COVID-19

Update - 26 February 2021

The Ministry of Health indicated last week that in the event of a local outbreak or Alert Level 3 / 4 then N95 masks are recommended for clinicians to use when taking swabs, or when seeing patients with respiratory symptoms or HIS criteria.  

Fit testing is recommended by health and safety regulators when a new brand of mask is used, and annually for all clinicians using N95 masks. The Ministry indicated it would only supply masks to practices that had been fit tested. We have firmly pushed back against this as testing adds only 5-10 per cent protection and is considered “the icing on the cake” rather than an essential aspect of using an N95 mask.

The majority of extra protection that N95 masks offer over and above that offered by ordinary surgical masks is achieved from simply using the mask and testing the seal when the mask is applied. You may wish to watch this seal testing video on YouTube.

Fit testing usually involves a controlled “smell” test whilst wearing a mask and takes between 15-30 minutes per person. Around 20 per cent of clinicians do not achieve a perfect fit when tested. This group may need alternative brands of masks, changes in facial hair distribution, or acceptance they are not getting the extra benefit from a perfect fit.

Practices have asked that we build capacity so that each practice has a fit testing kit and qualified fit tester on staff. This will take time to achieve. We know some practice are arranging fit testing of their staff through local OSH providers, this is totally understandable. We expect to have a clear plan of action describing the support we can offer for each district by the end of next week.

We are asking each DHB to help us train a cohort of “fit test trainers” that can come out to practices and build this capacity in your teams.

At a national level we are working with others to ask the Ministry to provide appropriate standards for fit testing in community settings (the required standards may not be the same in a practice as they are in an ICU) and to encourage DHBs to support fit tester training in their districts.

Additionally, we’re working with the Ministry to identify other aspects of infection control advice that need to change given the virus is now acknowledged to be spread via the airborne route.

For further information or comments please contact our medical director Dr Jo Scott-Jones, details at the base of this webpage.

This POAC service provides funding for the initial assessment for COVID-19. The funding criteria applies to care delivered from 26 August 2020. 

View the details in the programme section of our website:

• Lakes 
• Tairāwhiti 
• Taranaki
• Waikato

Information adapted from that published on The Royal New Zealand College of General Practitioners website. 

Although community spread seems to have been eliminated at this point, COVID-19 will remain a possibility in the community until the vaccine programme is well underway. Strict border controls will need to remain in place to keep COVID-19 out.

There needs to be a shift in emphasis to the principles of infection control. Hand washing, surgery hygiene, use of personal protective equipment (PPE) when appropriate, and physical distancing are still the mainstay of controlling infectious spread. We have a duty of care to our communities, and to our most vulnerable patients particularly the elderly, those with co-morbidities, and those living in deprivation.

A few key points for Alert Level 1:

• General practice is open for business, and full acute and chronic services should be offered.
• It is ideal practice to triage same day patients by phone and to “green / amber/ red” stream patients in Alert Level 1.
• All in-person visits should be preceded by assessment at reception for any symptoms of respiratory illness and COVID-19 risk.
• It’s still worthwhile to help patients keep a safe distance from each other and staff. This will help to minimise the spread of COVID-19 if community transmission returns. Don’t take down your sneeze guards if you have them.
• Patients with respiratory symptoms need to be separated from other patients within the practice, provided with a surgical mask and must maintain a two metre distance from others in waiting rooms.
• COVID-19 tests should be encouraged for all patients with potential symptoms.
• As always, scrupulous hand hygiene before and after each patient examination is essential.
• PPE should be used according to Ministry of Health guidance for patients with respiratory illness - they wear a mask, you wear a mask, droplet PPE when taking a swab.
• Proactive care and long-term management is key for patients with chronic disease.
• Full preventative services should be offered including screening, immunisations and contraception services.
• Medicolegally, any deviation from your standard practice as a result of COVID-19 should be documented in the patient’s notes.

In Alert Level 1 practices should continue to offer telephone, video or other virtual consultations to give patients flexibility in how they interact with their GP, and to maintain our ability to move back up a level if required.

Some practices are shifting to wearing masks with all patients, this is not part of our guidance, but understandable when many have had the experience of patients with respiratory symptoms slipping the net of pre-appointment questioning.

The RNZCGP and Unite Against COVID-19 websites have further information on management at various Alert Levels.

