Put plans into effect – winter is here, and not for the first time!

Initially published by NZ Doctor, Jo Scott-Jones discusses what you can do to reduce the number of phone calls, prescriptions and consultations for respiratory illnesses this winter.

Every year, it feels like the health system says “well, we didn’t see that coming”, as emergency departments get overwhelmed and hospital beds filled. Every year, poor old general practice teams get letters sent out telling them to “stop sending people to hospital” – as if we have any control over how sick people are, or how many people choose to go through the door that says “get your free care here any time of the day or night”.

I am pretty sure it is going to be winter until about the end of August, and don’t quote me on this, but it will probably be around the end of November before we are thinking we are getting through spring.

I’m going to stick my neck out and predict that people who are vulnerable to respiratory illness are going to be more likely to have exacerbations over the next four to five months, and we are likely to see quite a few children with bronchiolitis. It’s just a guess.

We can’t close the borders, tell everyone to stay indoors, wear surgical masks when in company and wash their hands constantly, although we know that would work. So, what else can we do?

Vaccinate – encourage all staff to have a flu vaccine, and if you and they think it’s clinically indicated, why not offer a second COVID-19 booster if it is six months after their last booster dose. Yes, it’s “off label”, but there is no longer an issue with supply, and there’s a bit of a window of opportunity before the system works out how it can charge for COVID-19 vaccines.

Control exposure – reinforce your “red” and “green” streams, reinforce your mask policy and reinforce handwashing procedures.

Health centres are not like office spaces and supermarkets – they are designed to attract sick people, so make sure you are protecting your staff (and other patients) from picking up lurgies.

Boost your immune system – not with turmeric and extra selenium, but with regular doses of rest, exercise, good food and convivial company.

It’s not rocket science, and you don’t have to do everything for everyone all at once and all the time. If you can impact three whānau a week, 12 whānau a month and 36 over the next three months, you will be doing an amazing job.

Start with understanding who is most vulnerable to exacerbations of respiratory illness.

It should be of no surprise that Health Quality & Safety Commission data show Māori and Pacific peoples are two to three times more likely to be admitted to hospital with asthma than other ethnicities.

It’s also obvious that people who have had exacerbations before are more likely to have them again, and predictable that people who aren’t taking the “prevention” medications are more likely to have episodes of sickness.

Then, you need to connect with those people.

You could proactively scan your data and see if you can find some people to contact – maybe those who haven’t been seen in person for over a year or who have been asking for short-acting medications with no long-acting agents.

If you know it happens a lot, you could focus on the “while I’m here, doc, I just need an inhaler [for my child/partner/cat]” people.

Plan what you are going to do that will make a difference. Debate your plan as a team – this is a great topic for a practice “set piece” meeting. Aim for everyone in the practice to be doing the same thing.

We came up with a quick list:

• Check the patient is on the best therapy for their condition.
• Check they know how to use their inhalers.
• Provide “rescue remedy”, such as a “back-pocket” steroid course.
• Give them a written plan to take away and stick on the fridge for easy reference.
• Make sure their immunisations are up to date.
• Refer to smoking cessation or healthy homes services if appropriate.

Every practice will have different processes. You might make up a “kete of kit” to hand out to people, including a practitioner’s supply order-derived course of prednisone, inhaler and spacer, along with an action plan.

When you log in to your practice management system in the morning, open a tab with the Asthma and Respiratory Foundation NZ action plans, so you can print one out easily if you need to.

Have an Asthma Control Test and a Chronic Obstructive Pulmonary Disease Assessment Test printed out and stuck on the wall behind your computer screen so you can ask the questions when you need to.

Make a “quick key” that records the range of actions on your “set piece” list in the notes.

Have a chilly bin in your surgery room with flu vaccines ready to go (and maybe some COVID-19 vaccines made up for that session).

Have an agreement within your team to task smoking cessation or healthy homes referral to the right team member to follow up.

It is likely that people who are in this vulnerable group are also going to be eligible for COVID-19 therapeutics (see “Pharmacotherapy” and “Heartbeat” this issue) – why not tell them in advance what to do? Remember to tell them how to get the medication if they test positive on a Saturday afternoon. Have a pre-printed leaflet for them to refer to.

Proactively improving the quality of care for people at risk of respiratory infections will reduce the number of phone calls, prescriptions and consultations. It might even have a small impact on the ice-zombie hoards storming the walls around secondary care.