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Omicron raises concerns for GPs managing COVID-positive patients


Anastasia Tsirtsakis


30/11/2021 4:40:28 PM

With general practice expected to take a leading role in caring for mild-to-moderate cases of COVID-19, questions persist as to whether there are the necessary supports in place.

A GP consulting with a patient in a carpark.
Seeing COVID-positive patients in practice could pose risks, with use of a carpark, where available, among the ideas being floated. (Image: AAP)

Over the past 20 months, the majority of patients with respiratory symptoms have been directed to obtain a negative PCR result to gain access to general practice, amid fears of COVID-19 exposure on the premises.
 
But as vaccination rates increase and public health measures ease, the Federal Government has been clear that it anticipates the majority of COVID-19 cases to be mild, and that they will be managed in the community, helping to reduce the burden on emergency services and hospitals.
 
While the vast majority of this care can be conducted via telehealth, new measures announced last month included an MBS item number to compensate practices seeing COVID-positive patients face-to-face.

The RACGP also released updated Home-care guidelines for patients with COVID-19, including guidance on face-to-face consultations and information on when to escalate care.

It points out that only practices with ‘appropriate facilities to enable patient and staff streaming’, alongside clear training and procedures should conduct face-to-face consultations with COVID-positive patients, and states that GPs with risk factors for severe COVID-19 should not participate in this type of in-person care.
 
But with the emergence of a new highly infectious variant, which has already made its way into the community and brought with it uncertainty over the potential impact on vaccine efficacy, there are ongoing concerns regarding whether the necessary supports are in place to safeguard GPs, nurses and other practice staff who chose to conduct face-to-face consultations with COVID patients.
 
Professor Mark Morgan, a Queensland-based GP and Chair of the RACGP Expert Committee – Quality Care (REC–QC), believes the guidance released by the college is a vital resource.
 
But when it comes to the logistics at a coalface level, he says questions remain around individual practice capacity and how the model can be sustainable.
 
‘That capacity to proactively monitor patients is new work and it’s quite different work from what GPs usually do,’ Professor Morgan told newsGP.
 
‘Most practices have organised themselves to work at full capacity most of the time … so to add a layer of monitoring a continuously growing cohort of patients at home is complex.
 
‘It’s not something that can just happen overnight alongside all the normal work that practices do.’
 
As part of a $180 million package to support primary care, it was also confirmed that 150 GP-led respiratory clinics around the country will continue to be funded until June 2022 and that Healthdirect will support triage of COVID-positive patients to practices.
 
While the majority of care is expected to be delivered by telehealth, GPs have expressed concern over the new item number, entitling practices to an additional $25 to see COVID-positive patients face-to-face if deemed necessary.  
 
Professor Morgan, however, says from both a small business and health and safety perspective, the current Medicare rebates do not ensure practices can set themselves up for the task.
 
‘That includes environmental cleaning, the need for ventilation, the need for PPE and disposal of PPE, the need to have had [respirator] fit-testing and the need to be able to see the patient without exposing them to any other vulnerable patients or staff members,’ he said.
 
‘All of that has to be considered before a practice can really see a patient with this disease.
 
‘But a small increase in the patient’s Medicare rebate for consults doesn’t go anywhere close to the true cost of providing that service with that sort of safety.’
 
RACGP President Dr Karen Price has also previously acknowledged that the $25 item number is likely inadequate to cover costs and encouraged general practices to privately bill face-to-face consultations with COVID-positive patients, where possible.
 
‘The costs of providing that service in an international pandemic cannot be borne by the sector who have really saved the nation with vaccination,’ the told newsGP earlier this month.
 
‘I’d encourage GPs to … make sure they’re not running at a loss. The removal of the mandatory bulk billing allows doctors to do that.’
 
Sourcing PPE, in particular P2/N95 respirators, has also been a sticking point during the pandemic, with access through Primary Health Networks inconsistent. General practices have previously been instructed to source PPE commercially at their own expense – except in limited circumstances – and it has yet to be confirmed whether practices will be given access to the National Medical Stockpile.

Medico-legal-considerations-article.jpg
GPs are concerned that the funding allocated for practices to see COVID-positive patients face-to-face will not cover the true costs of offering the service, including PPE.  

But even in the instance that they are, Professor Morgan says practices will need to also ensure that all practice staff have access, and that respirator fit-testing is offered, along with training on its use.
 
‘With the surgical masks currently being worn, you walk into a practice and you see they drop it off their mouth if somebody is having difficulty lip reading and they touch their faces, mobile phones and keyboards frequently,’ Professor Morgan said.
 
‘They also rely on Perspex screens – which is reasonable for droplet infection – but we know this is an airborne spread disease.
 
‘If you look at the level of attention to detail that our COVID wards and ICUs have used where they’ve got experience of managing patients with COVID-19, general practice has to actually hit that sort of level of experience, and I think we’re a long way off that in most practices.’
 
