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Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

Disclaimer

The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the text is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, The Royal Australian College of General Practitioners Ltd (RACGP) and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in this publication for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error, negligent act, omission or misrepresentation in the information.

Recommended citation

The Royal Australian College of General Practitioners. Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics. East Melbourne, Vic: RACGP, 2020.

The Royal Australian College of General Practitioners Ltd 100 Wellington Parade East Melbourne, Victoria 3002

Tel 03 8699 0414 Fax 03 8699 0400 www.racgp.org.au

ABN: 34 000 223 807 ISBN: 978-0-86906-580-8

Published July 2020

© The Royal Australian College of General Practitioners 2020

This resource is provided under licence by the RACGP. Full terms are available at www.racgp.org.au/usage/licence. In summary, you must not edit or adapt it or use it for any commercial purposes. You must acknowledge the RACGP as the owner.

We acknowledge the Traditional Custodians of the lands and seas on which we work and live, and pay our respects to Elders, past, present and future.

20902.11

Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics | i

Contents

Introduction 1

Guiding principles 2

1. Governance 2

2. Location and accessibility 2

3. Infection control 3

4. Triage and workflow 5

5. Assessment 5

6. Testing 5

7. Management 6

8. Follow-up, documentation and communication 7

9. Quality and safety 9

Resources 10

Appendix A – Notification templates for patients testing negative to COVID-19 11

Appendix B – Pathology request template 12

Appendix C – Completed encounter template 13

References 14

Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics | 1

Introduction

In response to the coronavirus (COVID-19) outbreak, new assessment, testing and management models have been introduced, including general practitioner (GP) led COVID-19 respiratory clinics (clinics).

These clinics aim to provide comprehensive and holistic care delivered by GPs to patients with respiratory symptoms. As well as undertaking swab testing and assessing patients who present with symptoms consistent with COVID-19, the clinics can also provide integrated care and management of patients to avoid fragmented care when the patient does not have a usual GP, or when the usual GP does not have capacity to manage suspected or confirmed COVID-19 cases. Providing feedback to and following up with a patient’s usual GP/general practice by communicating test results, physical examination outcomes and any management plans developed is key to the role of the clinics. When patients do not have a usual GP, the clinic can support their ongoing needs by linking them to appropriate service providers.

Triaging patients with respiratory symptoms at these clinics has many benefits, including:

• preventing the further spread of COVID-19 and reducing the risk of transmission to other vulnerable patients by directing patients away from general practices

• reducing the testing burden on existing general practices

• facilitating safe face-to-face consultations and examination of patients with respiratory illnesses

• increasing the capacity of existing general practices to provide ongoing healthcare to their patients, in a safe environment, to ensure patients do not neglect their healthcare due to fear and uncertainty around visiting their GP during the pandemic

• creating strong links between local service providers, including general practice clinics, pathology providers, local hospital networks/districts (LHNs) and Primary Health Networks (PHNs). This is supported through the adoption and use of Health Pathways.

2 | Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

Guiding principles

To address the needs of the health workforce and community during the COVID-19 pandemic, the RACGP recommends the following principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics.

The principles align with the core features that underpin the RACGP’s Vision for general practice:

• Patient-centred

• Continuous

• Comprehensive

• Coordinated

• High-quality

• Accessible1

1. GovernanceAll government-funded clinics should be part of a model of collaborative governance that includes:

• local general practice clinics

• LHNs

• local hospital respiratory clinics

• PHNs

• local ambulance services.

Additionally:

• risk and public liability should be covered by federal, state and territory governments when establishing clinics

• LHNs and local hospital respiratory clinics should provide specialist clinical governance support

• the state hospital system needs to support GP-led clinics, and vice versa

• clinics must function with strict adherence to pre-determined criteria for transfer of agreed patients

• doctors will require a provider number for the clinic.

2. Location and accessibilityTo ensure accessibility and patient and community safety, the clinic:

• must have direct public accessibility to reduce possible exposure to the community and risk to nearby business and facilities; that is, must not require a person to walk through another health facility (for example, a hospital) or public space (for example, a shopping centre) in order to gain access

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• should be located close to public and private transport networks (where possible) to reduce the need for patient travel

• should have available and adequate parking that adheres to council requirements

• should provide neighbouring residences/businesses with information about protocols and measures taken to ensure public safety while the clinic is established and operating.

Please note: Council parking restrictions, landlord and other business objections to the establishment of clinics may be overruled by state-specific state-of-emergency legislation. Clinics can contact their local public health unit for advice in response to clinic-location objections.

