Elective surgery a ‘complex issue’ as GPs continue to face PPE shortage

Anastasia Tsirtsakis

22/04/2020 5:00:14 PM

If a PPE shortage for GPs mean reduced COVID-19 testing capacity on the frontline, what will the consequences be for elective surgery in hospitals?

Doctors holding mask
It is estimated about 25% of elective surgery activity will reopen at the end of the month, but will there be sufficient PPE?

Elective surgery is set to resume in a staggered approach – but questions have been raised over whether supplies of personal protective equipment (PPE) will be enough for the new demand.
Federal Health Minister Greg Hunt said the easing of elective surgery restrictions will take place via a staged and controlled process that considers the ongoing need for the capacity to treat COVID-19 patients.
It is estimated about 25% of elective surgery activity will reopen on 27 April.
The national cabinet’s decision is largely down to the success of containment measures suppressing the spread of the virus, which has allowed for an increase in hospital capacity, including more than 3000 new ventilators and 60 million masks for the national stockpile.
But experts have called for the return to normal to be managed properly based on patient need, while ensuring distribution of PPE is equitable.
Associate Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), has welcomed the reopening of elective surgery, given the significant knock-on effect delays can have not only for patients themselves, but throughout the healthcare system.
‘I would be very keen to make sure that decisions on which elective procedures go ahead are made on a patient need, not on who can afford it,’ Associate Professor Morgan told newsGP.
‘The national stockpile of PPE needs to be effectively controlled and used across all of the places in the country where it’s needed, particularly general practice and [the] community. I think there’s a real danger if this isn’t managed properly and [hope] that isn’t taken over by purely economic considerations from the private health industry.’
While large supplies of PPE have reportedly been distributed through Primary Health Networks (PHNs), Associate Professor Morgan said a significant shortage remains for GPs.  
‘We hear huge concern from GP colleagues that availability is patchy and one week there’s an availability of masks but a lack of availability of gowns or eye protection,’ he said.
‘PPE is a complete kit; you can’t have one bit of the kit and not the next bit and go, “yeah, we’ve got an abundance here”. You need all of it.
‘I would hope that there’s real-time monitoring of availability of the full kit of PPE and where it’s needed before we get widespread relaxing of rules around elective surgery.
‘I certainly know locally that people want to actually physically see or actually have it hands-on, rather than just the promise that it’s available.’
Dr Kat McLean, who is actively involved in setting up a general practice respiratory clinic on the Gold Coast, has experienced the challenge first hand.
While she supports the opening up of surgery from a patient’s perspective, she said the overall picture is ‘complex’.
‘I do really worry that the supply chains of PPE to general practice are almost thought about in a different space to the hospitals and I worry that in some regard it’s still forgotten about,’ she told newsGP.
‘We’re still going to hardware suppliers and paint shops and sourcing unconventional [stocks] of PPE.’
Dr McLean said GPs want to be able to step up and support the health sector by keeping people out of hospitals, but that becomes exceedingly difficult when doctors cannot protect themselves.
‘We need to continue to be able to test really broadly, but we need PPE to be able to do the testing. So if we don’t have PPE our testing capacity drops,’ she said.
‘I’m anxious that we’re not well-prepared [and] I think we’re incredibly fortunate that things didn't escalate when they did, or we would be in dire straits now.’
RACGP Victoria Council member Dr Bernard Shiu is one of the GPs advising the Victorian PPE taskforce. 
He said the PPE flowing from the national stockpile is largely surgical masks, with a smaller number of N95 masks.  
‘The PHN will not be able to completely provide every single item for them. So they may still have to source it privately for their needs,’ Dr Shiu told newsGP.
If a clinic does not have adequate PPE, Dr Shiu recommends assessing what services they can provide.
‘Individual clinics need to look at what kind of patient they do see, and match it with what PPE they actually have,’ Dr Shiu said.

‘So the very important message is if you don’t have good enough PPE for that particular patient cohort, please do not see them. If you have the capacity to see them, go ahead and see them.’
Concerns remain that if GPs are forced to turn patients away, it will have a flow-on effect for hospitals, which could in turn impact elective surgeries.
And it is still very much early days.
The World Health Organization’s (WHO) director-general Tedros Adhanom Ghebreyesus has warned that on a global scale, ‘the worst is yet ahead of us’.
‘Easing restrictions is not the end of the epidemic in any country,’ Dr Ghebreyesus said at a media briefing in Geneva on Monday. ‘So-called lockdowns can help to take the heat out of a country’s epidemic.
‘Early data suggests that a relatively small percentage of the populations may have been infected. Not more than 2­–3%.’
But Associate Professor Morgan said those figures, given our limited understanding of COVID-19, are likely wrong.
‘You might find that 1% or 2% that’s being quoted is actually the false positive rate of the test rather than the actual rate of who has really got antibodies,’ he said.
‘You might have a percentage of people with antibodies, but until we know whether [people with] antibodies are protected, then you can’t say that anyone is immune from the risk of infection. So there’s a vast proportion of the population that is still at risk.
‘The prediction for Australia is that if we can keep the numbers small enough that public health departments can contain sporadic outbreaks … and allow us to relax some of the social distancing rules and some of the economic shutdown that’s happened.
‘But it’s very easy to exceed the ability of public health to manage once we have simultaneous outbreaks in different parts of a state.’
The Federal Government has said health administrators will monitor supplies of PPE, intensive care unit and bed capacity, while preparing for the next phase.
A review will be conducted on 11 May to decide whether all surgeries and procedures can recommence more broadly.
In addition to Category 1 elective surgeries, hospitals will initially recommence one in four closed operating lists, with a focus on Category 2 and some important Category 3, including:

  • procedures representing low risk, high-value care as determined by specialist societies
  • selection of patients who are at low risk of post-operative deterioration
  • children whose procedures have exceeded clinical wait times
  • assisted reproduction (IVF)
  • endoscopic procedures
  • screening programs (cancer and other diseases)
  • critical dental procedures.
 The RACGP has more information on coronavirus available on its website.
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Dr Ian Mark Light   23/04/2020 6:43:10 AM

With the threat people would hope Australia would be able to create its own PPE industry .
Already there are cottage suppliers in Bendigo for example gowns are being produced and Shepparton is producing surgical masks .
Disposable head visors have been produced .
Australia is acquiring a stockpile but efforts to build a national industry ought accelerate .