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COVID-19: Outpatient services; office consultations and procedures

27 March 2020

Updated 3 April 2020
 
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the risk posed to the community, health workers and all patients due to the COVID-19 pandemic. RANZCOG also recognises our responsibility to respond to this situation as a large organisation and also as a medical college and health leader.
 
The College respects the role of government, health departments and health administrators in coordinating a national response. The purpose of this communiqué is to address the issue of triaging of outpatient consultations. Availability and use of healthcare resources, the welfare of healthcare workers and patients are all considerations.
 
Practice settings will vary considerably and, therefore, no advice can cover all scenarios. For example, rural and remote, solo practice, public and private outpatients and independent clinics and services will have different needs and requirements.
 
Defining ‘routine’ gynaecological care is difficult. All patients, and referring GPs, will consider that referrals for specialist care should be addressed in a timely manner. Ultimately, all appointments are at the discretion of the treating doctor, giving heed to feasibility, personal and patient safety and consideration of alternative pathways.
 
Most health authorities have already recommended reducing face-to-face patient interactions and to actively transition outpatient appointments to telephone or telehealth, where safe to do so. Telehealth consultations can be conducted in Australia and New Zealand. Where practical, this may adequately address patient issues and act as an appropriate triage to determine the need for an in-person assessment. In Australia, the Federal Government is reviewing the criteria for MBS billing and it is hoped that accessibility will be broadened very soon.
 
As a general approach, consider
 
  • Is the patient’s condition urgent, semi-urgent or elective?
  • Can the initial assessment be performed through telehealth?
  • Can the patient be better, or more efficiently, assessed, or managed, by another service or service provider?
  • Will the patient require specimen collection or imaging?
  • Care with privacy and documentation should be maintained.
 
Patients with confirmed Covid-19, those in isolation or who are screen positive should not be seen in-person unless the clinical circumstances allow for no other options. Appropriate PPE should be used.
 
All patients and accompanying persons should be routinely screened for risk factors including travel, exposure and symptoms. Patients meeting these criteria should be advised to attend a sanctioned screening centre.
 
Office and outpatient hygiene precautions
 
  • Reduce, where possible, the number of consultants and staff present in consulting rooms at any one time 
  • Discourage accompaniment  of partners, children or others, unless essential.
  • Hand washing before and after seeing patient
  • Avoid non-clinical contact
  • Observe social distancing and introduce options to reduce the time in waiting areas
  • Arrange waiting room and consulting room seating with safe spacing
  • Wipe down all surfaces that the patient has touched with appropriate disinfectant
 
The following questions and suggestions are not exhaustive and will be constantly reviewed, revised and updated. Again, we emphasise that all practitioners should use their own discretion. It is often valuable to seek a second opinion, if available.
 
 
What should I do about colposcopy patients?
 
Patients with a positive cervical screening test will be appropriately anxious. Likewise for the health care provider, balancing patient, personal and community risk with best practice is challenging during these exceptional times. Resources and general guidance provided AHPRA (Australia), Medical Council of NZ, Medical Defence Organisations are available. Seeking a second opinion may also be beneficial.
 
The overriding principles and good practice points for colposcopic assessment and treatment include;

1.            Counselling through telehealth can be very effective. Advising colposcopic assessment where high risk features are identified is appropriate
2.            When seeing patients face to face, follow the general recommendations for social distancing
3.            Higher risk patients (pHSIL, HSIL, glandular with or without symptoms) should continue to be seen
4.            Unless there are contraindications, consider treatment under local anaesthetic cover. Colposcopy associated treatment is considered a category 2 elective surgery (HSIL with suspicion of invasion category or extensive HSIL or glandular pre-cancer (ACIS) category 1).
5.            Local hospital requirements may limit your access to resources to provide treatment. Consider referring treatment to a colleague with access or deferring treatment if your colposcopic assessment suggests a low level of concern for a malignancy.

What should I do if a patient is referred to me with abnormal uterine bleeding?
 
Consider if this is an acute emergency or chronic condition, and the risk of malignancy. Telehealth consultation will assist in triage. The Cancer Australia flowcharts are useful for assessing patient with abnormal vaginal bleeding.
 
What if my patient needs an STI screen?
 
Where possible, screening should be undertaken in primary care, or through telehealth (accepting the need for pathology specimens). Acute pelvic pain e.g. suspicion of e.g. ectopic pregnancy or tubo-ovarian abscess is Category 1 and requires more comprehensive assessment.
 
What if my patient requires contraception management?
 
Non-procedural advice can be conducted through telehealth. If a procedure is required e.g. high risk of unintended pregnancy, insertion of LARC, consider the best setting for this to be performed.
 
My patient is considering fertility treatment. What should I tell her?
 
The Fertility Society of Australia has issued guidance. As a guiding principle, ask if the situation is time critical e.g. cancer patients prior cytotoxic or radiation treatment.
 
RANZCOG recognises that decisions around resource allocation are complex, and multifactorial, and accepts that discretion will be applied, by individual practitioners and local jurisdictions, in this regard.



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