3. Infection control The clinic should be managed in alignment with:

• The Department of Health (DoH) Coronavirus (COVID-19) guidance on use of personal protective equipment (PPE) in non-inpatient health care settings, during the COVID-19 outbreak

• The DoH Coronavirus (COVID-19) environmental cleaning and disinfection principles for health and residential care facilities

• The RACGP’s COVID-19 infection-control principles

• The RACGP’s Infection prevention and control standards (5th edition)

The following protocols and considerations are essential for effective infection control.

a. Clinical and other equipmentTo maintain effective infection control, the clinic must:

• be adequately stocked with personal protective equipment (PPE), to minimise clinic staff risk exposure. Stock levels and quality of supplies should support ongoing capacity to assess and test patients

• stock each section of the clinic with items necessary to complete tasks within that section; that is, the assessment area should be stocked with examination equipment, prescription paper, computers for documentation.

b. Clinic’s physical layout The clinic’s physical design must align with infection-control principles, including but not limited to:

• separate entrances for staff and patients, where possible

• clearly marked and signed one-way patient flow, where possible

• clearly marked, segregated areas for triage assessment

• isolated areas for patients presenting with severe symptoms

• furniture layout and consultation spaces that ensure social distancing; for example, 1.5 metre minimum distance between chairs, chairs facing opposite directions, floor markings showing required physical distancing

• wipeable furniture/floor surfaces to allow effective environmental cleaning

• removal of all unnecessary objects and items, as well as removal of aerosolising equipment (that is, nebulisers and spirometry) if using an established clinic

• removal of check-in kiosks if using an established clinic.

4 | Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

c. Staff/contractor protocols To ensure staff safety, the clinic should:

• have documented evidence showing all staff (including non-clinical staff) have completed infection-control training

• have documented evidence showing all staff have received the current seasonal influenza vaccine, as per RACGP Infection prevention and control standards (5th edition) Section 2.1*

• take standard, contact and droplet precautions by requiring staff/contractors to wear a surgical mask, gown, gloves and eye protection when providing direct care to a suspected case or when within 1.5 metres of a suspected case. If a patient exhibits severe symptoms indicative of pneumonia, staff must don a P2/N95 mask and the patient must be isolated prior to transfer to a hospital for further assessment, testing and management

• not conduct aerosolising procedures in the clinic. Patients who require aerosolising procedures must be transferred to a hospital where the procedure may be performed in a negative-pressure room. This includes no sputum collection.

*If a staff member is unable to receive the recommended current seasonal influenza vaccine (for example, if there is a shortage of vaccine), practices need to use clinical judgement to decide if the staff member should be working in the clinic.

d. Protocols for use of PPERegarding the use of PPE for consecutive consultations:

• gloves must be removed and hand hygiene performed between patients

• safety glasses and face shields can be worn during consecutive patients’ specimen collections in the same location

• if surgical masks are in short supply, they can be used for periods of up to four hours during consecutive patients’ specimen collections in the same location

• a gown or apron can be worn for specimen collections from consecutive patients in the same location

• if leaving the location, or the PPE becomes contaminated, the PPE must be safely removed, discarded and new PPE donned.2

e. Patient protocolsPatients entering the clinic should:

• remain 1.5 metres from others within the clinic unless directed by staff

• have access to and be directed to use hand-hygiene products, such as an alcohol-based hand sanitiser or hand-washing facilities

• wear a surgical mask for the duration of their consultation (including in waiting areas), unless directed by staff; for example, to conduct an assessment/testing. If possible, provide masks with elastic ear loops as they are easy to put on and to temporarily remove during swabbing.

f. Environmental cleaning protocols To ensure safe environmental management, the clinic should:

• minimise the volume of equipment in clinical areas to reduce the cleaning burden and risk of transmission

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• adhere to strict environmental cleaning as per the most current advice from the DoH Coronavirus (COVID-19) environmental cleaning and disinfection principles for health and residential care facilities

• clean and disinfect frequently touched surfaces with detergent and disinfectant wipe/solution between each episode of patient care – use a cleaning detergent followed by a disinfectant, or use a two-in-one product with both cleaning and disinfecting properties

• require team members who are cleaning to wear fresh, non-contaminated gloves; a surgical mask; and eye protection.

4. Triage and workflowPatient triage and assessment should be managed through a pre-determined protocol and managed by GPs and nurses skilled in this area.

a. Reception • The reception station must be located near the entrance and before the waiting room

so patients can be briefed on requirements and expectations while in the clinic.

• The reception station must be stocked with hand sanitiser and surgical face masks.

