COVID-19

An update from Brandi Hudson, Māori health director.

A COVID-19 Māori response action plan is presently being drafted by Pinnacle staff for Pinnacle MHN. This will assist us to be strategic about how we prioritise our resources and collaborate with hauora Māori organisations and the DHBs.

Māori vaccination rates continue to track lower than the rest of the population. Presently in Pinnacle MHN, 36 per cent of Māori patients have received their first dose and 15 per cent have had their second dose.

Tairāwhiti iwi organisations have set up fun incentives and competitions to encourage whānau to receive their vaccinations. These include whānau vaccination selfie competitions, grocery vouchers and iwi radio promotions.

We know that vaccinating those who have not had theirs yet will be challenging due to hesitancy issues, their trust in the health system and finding those who have not responded to phone and email messages. We are already considering short and long term strategies to address the issues including working with the Māori doctors in our network.

The Ministry of Health has given a short update on the topic of pulse oximeters. Specifically they were asked the following questions, and have replied yes to all.

• Have we decided to, or managed to secure a supply of pulse oximeters going forward?  
• Have we got clinical engineering endorsement on any pulse oximeters for use in the primary care setting?
• Are we planning on establishing a central supply of Pulse Oximeters that can be distributed out to “hot spot” areas in the event of a local  outbreak?

The caveat to their response continues to be that the current focus of the health system response to COVID-19 is to manage all COVID-19 “community” cases in managed isolation facilities. Currently all the pulse oximeters that have been approved and procured are being sourced specifically for managed isolation/quarantine and DHB settings. 

The volume being purchased reflects the current level of requirement, this will escalate with the proper clinical and engineering sign off, validation for import etc as and when required. We will continue to update you as we hear more.

Te Puni Kōkiri’s new COVID-19 portal for Māori is live. The one-stop portal has information on COVID-19 and the vaccine rollout through Karawhiua.  It includes information of particular interest to whānau and Māori communities. You will see what iwi, hapū, Māori organisations and marae are doing across the motu and find out where to get Whānau Ora support, help for your business, and information on schooling, among other topics.  

Update from Dr Jo Scott-Jones, medical director.

There is now Ministry of Health advice on what constitutes a mask exemption. There is some guidance for medical practitioners on the COVID 19 Questions and Answers for Primary Care Workers page about the sort of medical conditions which may be valid reasons for people seeking exemptions for mask wearing. Currently it states the following.

Do I need to provide a medical certificate for someone seeking an exemption to wear a mask?

No, exemptions are self-declared, with no formal paperwork required.

People who will have trouble wearing a mask due to health conditions or disability are exempt. This can include people with mental health conditions, chronic respiratory problems, facial eczema, history of oral surgery, etc. They do not need to confirm this exemption with their health provider, however, some may choose to discuss their situation with their clinician.

The legal situation is that masks are mandated for employees in workplaces that are public facing. 

There are a few situations in which they can be exempted from wearing a face covering, including medical conditions, disabilities or needing to remove the mask to communicate, however they do not require a medical certificate for this exemption. The employer will need to consider the safety risk that the mask exemption poses for the individual, other employees and the public and consider re-assigning the employee to a position that does not involve facing the public if necessary.

Disabled Persons Assembly (DPA)

Disabled Persons Assembly (DPA) will simply send out a card saying “mask exempt” to anyone that asks for one, there is no proof of anything required. This is what the Government expects.

They are however overwhelmed with calls and simply asking people to leave their details on their phoneline, they will post / email something out people. The website suggests they are the only supplier of mask exemptions, but they are not, practices can do the same.

In effect the person could write on a piece of paper themselves and this would have just as much legal validity as a “certificate” at this point in time.

Options for practices

1. Direct people to the DPA.
2. Provide a letter which says “The bearer of this note has indicated that they cannot wear a mask. Signed (practice stamp).” – these could be handed out by reception staff to anyone that asked for them.
3. Provide a more detailed personal letter to people known to the practice indicating the medical condition that you mutually agree precludes mask wearing (there are no standards or rules.)

For employers, the message is that exemption letters from GPs hold no weight and have no validity over and above a self declaration, the Govt suggests people contact DPA and get a card sent in the post.

To stop the requests from employers happening, I would suggest a phone call from the GP owner or practice manager to the employer explaining that this is not needed, but if the GPs cant get the energy to do that for each employer who asks, give the person a letter as above.

My other advice would be to feel free to charge for these letters. 

