent with COVID or simple viral urti with high fever.

Then there is the aduld or elderly with cold or flu.

Questions to consider. Do you have enough staff, rooms, isolation and PPE?

Hopefully Dave we can get the new cases down to virtually zero once returnees stop arriving in the country (Qatar flights 920 and Emirates 488 - looking at YOU).  Then we can start to relax a little.  Until then I agree with designated centres for ALL likely viral illnesses or cough temp presentations in which we have a huge push to triage away after assessing history / obs SAFELY.  It is NOT appropriate or necessary for every single medical centre to be doing this.  I am already calling for purely accident centres where patients and staff can be safer.  This needs a really smart roll out soon and I'm sure people are working on this. To head into the 'mayhem'  of ILI cases in the winter (and really the collapse of any case definition) is where no one needs to go.  This worked (by luck) with H1N1 - it absolutely doesn't work this time around.  People are already queuing in their cars for asessment, many not meeting case definition; some of these people need direction to specific medical centres, not drive-through swabbing where staff are experiencing abuse. People are equating a swab with care and it's tragic to see patients being mis-directed at present.

does anyone have a good handout to manage your cold/ flu / COVID 19 symptom at home ?

Thank you

Pauline

Pauline, I have one I'll forward to you tomorrow.

Quote from Chen on 23 March 2020, 6:04 pm

Thanks David. From my clinic in North Auckland no one has been informed of specific COVID-19 Clinics in the vicinity. The closest thing that has been suggested is a Northcross Drive-through Swabbing Service. Referrers need to call up their reception before referring patients and ensure they are appropriate. If doctors see any Dedicated COVID-19 Clinics go up, can they please let others on the forum know so we use them in the most appropriate way. Kindly.

Update

Hawkes Bay - DHB declined a member's request to set up a regional C&F centre.

Wellington, Christchurch, Wanganui - might be under way; scale? Hours? Staff?

Tauranga - drive-through facility up and going; doctor and nurse able to consult a patient - seems like this would NOT be able to deal with a very large percent of the region's C&F patients.

Plus numerous testing stations which don't solve the problem of Covid-19 transfer in doctors' surgeries. All limited hours of operation.

IMO the best solution is for the MoH to take charge and mandate cold and flu centres and contact suitable staff from the public and private sector to staff them.

If there's no will in central government and no move from ourselves to form C&F centres, then, sadly, iatrogenic infection seems very likely. ALL facilities that let patients with viral illness in will pose a risk to their own staff and patients.

Almost insoluble problem trying to separate the potential Covid from other infections and from all other illnesses/accidents while at the same time keeping staff safe and patients safe from each other. Lockdown should reduce respiratory infection transmission in general easing this a little. Our solution, rapidly evolved over the last 2 weeks, and still in a state of flux:

All phone-in/booked patients GP and Urgent Care phone triaged by a doctor. Walk-in patients triaged at door by nurse in PPE. Respiratory symptoms or any fever, travel within 14 days, Covid contact within 14 days, all excluded from clinic. If needing to be seen they are redirected to "In Car Viral Assessment", seen by doctor in full PPE, with an assistant also in PPE to scribe and pass equipment from the "clean" box  (thermometer, stethoscope etc if needed). Patient is swabbed if necessary. I swab from the side, through open car window, with patient looking straight ahead so they don't cough on me. Equipment into "dirty" box for wiping down before reuse. Preprinted script if needed filled in by assistant and taken to adjacent pharmacy. All this happens in the undercover loading bay. For very sick patients the adjacent storeroom has been converted to a treatment room with some resus equipment. Not used yet. After assessment patient drives out of loading bay, parks in carpark and pharmacy put dispensed script on car roof or bonnet where the patient can retrieve it. Most don't qualify for POAC and getting payment is so far an unsolved problem, for us and pharmacy.

Nebulisers have been banned altogether apart from one in the new converted storeroom, to be used for adrenaline neb for croup or anaphylaxis, either in car or clinic, treating staff in PPE.

Non-infectious patients and all other work treated by phone/video if possible, leaving the clinic, with widely spaced chairs, as safe as we can be for those who need to come in.

Still lots of problems.

  1. Those with an injury needing treatment who also have respiratory symptoms, Covid contact or travel. Patients who want treatment lie in triage.

2. The very sick patient rushed into resus without triage because, well, that's what we do.

3. Our whole system depends on patients having a car and a cellphone. This works for almost all our patients but won't work in poorer/more urban areas.

4. Don't try distinguishing regular respiratory infections from Covid - can't be done, as we found after our first community-acquired Covid patient was allowed into clinic and sat in waiting room. Fortunately widely spaced chairs regularly wiped and no transmission resulted, although 1 staff member stood down on full pay.

5. And my biggest fear - severe risk or death for the non-Covid patient with another life-threatening condition who has suboptimal assessment. Pneumococcal pneumonia, meningococcal disease, complex medical problems in the elderly. Delayed/reduced community lab testing is already a major risk for patients on warfarin (sorry GP problem snuck in here). There was a reason we always insisted on seeing people in person, and we need to remember that, even as we treat patients on the phone.

Stay safe, as the patients now say to me.

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