• The receptionist must:

– instruct arriving patients to don a surgical face mask as per RACGP How to don personal protective equipment guidance, which can be displayed at the clinic entrance for patients to refer to

– instruct patients to perform hand hygiene

– obtain patient information/identifiers

– inform arriving patients of the process for clinic workflow

– explain the requirement to stay 1.5 metres away from other patients

– direct patients to the waiting room or triage station

– escalate the situation to a GP if patients require immediate review.

b. Triage station (if being used)The triage station must be manned by a nurse or GP who has received training in patient triage and clinical assessment. Patients should be reviewed by a GP when clinically appropriate.

5. Assessment• Assessment for COVID-19 should be carried out as per the most up-to-date

‘Assessment for suspected COVID-19 flowchart’ from the National COVID-19 Clinical Evidence Taskforce.

• Assessment for other pathology should be conducted at a designated inpatient unit or emergency department if required, as per current best practice.

6. Testing• COVID-19 testing should be conducted according to protocols outlined by

state/territory health departments when the patient meets the clinical or epidemiological criteria defined by the Communicable Disease Network Australia (CDNA) National guidelines for public health units.

• Testing for other pathology should be conducted as per current best practice.

6 | Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

7. Management

a. Patient educationThe clinic must provide education to patients on their requirement to self-isolate until further advised. Patients required to self-isolate can access updated information on the Department of Health website or state/territory health department website. Ideally, this information should be printed and handed to patients, or emailed to patients.

Patients must be advised to wear a surgical face mask when travelling home after the consultation if they are suspected of having COVID-19.

b. Referral to hospital Patients should be transferred to hospital for assessment and testing if they display ‘red-flag’ symptoms, including:

In adults:

• respiratory rate >20 breaths per minute

• heart rate >100 with new confusion

• oxygen saturation <=94%

• shortness of breath at rest

• difficulty breathing

• cold, clammy or mottled skin

• little or no urine output

• expectorating blood

• neck stiffness or non-blanching rash3

In infants/children:

• tachypnoea/severe respiratory distress

• severe hypoxaemia or cyanosis

• marked tachycardia

• altered mental state.4

Hospital-transfer protocols should include:

• notifying the hospital of the imminent arrival of the patient to ensure infection-control processes are implemented prior to their arrival

• using an ambulance service to transport severe cases to reduce the risk of community transmission

• notifying the hospital/ambulance service of the patient’s COVID-19 status

• advising on infection control if the patient is transported privately

• giving the patient a surgical mask to wear during transport to hospital.

c. Referral to specialistWhen referral to another specialist is required, the following processes should be adhered to:

• The referral should include the result of any COVID-19 testing (if available). If not yet available and the patient is suspected of having COVID-19, the specialist appointment should be delayed until the result is available, if possible. This should be communicated in the referral.

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• If the specialist appointment is urgent and the person’s COVID-19 status is positive or suspected, the specialist clinic should be notified of the imminent arrival of the patient to ensure infection-control processes are implemented prior to their arrival.

d. Requesting further pathology and diagnostic imaging Further pathology and diagnostic imaging can be requested as required and should adhere to the following:

• If the patient tests positive to COVID-19, any requests must include their status on the request form, including the date of testing.

• When possible, a COVID-19-positive patient should not attend for non-urgent pathology or diagnostic imaging until meeting the criteria for release from isolation as outlined in the CDNA National guidelines for public health units.

• If the pathology or diagnostic imaging is urgent, the clinic should liaise with the local emergency department to arrange for the patient to attend, ensuring the hospital is aware of the patient’s COVID-19-positive status.

e. PrescribingSuspected COVID-19 cases must self-isolate until they meet the criteria for release from isolation as outlined in the CDNA National guidelines for public health units and should not attend a pharmacy to collect prescriptions.

The clinic can send prescriptions directly to the patient’s pharmacy using the interim prescription via telehealth process. An image of the prescription can be sent electronically via email, text message or fax (provided patient consent is obtained and privacy requirements are met – refer to the RACGP’s Using email in general practice). The Home Medicines Service allows vulnerable patients to have their Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) medicines delivered to their home.

8. Follow-up, documentation and communication

a. DocumentationThe clinic should maintain clinical records of all consultations through the COVID-19 GP Respiratory Clinic App, adhering to the principles outlined in the RACGP’s Improving health record quality in general practice.

Clinical information entered into the app will populate a ‘completed encounter’ document (refer to Appendix C). This document can be provided to the patient’s usual GP, the emergency department if referral is required, or directly to the patient to ensure effective clinical handover and continuity of care.

