The automated consultation: lessons from swine flu
In the wake of a flu pandemic, medicine, like almost all other services and day-to-day activities, has to adapt and change. Sarah Whitehouse looks at the international medicolegal risk and learning associated with the H1N1 virus
A flu pandemic occurs when a new influenza virus to which people have no immunity emerges and starts spreading as normal seasonal flu.1 Estimates show that, given a 50% clinical attack rate, a locality with 100,000 people could expect 11,000 clinical cases of influenza-like illness in the peak week of a pandemic.2
Such a concentrated number of clinical cases would certainly change the way that healthcare professionals operate, calling for modified clinical care standards and professional guidelines and, with them, different types of medicolegal risk.
This article focuses on swine flu in the context of learning from new and evolving experiences in a constantly changing medical environment. It reflects the importance of adapting to new guidance as it is updated, and of documenting and dating any advice given.
By the time you read this article, written in November 2009, the pandemic situation and the difficulties facing healthcare professionals may look very different – but it is worth reflecting on some of the experiences that our members have been contacting us about.
Remote diagnosis
To reduce the spread of infection, and when faced with limited resources and an overwhelming number of new cases, telemedicine is often the first point of contact for patients who fear they may be suffering from swine flu. Patients who are not considered to be high-risk are expected not only to self-diagnose, but to self-care.
In the UK, the National Pandemic Flu Service (NPFS) has been established to triage patients and lighten the doctor’s load. The helpline and website algorithms provide a self-care service, allowing patients with swine flu symptoms fast access to information, a referral to seek further medical attention, or antivirals to pick up from a collection point.3
Similarly, New Zealand’s Influenza Pandemic Action Plan advises self-care in the first instance, seeking medical advice from the Healthline or, if a patient’s condition deteriorates, a healthcare provider. Between mid-June and early July 2009, calls to the Healthline exceeded 6,000 per day.4
Dr Nick Clements, MPS Head of Medical Services, (Leeds), warns: “All the usual risks are potentially magnified when you don’t see the patient face-to-face, you can’t examine the patient, and if you don’t take a full and proper history.”
Safety is the core principle of the website algorithm and phoneline. The Royal College of General Practitioners (RCGP) Chair, Professor Steve Field, supports the UK system: “It is very clear that patients with other conditions and pregnant women should be advised to contact their GP,”5 and additionally, children under one with flu-like symtoms should be seen by a GP.6
Once a GP practice has taken a call, they have accepted responsibility, and all calls seeking clinical advice should be documented. However, Dr Matthew Thompson, a GP and Senior Clinical Scientist at the University of oxford, is aware of the difficulties in remote, non-professional triage.
“What we are seeing in the UK goes against the medical tradition of taking a detailed history in a face-to-face consultation. It is difficult for experienced GPs to diagnose remotely; I would argue it is almost impossible for an untrained call-centre worker to make that same diagnosis accurately.”
Missed diagnosis
Dr Thompson notes: “Statistically, one in two children who have symptoms of meningitis will be missed by GPs in a normal setting. We can’t yet predict how many more will be missed through the automated consultation.”7
Early symptoms of meningitis can be easily mistaken for those of flu: fever, headache, stiff neck, dislike of bright lights, drowsiness, joint pain, vomiting, diarrhoea, confusion and, in some cases, but not all, a rash. Additionally, Christopher Head, Meningitis Research Foundation’s Chief Executive, warned: “Flu can make people more vulnerable to meningitis and septicaemia – outbreaks of flu are typically followed by more cases of meningitis.”
In a poll of 200 UK GP practices, more than a third of GPs had experienced patients suffering from complications after being misdiagnosed with swine flu. Complications in treatment ranged from mild adverse reactions to Tamiflu to cases of tonsillitis, meningitis and pneumonia.8
In the Caribbean, remote diagnosis is less prevalent. Here, the chief medical officers met early in the pandemic to devise a unified plan of action that encompassed most of the islands. Initially, both public and private medical practices preferred traditional case diagnosis by consultation, but when suspected and actual cases began to increase, specific case definition information was given to the public, who were advised to remain at home unless they suffered complications.
Dr Brian Charles, a consultant for MPS based in Barbados, explains: “In order not to miss other diagnoses, the public are encouraged to seek medical attention if symptoms are severe or persistent. Telephone consultation is available in some areas in the private setting, but is generally not encouraged, due to the likelihood of missed or mistaken diagnoses.”
He added: “If a patient phones in with symptoms of respiratory tract illness, they are advised to seek formal medical attention. All cases of acute respiratory illness and severe acute respiratory illness are seen by a doctor. once triaged as acute respiratory infection, they are isolated, evaluated, and swabbed if necessary.”