COVID-19 is a possibility in the community, physical distancing and handwashing is still the mainstay of controlling COVID-19.

We have a duty of care to our communities, in particular the most vulnerable people like the elderly and those living with co-morbidity and in deprivation.

The principles of Alert Level 2 are the same as Alert Level 3.

1. Reassure patients general practice is open for business. "The first service to contact for community medical care is your general practice."
2. Offer telehealth consultations to patients.
3. Ask yourself whether you will add significant value to the patient by an in-person consultation compared to a telehealth consultation.
4. In-person visits should be preceded by telehealth triage or assessment.
5. Maintain physical distancing procedures within the surgery. In particular, patients with respiratory symptoms need to be separated from non-respiratory within the practice, maintain 2 metre separation in waiting rooms.
6. Scrupulous hand hygiene required.
7. Use PPE as appropriate (mask for clinician, mask for patient with symptoms - droplet PPE taking a swab).
8. Equity is central to care with a focus on M?ori, Pacific and vulnerable populations.
9. Investigations should be provided for acute and chronic medical care.
10. Proactive care is important for patients with chronic disease.
11. Continue to increase the focus on long-term management for those patients with chronic conditions.
12. Continue to increase focus on elderly, children, and mental health.
13. Core services should be provided - preventive screening, immunisations, contraception services and acute care.
14. Medicolegally any deviation from your standard practice as a result of COVID-19 should be documented in the patient's notes.

As a guide in Alert Level 2 we anticipate that around 50 per cent of consultations will be "in-person" and 50 per cent will be through telephone, video or other telehealth means.

• See also the Ministry's health and disability services at Alert Level 2 advice (PDF).

An update from Dr Jo Scott-Jones, Pinnacle MHN medical director

The community response levels that we are all now too familiar with are designed to inform the public and businesses about how to behave to reduce transmission of the virus. These response levels have an impact on the way we do business, but they are NOT designed to respond or direct the way specific HEALTH SERVICES work. You will recall that as the community response level dropped from Alert Level 4 to Level 3 there was no significant change in the advice for health service delivery.

This can cause confusion for our general practice teams. In all alert levels general practice is an essential service and practices will be open. However, appointments will be conducted online or by phone where possible. Patients can see a doctor or nurse face-to-face if required.

During the lockdown we know there was a significant drop in core activity such as immunisation and cancer screening that is likely to have caused additional morbidity, and mortality. If and when the community response Alert Levels change we need to learn from the lesson of the past few months and ensure that we continue to deliver the most important services as safely as possible.

The basic principles

1. Keep yourself, your staff and your patients safe.

• Telephone first all patients and direct them to "green / amber / red" streams of care.
• Provide for physical distancing for people using the waiting room.
• Wear a mask if the patient has respiratory symptoms, have the patient wear a mask.
• Use droplet PPE if you are taking a respiratory swab.
• If staff cannot maintain social distancing at work - wear a mask / face covering.

2. Keep providing core services for as long as you can within principle 1.

• Immunisation, cancer screening, minor surgery for suspected cancer, contraception services as safely as you can for all patients.
• If you have to reduce access to any service keep it going for the highest need populations for as long as possible, such as Māori, Pacific, Deprivation 9-10 and those at highest risk, for example previous cervical cancer needing follow up.

3. Make contact tracing easy

• Have the Ministry of Health QR code available for patients and staff. (All businesses must display a NZ COVID Tracer QR code from 11:59am on Wednesday 19 August, get your QR poster.)
• Have a system to help contact tracing for people in your waiting room (CCTV / a written list).
• Ensure staff are keeping records of their close contacts.

4. Help identify cases

• Swab people according to the criteria - offer swabs to everyone with symptoms, especially if they meet HIS criteria, don't do asymptomatic swabs unless you are told to by public health units.
• Gear up and provide swabbing in your clinics if you aren't already.
• If to meet principle 1 you can't provide swabs yourself then support the alternative swabbing services (if you bake a cake - mine's a chocolate one.)

If the prevalence of the disease increases in your community then you may not be able to differentiate between the "amber" and the "red" patients - the amber stream may need to be closed down.

If services get overwhelmed you may need to reduce access to core services - If this happens please let us know and we will support you to find help for your patients if we can.

I currently am working with the Ministry of Health and the College on the community health response framework and will keep you up to date with all developments.

