Medical Director update 12 November

Medical Director update 12 November: Treating unvaccinated and unmasked patients

This update provides you with the best information we have right now.

Last year when we moved from 'normal' life to COVID-19 life everything was new and novel, uncertainty reigned, but we had a lot of something we no longer always do: energy.

Let me begin today's MD update with a couple of very important messages about safety. We're fatigued now and this seems relentless, but we've got to keep going, and we can.

Keeping yourself physically safe As we move to managing COVID-19 in the community then it's increasingly likely that you'll come into contact with the virus. Take some time now to think through your protocols because keeping yourself and your practice staff physically safe is the most important thing you can do to stop yourself getting COVID19.

See how Irish GPs are decontaminating GP clinic rooms How to put on and take off PPE for home visits Fellow Dr Sandhya Ramanathan has become world famous for her YouTube channel about managing COVID-19 at home, which can also be shared with patients Keeping yourself mentally safe GPs and rural hospital doctors fronting a worldwide pandemic is important but exhausting work. Looking after our own mental health is crucial. Seeing friends, planning time away from the surgery, and a regular poker night is what keeps me happy. What are you doing?

The College has mental health resources for our members and will fund EAP sessions too if you need to talk or work through issues.

Our communications team has developed a list of GPs offering support to other GPs feeling burnt out and will be happy to share that with you too.

We can also learn from what others have done ahead of us. This week President Dr Samantha Murton hosted an international webinar with colleagues from Norway, Ireland, and Singapore who shared how they'd managed (and are managing) COVID in their communities. Watch the recording on the dashboard.

Update on treating unvaccinated/unmasked patients Since giving out our high level advice a number of our members have come back with very valid queries.

As we stated, GPs have a duty of care to treat all enrolled patients. It is essential that a separation continues between patients who have respiratory and non-respiratory symptoms - whatever their vaccination status.

How each medical centre manages this will be dependent on a number of factors including whether COVID-19 is endemic in the community, the medical centre layout, and existing procedures. The principles outlined below are to give overall guidance. How this is interpreted is up to individual practices and considering the risks and protection of staff and patients.

Prior to the vaccination rollout we managed all patients as if they were at risk of getting COVID-19. Access to vaccinations now means we have patients who are at less risk of getting COVID-19, but there remains a group who continue to be at high risk. This group includes children under 12 years, people who have not (or cannot) be vaccinated, and those who are vaccinated but have significant co-morbidities or immunocompromised.

Recent correspondence with epidemiologist Professor Rod Jackson, highlighted the issues very well: "Protection wanes with time since vaccination and of course is highly dependent on the number of times a person is exposed, as well as a range of other factors. There is however no doubt that the risk of infection is significantly higher in unvaccinated people and that vaccination significantly slows down the spread of covid through a workforce or community. Those numbers like a 10-20-fold reduction in transmission come from modelling the cumulative effect of reduction in risk of infection per exposure and the slowing down of spread. These are reasonably robust models. Furthermore, we will soon be rolling out boosters which will substantially increase the protection against infection. Of course, the greatest benefit of vaccination is the protection against severe disease which does not appear to wane much with increasing time since vaccination. This not only keeps people out of hospital, but it also reduces the time people are likely to be away from work, as well as bei ng hugely beneficial for the individual."

From your feedback it is apparent that managing this group through a "red stream" has unintended consequences and puts them at additional risk of being exposed to COVID-19 from other patients in the same area. We have therefore modified our advice based on the principles of triage/assessment, usual hygiene standards, keeping patients separated within the waiting room as much as practicable, other social distancing measures, wearing appropriate PPE, and ensuring rooms are ventilated as much as possible.

We have also asked the Ministry of Health to look at the evidence for PPE requirements between vaccinated and unvaccinated patients. When we receive this information, we will share it with you.

Principles of Care: Unvaccinated patients

As a general practice you may have concerns about patients entering the practice who are not vaccinated/not able to be vaccinated. Although these people present a potential clinical risk to themselves, practice staff and other patients, you have a duty of care to provide medical services to all patients registered with you, even if they are not vaccinated.

We have had protection in place for all patients in this category since the start of this pandemic. You therefore should continue the established measures to minimise the risk that unvaccinated patients may pose to staff and other patients.

Where possible patients should continue to be triaged before they arrive in the practice. Vaccination status will be known for many but should be confirmed. If the patient is unvaccinated or refuses to say, then they should be:

• • •

Offered a tele consult in the first instance to manage their medical problems remotely If a face-to-face consultation is considered clinically necessary, then the practice needs to arrange for the patient to be seen face-to-face by a clinician.

The patient should be treated according to practice procedures and appropriate precautions taken including: o separation in the waiting room (or outside the practice) o masks for the patients o usual hand hygiene o the use of appropriate PPE by clinical staff interacting with the patient o ventilation as much as possible in consulting room (ventilation guidance available here, opens to PDF)

It is essential that a separation continues between patients with respiratory symptoms and non-respiratory symptoms whatever their vaccination status. Patients who are unvaccinated need to be identified as they are at higher risk of having COVID disease and will need to be treated with extra caution when presenting with respiratory symptoms.

Principles of Care: Patients who refuse to wear a mask Patients who refuse to wear a mask (or have an exemption), may not be identified until they reach the practice. Again, there is a duty of care to see these patients if they are unwell. If they have respiratory symptoms they should be managed according to the practice respiratory stream protocols.

Otherwise these patients should be managed by: • • •

If they present without a mask, they should be asked to wait outside or to wear a mask while in the practice Their vaccination status should be confirmed The patient can be triaged and offered a telehealth consult to manage their medical problems remotely.

• •

However, if a face-to-face consultation is deemed necessary, or the patient refuses the telehealth consult, then the patient will need to be seen by a clinician, The patient should be treated according to practice procedures and appropriate precautions taken including: o separation in the waiting room (or waiting outside the practice) o keeping consultations to standard time limitations o usual hand hygiene o the use of appropriate PPE by clinical staff interacting with the patient o ventilation as much as possible in consulting area (ventilation guidance available here, opens to PDF)

If extra practice equipment is required in either of the above situations, the patient must be notified of any charge when they initially present. The charge must be reasonable (not punitive).

It is important that the practice processes do not adversely affect the equity of access to General Practice services.

Kia kaha!

The Royal New Zealand College of General Practitioners Level 4, 50 Customhouse Quay, Wellington 6011 PO Box 10440, 7 Waterloo Quay, Wellington 6140 Tel: +64 4 496 5999 | Fax: +64 4 496 5997 www.rnzcgp.org.nz Unsubscribe | Advertising | Contact