While national guidance stipulates that P2/N95 respirators reduce the risk of practice staff having to isolate if they come into contact with a COVID-positive patient, Professor Morgan says there needs to be further clarification as to whether this will be consistent across all states and territories and whether there is a risk of practices having to close for deep cleaning.
 
The medico-legal considerations
While practices are taking measures to ensure the safety of their staff, under the newly proposed model, there are a number of medico-legal considerations.
 
Professor Morgan says it remains unclear as to whether staff will be entitled to claim workers’ compensation, should they contract COVID-19 at work.
 
Meanwhile, when it comes to managing COVID-positive patients, it is yet to be determined who is directly responsible for the patient – the triage service, the general practice, or the public health unit – and whether that responsibility will be uniform across the country.
 
What is clear, Dr Jane Deacon from MDA National told newsGP, is that GPs should consider their decision to take part carefully, given their likely limited experience in managing patients with COVID-19.  
 
‘This is a new model for GPs and whether they want to be involved in that process will be up to the practice,’ she said.
 
‘GPs will be experienced in telehealth by now, but with the conversion to face-to-face consultations, this may present difficulties.
 
‘Alternatively, GPs may consider home visits, which creates other issues – or will they refer the patient back to the hospital if they deteriorate?’
 
Dr Deacon said that managing the process will require extensive planning, including whether the practice has enough resources and staff. But establishing both the hospital and patients’ expectations of the GP’s role, she says, is vital.
 
‘As I understand, patients with COVID can deteriorate quite quickly,’ Dr Deacon said.
 
‘Many practices are closed on the weekend, so that would present a problem for follow up consultations.’
 
Whether there will be a consistent nationwide model rolled out is not yet known, but it is anticipated to vary from state to state. Dr Deacon said GPs should obtain as much information as possible from the health service that they are liaising with to be able to pre-empt and work through any issues.
 
‘Funding and indemnity issues need to be clarified as well,’ she said.
 
‘Of course, some practices, especially ones with more staff and more resources, may be happy to be involved in this.
 
‘But these are some of the things I think they should consider before they agree to be involved.’
 
Professor Morgan says that if the approach to living with COVID is to ‘let it rip’ through the community, he anticipates rising vaccination rates will mean ICUs will cope and hospitals will largely be spared, with the burden instead shifting to general practice.
 
‘Effectively, what they’re asking or expecting to happen is for practices that have got physical buildings and spare capacity to run like respiratory clinics with that level of protection and organisation to manage COVID-19 patients,’ he said.
 
‘And I don’t believe that there is adequate support in place for that to happen.
 
‘So I think there will be very few practices that are comfortable and confident to set up face-to-face visits for COVID-19.’
 
Disclaimer: The general information provided by MDA National is intended as a guide only. GPs should contact their indemnity provider when requiring specific advice in relation to their insurance policy or medico-legal matters.
 
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Dr Margaret Anne McAdam   1/12/2021 8:12:28 AM

What exactly is the role of the GP Respiratory centres ? When they were announced they were to be “clinically assessing “ symptomatic patients but they appear to have evolved to swab collectors , refusing to examine patients. Any pathology collector can fill that role. They are paid three times what gps are and provided all the ppe needed. Why ? They need to be centres Gps can refer to to have patients examined when they can’t bring in symptomatic or covid positive patients . Many gps are in shopping centres, don’t have car park options, don’t have separate waiting rooms and can’t see them safely without putting other patients at risk. The ppe supplies to general practice from PHN s have been meagre and not reliable. The role of these centres needs to be reviewed to ensure they are fit for their original intended purpose. Otherwise EDs will be overwhelmed as Gps have no other alternative to refer to.


Dr Kate   1/12/2021 9:53:49 AM

Yes Dr Margaret, the obvious question is why is the Medicare rebate for face to face assessment and treatment of unwell covid positive patients not set at the fee the 'GP Respiratory Centres' have been receiving? This rebate , with the option of charging a gap fee for the thorough assessment and ongoing care in their usual practice would go a long way to encouraging worn out GPs to make the necessary logistical changes required to see these patients. We are planning to block off one doctor each afternoon for 3 hours to see (in full PPE in a room with external access)) up to 9 patients who have been assessed by phone by our practice as needing clinical review that day - but even at a level B or C consult plus $25 this is costing the GP money and who wants 3 hours in PPE in Summer for lower income? And meaning a whole load of other regular patients with non Covid needs wont get an appointment in that 3 hours.


Dr Kathleen O'Brien   1/12/2021 10:01:40 AM

The GP-led respiratory clinic in my area does clinically assess and examine patients. They provide an important and valuable service to our patient population.


Dr Ben   1/12/2021 12:39:45 PM

$25. No PPE provided. Has to be COVID-19 positive
vs.
$120 to swab . Full PPE. <0.1% positive.

I'll pass.