27.01.21

The recent Northland case, and new strains of virus which have greater infectivity rates evident at our borders, indicate we are only a few missteps away from widespread community transmission. It would be a tragedy if the next case is diagnosed after hospital admission, and as much as ever GPs are at the front line of disease prevention. 

It is worth reminding staff and patients that the criteria for testing have not changed – anyone with symptoms should be offered a COVID-19 swab. The daily numbers of swabbing for COVID-19 across our network have been steadily dropping since September 2020 (see graph below) and whilst the public health units are not concerned, now is the time to refresh practice COVID-19 prevention and testing protocols, and review your business continuity plans - see links below to all our COVID-19 resources. 

It is still important to triage patients at reception (or by phone triage prior to consultations), and to “red” stream patients who have high risk criteria. Many practices are also still using separate rooms to take swabs.

COVID-19 network swabbing daily numbers

26.01.21

We have had numerous enquiries about COVID-19 testing for asymptomatic patients who are concerned about the Northland community case. There has been no change in the criteria for access to free COVID-19 tests at this time.

Anyone with symptoms should be encouraged to have a swab, asymptomatic close and casual contacts will be advised by the Ministry of Health to have a test. People who are concerned that they may have had contact/been in the vicinity of the current community case should call Healthline for advice on 0800 358 5453 – if they are advised to have a test this is free under the scheme. 

The places and times that are of concern are available on the Ministry of Health website. 

What to do if a person was at one of the locations of concern during the relevant timeframe

If a person contacts you who was at one of the locations of concern during the relevant timeframe advise them to:

• stay at home
• contact Healthline on 0800 358 5453 to understand if and when they need to get tested.
• if they begin to feel unwell or start to develop COVID-19 symptoms, get a test immediately
• if they receive a negative test, they need to continue monitoring their symptoms for the next 14 days - if they develop any COVID-19 symptoms they will need to organise another test
• ensure they wash hands regularly with soap and water, or with hand sanitiser.

In the unlikely event of a patient just turning up at your surgery and expressing anxiety, the ideal would be to consult with Healthline first so they can register the patient and the concern. If this option isn't practical, taking a swab becomes your judgment call and should be based on your assessment of the risk.

It is important to emphasise to all patients and staff who have a smartphone the value of using the QR scanner and bluetooth function on the NZ COVID Tracer app.

If you have to close the practice (on advice from Medical Officer of Health) after a confirmed case

• Inform the PHO CEO (phone 021 925 812 / email helen.parker@pinnacle.health.nz) as soon as you know this is a necessary step, let us know the potential length of closure and re-opening protocol.
• Instigate your business continuity plan (please see our page on planning for pandemics and emergencies for more guidance).
• Inform staff of pending closure and process to follow.
• Inform patients of impending closure.
• Notify neighbouring practices / services of impending closure and agree process for practice patients during closure period.
• Continue to provide virtual services wherever possible.
• Arrange thorough cleaning of practice.

If you have to close the practice due to workforce issues

• Inform the PHO CEO (phone 021 925 812 / email helen.parker@pinnacle.health.nz) as soon as you think this may be necessary.
• Inform staff of pending closure and process to follow.
• Inform patients of impending closure.
• Notify neighbouring practices / services of impending closure and agree process for practice patients during closure period.
• Continue to provide virtual services wherever possible.

The Ministry of Health has confirmed there is no centralised advice or support for travellers, but there are some generic guidelines. Different airlines, countries, businesses, universities and schools overseas will have different requirements. Private COVID-19 testing is available in all districts, contact your lab for guidance on availability and processes.

• Swabs taken for travel purposes cannot be claimed via Primary Options.
• You can charge the patient as you see fit.
• This is not an ordinary consultation for the purposes of any fee capping for VLCA practices.

Our local leads are available for questions, concerns and advice. Please also contact one of the team if you have any issues with PPE stock - all our leads are working closely with the DHB in their region.

• Waikato - Jayne Emerson, phone 021 243 8523, jayne.emerson@pinnacle.health.nz
• Taranaki - Tama Tamatea - phone 027 212 6704, tama.tamatea@pinnacle.health.nz
• Lakes - Pen Blackmore, phone 021 413 760, pen.blackmore@pinnacle.health.nz
• Tairāwhiti - Matt Tong, phone 027 616 4817, matt.tong@pinnacle.health.nz