It is not considered necessary to create additional patient notes.

b. Review of resultsThe clinic must have a system to review results that enables prompt identification of positive cases, even when the requesting GP is not on duty.

c. Notifying patients of resultsThe clinic must have a documented process to notify patients of COVID-19 test results, including any actions required depending on the nature of the result (for example, self-isolation). The method of notification will depend on the result.

• Positive COVID-19 test results must be communicated to patients directly using telehealth (to reduce further exposure risk via face-to-face consultations) along

8 | Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

with education on subsequent management. The local public health unit will also contact the patient; however, it is the responsibility of the clinic and the GP to notify and manage the patient.

• Negative COVID-19 test results may be communicated to patients using SMS (if consent has been obtained) or phone templates provided in Appendix A. An SMS may also be sent directly by the private laboratory. Some pathology providers will contact patients who have tested negative directly, if requested by the GP via the pathology request form. Ultimately, it is the responsibility of the GP to ensure the patient is notified.

d. Follow-up with usual GP and other services*Follow-up with the patient’s usual general practice and service providers – including the communication of test results and any other follow-up recommendations – is essential to minimising fragmentation of patient care. To achieve this, the clinic must be able to:

• securely transfer clinical information and pathology results to the patient’s usual GP. This may be done by requesting the patient’s GP receives a copy of all pathology results on the pathology request form; the usual GP will then be notified of results directly by the pathology provider. Alternatively, the clinic can provide the patient’s usual GP with the ‘Completed encounter’ document developed through the COVID-19 GP Respiratory Clinic App (refer to Appendix C)

• securely transfer clinical assessments, including any pathology screening, to a hospital/emergency department when patient transfer, hospital admission or follow-up testing is required at a different site

• securely transfer patient information to services involved in supporting the patient in the community; for example, income support services, community health workers

• receive notification that any clinical handover documentation has been received.

*Clinics should consider using existing infrastructure, such as My Health Record, to minimise fragmentation of care. However, contributing information to a patient’s My Health Record does not eliminate the need to adhere to usual communication workflows.

If the service is provided by the patient’s usual GP (who is their nominated healthcare provider), a Shared Health Summary should be used to upload information to the patient’s My Health Record.

If the service is provided by a GP who is not the patient’s usual GP, an Event Summary should be used to upload information to the patient’s My Health Record.

The use of My Health Record is not a requirement, but may provide additional benefit.

e. Notification to public health unitThe clinic must have a process in place to notify and document notification of positive cases to the local public health unit on receipt of results, as per local legislative requirements.

Usually, the GP who requests the test will notify the public health unit of a positive result; however, processes will differ depending on each clinic’s capacity.

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9. Quality and safetyThe clinic must exercise the same duty of care expected from traditional general practice and should principally operate in line with the RACGP’s Standards for general practices (5th edition).

All clinics should have policies and procedures in place to provide a safe working environment for staff and contractors. This includes being committed to maintaining the health, safety and wellbeing of the whole clinic team. Clinics are obliged to meet their responsibilities as employers by adhering to relevant federal and state/territory workplace health and safety laws.

10 | Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

Resources

RACGP resources• COVID-19 infection-control principles

• Infection prevention and control standards (5th edition)

• Standards for general practices (5th edition)

• How to don personal protective equipment

• How to remove and dispose of personal protective equipment

• My Health Record resources

Federal Department of Health resources• COVID-19 infection control training

• CDNA national guidelines for public health units

• Coronavirus (COVID-19) environmental cleaning and disinfection principles for health and residential care facilities

• Coronavirus (COVID-19) guidance on use of personal protective equipment (PPE) in non-inpatient health care settings, during the COVID-19 outbreak

Other resources• National COVID-19 Clinical Evidence Taskforce

Public health unit contacts

State/territory Public health unit contact

Australian Capital Territory 02 5124 9213 (business hours)

02 9962 4155 (after hours)

New South Wales 1300 066 055

Northern Territory 08 8922 8044

1800 008 002

Queensland Find your nearest unit

South Australia 1300 232 272

Tasmania 1800 671 738

Victoria 1300 651 160

Western Australia 08 6373 2222

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Appendix A – Notification templates for patients testing negative to COVID-19

(Adapted from Queensland Health Interim infection prevention and control guidelines for the management of COVID-19 in healthcare settings Version 1.12 Appendix 4 – Infection control guidance for fever clinics for COVID-19)

SMS templateCOVID-19 was not detected in your test. Call [insert number] if you need more information.