For referral to the Disabled Persons Assembly you could put up a sign saying the following:

"If you have a disability or health condition and you can’t wear a face covering safely or comfortably and would like an exemption card sent to you, please email a request for a mask exemption to info@dpa.org.nz or leave a message on 04 801 9100.

The exemption card is available as PDF and jpeg versions which can be printed in credit card size, A5 or A4, or simply downloaded onto your phone. There is also a physical wallet-sized version of the card. If you would like the physical version sent to you, please let Disabled Persons Assembly NZ (DPA) know your postal address."

Update from Dr Jo Scott-Jones, medical director.

Several large practices have asked for clarity around the rules of indoor gatherings under Level 2 delta and how those affect the number of people inside the practice at a time.

In brief, the surgery does not have to limit the number of people in the building.

The focus on 50 – 100 people at various events and venues in the Government advice does not preclude schools, universities, large businesses and others who have more than 50 people in one place from functioning. If it is impossible within a space to provide physical distancing then it may be appropriate for a business to limit the number of people on site.

Having 50 people in one room is almost never going to happen in a general practice.

The key things health care providers need to focus on are:

1. who is in the building when – QR coding, plus another private process for those who don’t have a smartphone
2. mask use – all staff and all patients should wear appropriate face coverings – for clinical interventions these should be face coverings that meet the PPE standards (surgical mask / N95 mask)
3. physical distancing – 1m for staff, 2m for patients
4. good ventilation
5. red / green streaming of patients.

Can spirometry be used in practice at level 2 plus? i.e. diagnostic vs review vs occupational testing?

Spirometry can be used at Level 2. PPE advice is on the Ministry’s website. If the patient is green streamed, there is no reason not to use spirometry.

Can we use nebulisers at Level 2?

Nebulisers should be avoided if possible. There is controversy if they are aerosol generating procedures and we would recommend avoiding in a general practice setting.

Are there any changes in the Level 2 risk matrix for staff?

No not at this point.

What is the balance of telehealth vs in person consults?

As we move down the levels face-to-face becomes more the norm. The College hasn’t mandated the balance between the two. However, we have said that screening for respiratory symptoms should continue to be carried out. Telehealth should try to be offered as an option if appropriate but face-to-face in green or red stream is acceptable.

What happens with patients wearing masks in the consultation room? 

Masks should be worn by patients and patient-facing staff at Level 2. This is consistent with the national advice at Level 2, which has changed. We know that medical centres have been conduits overseas for the spread of respiratory viruses, in particular COVID-19. In the present settings, general practice should be the leader in appropriate use of mask indoors especially in a health care setting.

What’s the advice about undertaking of more routine non-essential work (e.g. Medicals)?

These should be carried out as we move to more ‘normal’ settings.

 Please see our COVID-19 PPE guidance news page.

Border workers who are currently undertaking regular nasal (nasopharyngeal) or throat/front of nostrils (oropharyngeal & bilateral anterior nares) swab tests for surveillance purposes now have the opportunity to undertake regular saliva testing as an alternative. 

Workers who choose saliva testing must undertake a series of 2 saliva tests at least 2 days apart within a 7-day period instead of a single swab in any 7 or 14-day period for surveillance purposes. 

However, a nasopharyngeal or oropharyngeal & bilateral anterior nares swab test will still be undertaken for diagnostic purposes if a worker is unwell, or to confirm a positive saliva test result as genome sequencing cannot be done on saliva tests at this point in time, and a NP PCR test is the “gold standard” for sensitivity and specificity.

If your practice is swabbing border workers currently undertaking swab tests for surveillance purposes, you must offer them the option of saliva testing as an alternative and record their testing history in the Border Workforce Testing Register maintained by the Ministry of Health.

• More information on saliva testing is available on the Ministry of Health website. 
• If you need assistance, please contact BWTRsupport@health.govt.nz for guidance.

This POAC service provides funding for the initial assessment/swabbing for COVID-19.

View the details in the programme section of our website:

• Lakes 
• Tairāwhiti 
• Taranaki
• Waikato

For High Index of Suspicion claims please note the definition and rules that must be followed to claim under that category. The primary care quick reference guide is clear about HIS criteria - pages one and two. 

• The person must have symptoms.
• People without symptoms who have been asked by the Ministry (e.g. contact tracers) to have tests are not HIS. 

In keeping with Ministry of Health guidance, from Monday 13 September the eligibility criteria for a COVID-19 swab with HIS ($287.50 incl GST) will change slightly.