Prescribing antivirals
The WHO recommends that antivirals should only be used for those with a serious case of flu. Antivirals are given only to high-risk groups of patients in Australia, the USA, New Zealand, and Ireland, whereas in England they are prescribed to all those who declare swine flu symptoms. In New Zealand, Tamiflu can be purchased over the counter, and was available before swine flu cases took hold.
There are differences even within the UK. Dr Henry Prempeh, Health Protection Consultant for NHS Forth valley, says that in Scotland, access to Tamiflu is more restricted compared to England, with only high-risk patients being eligible.
Professor David Spiegelhalter, Winton Professor of the Public Understanding of Risk at the University of Cambridge, in his analysis of weekly UK Health Protection Agency (HPA) reports, found that of swabs taken from people receiving Tamiflu from the NPFS, only around 1 in 20 were positive for H1N1 when the helpline was first established. This positivity rate has increased recently, but it still means that around 90% of people receiving Tamiflu from the NPFS do not have H1N1.9
The uncertainties surrounding the nature of swine flu perhaps account for an increase in prescribing antivirals by the NPFS. Professor Spiegelhalter adds: "Some of the unknown uncertainties of swine flu are infectiousness, severity, risk of re-combination with other flu viruses, resistance to antivirals, pattern of re-emergence, and vaccine effectiveness and side effects.”10
In Ireland, Tamiflu is prescribed more sparingly. The Irish Health Service Executive (HSE), in its guidance for healthcare professionals, reminds GPs that: "Antiviral drugs are a valuable resource and need to be used judiciously so as to avoid the development of resistance.”11
Additionally, in Singapore, only those clinics which have been designated “Pandemic Preparedness Clinics” (PPCs) have access to Tamiflu. Patients are increasingly requesting Tamiflu as an alternative to enforced hospitalisation. Dr Lawrence Ng, MPS medicolegal consultant based in Singapore, tells how: "Doctors sometimes feel obliged to prescribe if they have access to Tamiflu, yet if there are adverse side effects, such as psychiatric symptoms or hallucinations in teenagers and young children, it is the doctor who has responsibility.”
Medical records
As a healthcare professional, you should be aware that antivirals may have already been prescribed when a patient presents for consultation, and of the need to take an accurate patient history to aid diagnosis – notes may not be completely up-to-date.
If a helpline makes antiviral drugs available to the patient, call-centre workers have the responsibility to make a record of that fact. The responsibility cannot fall to a third party, such as the patient’s GP. MPS advises that, in the UK, call-centre workers are employed by the NHS, so any claims involving them would be met by the National Health Service Litigation Authority (NHSLA).
A spokesman for the Department of Health said: “Once a person has been authorised an antiviral they will not be able to access another one through the National Pandemic Flu Service (NPFS) – there will be a record of an authorisation against their health number which is recorded in the NPFS database, but the authorisation is not automatically reflected on a patient’s medical record.”
Managing risk
When carrying out a telephone consultation, you should make a sound clinical judgment before giving advice. If you are unable to do this, or if there is doubt that the diagnosis is swine flu, you should arrange for a patient to be seen. Because of the need for isolation, this could potentially entail a home visit.
Advice delivered by non-healthcare staff should focus on identifying emergency situations where time is crucial.
You should ensure there is a safety net in place – patients should be clear about when and in what circumstances they should contact the practice again, for example, if their symptoms do not improve by a certain time, or if they worsen. You should follow relevant pandemic flu guidelines and be aware that they are being continually reviewed and updated. Document and date any advice given, including any telephone conversations.
Medicolegally, Dr Nick Clements explains that each swine flu-related case or claim would be treated on an individual basis. “The fact that a diagnosis is wrong does not mean that the doctor did the wrong thing – if the doctor had asked the correct questions and behaved as a reasonable doctor would do in such circumstances, then his/her actions would be defensible.”
Dr Clements also reassures doctors: “Authorities such as the GMC and, in other jurisdictions, the relevant medical councils, have to adapt the test of reasonableness in the circumstances of a flu pandemic. The English and Welsh Courts would apply the Bolam test.”
Stretched resources
The outbreak of pandemic flu is a genuine concern for countries such as South Africa, whose medical resources are already stretched.
South Africa does not have a telephonic call-in service for Tamiflu, although the Department of Health has established a swine flu hotline to help doctors with any queries or concerns they might have. MPS South Africa medicolegal consultant Dr Tony Behrman explains: “Treatment with Tamiflu is given empirically, based upon the severity of the presentation, as well as a history of being in contact with someone with a known case.”