If you have been issued with a self-quarantine direction, you must remain quarantined until the end date you were given in the direction, regardless of this test result, as you may still develop COVID-19 infection.

If you’re worried about any of your symptoms, call your doctor. If you have serious symptoms, like difficulty breathing, call 000 and tell them if you have been directed to quarantine.

Telehealth (phone or video) templatesCommence by confirming the patients details.

Hi [name]. COVID-19 was not detected in your test. Have you been told to self-quarantine?

If the patient has been issued with a quarantine order:

You must remain in self-quarantine until the end date you were given in the direction because you may still develop COVID-19 infection. If you’re worried about your symptoms during this time, please call your doctor. If you have serious symptoms, like difficulty breathing, call 000 and tell them if you have been directed to quarantine.

If the patient has not been issued with a quarantine order but is currently unwell:

You must stay home until all your symptoms have disappeared. You can then return to work/life as usual, in line with current restrictions. Continue to practice social distancing and good hand hygiene.

If the patient has not been issued with a quarantine order and is currently well:

You can return to work/life as usual, in line with current restrictions. Continue to monitor any new symptoms, and practice social distancing and good hand hygiene.

12 | Guiding principles for the establishment and ongoing management of GP-led COVID-19 respiratory clinics

Appendix B – Pathology request template

This template can be used by respiratory clinics when requesting pathology for suspected COVID-19.

Example

PATHOLOGY REQUEST FORMEncounter date:

Patient details

Patient:

Address:

Mobile:

Home phone:

Patient identifiers

DOB:

Gender:

Aboriginal and/or Torres Strait Islander status:

Medicare number:

Reference:

Requested by

Provider name: Provider ID:

Clinic address:

Clinic fax number:

Clinic phone number:

Please send copy of results to

GP name:

GP phone:

GP address:

Tests and notes

Tests ordered:

Consent

Medicare Agreement (Section 20A of the Health Insurance Act 1973)

I offer to assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s) established as necessary by the practitioner.

Patient has given verbal consent to assign their right to Medicare benefits.

Patient has given verbal consent to share their pathology results.

Patient has given verbal consent for their pathology results to be sent via SMS. (Positive results will not be communicated via SMS).

Provider signature

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Appendix C – Completed encounter template

This template will be populated with the encounter notes you enter into the COVID-19 GP Respiratory Clinic App. These encounter notes can be provided to the patient’s usual GP, to the emergency department if referral is required, or directly to the patient.

App example

Completed encounterAs at: [date] Organisation:

Address:

Phone: Website:

Patient detailsPatient: Address: Mobile: Home phone:

Patient identifiersDOB:Gender:Aboriginal and/or Torres Strait Islander status: Medicare number:Reference:

Exposure detailsPresenting symptoms:

Patient travelled in the last 14 days: Countries:

Contact with confirmed:

Type of exposure: Exposure date:

Exposure details:

Further patient and assessment detailsUnderlying conditions and comorbidities:

Usual medications:

Allergies:

Relevant history:

Examination:

All vital signsBlood pressure Heart rate Respiration rate SPO2 Temperature

Outcome detailsSpecimen collected for COVID-19 pathology:

Script given:

Outcome of encounter:

Assessment and plan:

Provider signature: Provider name:

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References

1. The Royal Australian College of General Practitioners. Vision for general practice and a sustainable healthcare system. East Melbourne, Vic: RACGP, 2019.

2. Department of Health. Coronavirus (COVID-19) guidance on use of personal protective equipment (PPE) in non-inpatient health care settings, during the COVID-19 outbreak. Canberra: DoH, 2020. Available at www.health.gov.au/sites/default/files/documents/2020/05/coronavirus-covid-19-guidance-on-use-of-personal-protective-equipment-ppe-in-non-inpatient-health-care-settings-during-the-covid-19-outbreak.pdf [Accessed 20 May 2020].

3. Department of Health. Coronavirus (COVID-19) telehealth and consultations in GP respiratory clinics infographic. Canberra: DoH, 2020. Available at www.health.gov.au/sites/default/files/documents/2020/04/coronavirus-covid-19-telehealth-and-consultations-in-gp-respiratory-clinics-infographic_0.pdf [Accessed 20 May 2020].

4. The Royal Children’s Hospital Melbourne. COVID-19 clinical practice guidelines. Melbourne: The Royal Children’s Hospital Melbourne, 2020. Available at www.rch.org.au/clinicalguide/guideline_index/COVID-19/ [Accessed 17 June 2020].

Healthy Profession.Healthy Australia.