The new criteria for this claim is that the patient is symptomatic and in an evolving area, have visited a location of interest or be a close contact of a positive case.

In addition, they need to have had a full respiratory assessment in an area within your practice which has then required decontamination (i.e. not drive through or car park swabbing). 

All other COVID-19 swabs will be eligible for the COVID-19 swab claim ($138 incl GST).

NB: This also includes any asymptomatic border workers, asymptomatic people advised through contact tracing to be tested and asymptomatic workers required to have regular testing due to crossing Alert Level borders. 

These changes do not apply to care provided prior to 13 September, irrespective of the date the claim is submitted. 

For more information please contact Sally Newell, clinical services manager.

The Higher Index of Suspicion (HIS) criteria for COVID-19 for use by health practitioners has been updated. It now includes people who have, in the 14 days prior to symptom onset, travelled from an area with an evolving COVID-19 community outbreak (including in New Zealand and in any country/area with which New Zealand has quarantine-free travel), or any other criteria requested by the local Medical Officer of Health. 

The KEY issue is that HIS criteria are people WITH SYMPTOMS who meet certain epidemiological criteria - for details of the definition see the Ministry of Health website: Case definition and clinical testing guidelines for COVID-19.

The case definition and clinical testing guidelines on the Ministry of Health website have been updated to reflect these changes. 

Change in notification of HIS criteria

• The Ministry of Health has suspended the requirement for notification to the Medical Officer of Health of people who meet HIS criteria due to being in district health board regions with emerging outbreaks (notably Auckland and Wellington at the moment).
• Notifications to local Medical Officer of Health are only necessary for people outside of potential border contact if the symptomatic person was in the location of interest at the specified time.
• Please continue to indicate on the swab request if the person meets HIS criteria (including whether they have been in an region of emerging outbreak).
• This suspension will be reviewed once the Public Health Units have resumed BAU activities.
• Clarification was sought on the definition of the edges of an area of emerging outbreak - the advice is to treat any DHB region that has locations of interest within it as an area with an evolving outbreak. This means that all symptomatic people within these areas are regarded as HIS.

HIS criteria are still important as they determine for us:

• the level of PPE to wear (if in poorly ventilated space when swabbing or examining this means P2/N95)
• funding you receive (to cover clinical time/consumables and admin burden)

Public health units are swamped with contact tracing and prioritising symptomatic essential workers and those with no tracer app info. They are not acting on notifications of patients with HIS criteria.

The HealthPathways COVID-19 pages regularly updated and developed. Please contact the Midland Region HealthPathways team by email if you need the username and password.

COVID-19 Management of mild to moderate COVID in the community: Learning from Canada

Links to Professor Dee Mangin's webinar and PowerPoint are now available on HealthPathways. This is found on the shared 'COVID-19 Assessment and Management' pathway under the information section/for health professionals. 

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.
• N95 masks should be considered for use for patients with HIS especially if seen in a confined environment.
• 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. N95 masks should be considered for use for patients with HIS especially if seen in a confined environment.
9. Equity is central to care with a focus on Māori, Pacific and vulnerable populations.
10. Investigations should be provided for acute and chronic medical care.
11. Proactive care is important for patients with chronic disease.
12. Continue to increase the focus on long-term management for those patients with chronic conditions.
13. Continue to increase focus on elderly, children, and mental health.
14. Core services should be provided - preventive screening, immunisations, contraception services and acute care.
15. 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 in person if required.

During the 2020 Level 4 lockdown there was a significant drop in core activity such as immunisation and cancer screening that is likely to have caused additional morbidity, and mortality. We need to learn from this event and ensure we deliver the most important services as safely as possible whatever the Alert Level.

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.
• N95 masks should be considered for use for patients with HIS especially if seen in a confined environment.
• 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.)
• 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.
• Provide swabbing services in your clinic.
• If to meet principle 1 you can't provide swabs yourself then support the alternative swabbing services.

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.

If your service is under stress contact Dr Jo Scott-Jones, drjo@pinnacle.health.nz.

The Ministry of Health has advised that the temporary COVID-19 waiver for signatures on prescriptions from systems that are not fully integrated with New Zealand ePrescription Service (NZePS) has been extended until 21 September 2021 to allow them to be updated. 

The full extension advice can be viewed online, as well as further details on NZePS. If your PMS produces prescriptions with a barcode for e-prescribing, you are fine.

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.

• 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

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

• Inform the PHO medical director (phone 027 475 0488 / email drjo@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 medical director (phone 027 475 0488 / email drjo@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.