Although the swine flu pandemic is the first to occur since the emergence of HIV/AIDS, WHo early data suggests people co-infected with H1N1 and HIV are not at increased risk of severe or fatal illness, provided they are receiving antiretroviral therapy.12
Stringent response
In Singapore, Dr Lawrence Ng explains why the response in Singapore has been different to that in the UK, Australia and New Zealand: “We have historical reasons for being more cautious – namely the SARS epidemic in 2003. The government ensured infection control measures were quickly put in place and doctors knew what to do at clinic level. In clinics, infectious and non-infectious cases were separated and kept 1-2 metres apart.”
No swine flu hotline has been established in Singapore – GPs are paid on a fee-for-service basis, which only accounts for face-to-face consultations. Instead, suspected swine flu patients are required to wear surgical masks, and medical professionals wear N95 masks.
At the outset, only one hospital in each locality was designated for H1N1 cases, with dedicated ambulances taking patients from GP surgeries or their home to the hospital in order to minimise infection – a protocol enforceable by law.
Doctors in Singapore have to follow set procedures – and enforcing the stringent infection control measures can damage the doctor–patient relationship. Dr Ng warns of the need to exercise care with patient confidentiality, as doctors are obliged to report swine flu patients.
Appropriate indemnity
During a pandemic flu outbreak, GPs may be expected to extend their current responsibilities and some retired GPs might be asked to return to clinical practice – perhaps helping with vaccination or death certification.
In the UK, the General Medical Council’s (GMC) revised version of Good Medical Practice: Responsibilities of Doctors in a National Pandemic, places emphasis on doctors doing the best that they can using the resources available to them.13 For example, if someone has a heart attack and the nearest hospital is closed or full during a pandemic flu outbreak, then a GP would be expected to do their best to help within their own levels of competence.
Members of MPS who are working in general practice during a pandemic flu emergency would be entitled to seek MPS indemnity and assistance in the usual way if they were subject to a clinical negligence claim, or another medicolegal matter, eg, a complaint.14
Dr Nick Clements advises: “If doctors change their working hours, change their job role, or return to work as a result of a flu pandemic, they should let MPS know.”
Looking ahead
In preparing for a flu pandemic, MPS Educational Services advises developing a practice plan, and making sure that you understand how to deal with the outbreak, look after your patients, protect yourself and avoid panic. You should familiarise yourself with any algorithms or pandemic flu plan publications distributed by your healthcare providers.
Practising in a flu pandemic, the over-arching medicolegal advice is to work to the best of your professional ability, using the limited resources available to you based on clinical need. Such focused working can perhaps help to reinforce the importance of good governance in medical practice generally.
Case studies
Patient K, a 19-year-old university student, has symptoms of severe swine flu. Do you have to go and visit the patient?
As a doctor, you have a professional obligation and a duty of care to all your patients. In the UK, the GMC, in Good Medical Practice: Responsibilities of a Doctor in a National Pandemic, states that “you must not refuse to treat a patient because their medical condition might put you at risk”.
I have been given a long list of patients to call back who have suspected swine flu, some of whom have been waiting for a long time, even when concerns relate to children. Am I liable for the delay?
You cannot be held responsible for delays outside your control and can only do your professional best in an unusual situation. As far as usual duties are concerned – you may have to be flexible in the best interests of patients. once you have taken the call, you have assumed responsibility to the patient. Recognise, and work within, the limits of your competence.
References
1. Preparing for pandemic influenza: guidance for GP practices, Department of Health, Royal College of General Practitioner (RCGP) and the British Medical Association, p6, December 2008.
2. DH, Pandemic flu: Managing demand and capacity in healthcare organisations (surge), April 2009
3. www.pandemicflu.direct.gov.uk
4. www.nzdoctor.co.uk, Flu-carriers urged to stay home and use the phone, 5 August 2009.
5. RCGP, News release: Chair Prof Steve Field voices support for the National Pandemic Flu Service, 4 August 2009.
6. DH, Pandemic H1N1 2009 Influenza: Clinical management guidelines for adults and children, October 2009.
7. Clinical recognition of meningococcal disease in children and adolescents, Thompson MJ, Ninis N et al. Lancet. 2006 Feb 4; 367(9508):397-403.
8. Pulse poll of 205 GP and practice managers, 16-18 September 2009
9. Health Protection Agency weekly reports, week ending 15 October 2009, www.hpa.org.uk
10. Professor David Spiegelhalter, The two sides of swine flu risk: as managed by government, as felt by individuals, Risky Business Conference, London 2009.
11. Health Service Executive, Guidance note on antiviral treatment, (July 2009)
12. WHO Pandemic (H1N1) 2009 briefing note 9, Preparing for the second wave: lessons from current outbreaks, 28 August 2009.
13. General Medical Council, Good Medical Practice: Responsibilities of a Doctor in a National Pandemic, October 2009.
14. MPS Position Paper: Indemnity arrangements for GPs during a pandemic flu outbreak, June 2009.