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COVID-19 Information: Patient Care

What does the announcement about ceasing elective surgery mean for patients and me?

The Australian government has announced as of 11:59pm 1 April that only Category 1 and exceptional Category 2 elective surgery in both public and private systems will be allowed (Link). For most, this will mean no cataract surgery unless it is absolutely sight threatening. Please see RANZCO correspondence to members dated 26 March.

New Zealand is in lockdown for one month which effectively means the same conditions apply.

To ensure the appropriate triage of patients during the COVID-19 pandemic, the College has adapted the Moorfields Eye Hospital Guidelines to suit our context. The RANZCO COVID-19 Triage Guidelines can be accessed to inform your clinical decision-making.

  • These guidelines define high, medium and low urgency. High and medium urgency are time-sensitive (should be reviewed within 3 months) and should continue for now. Low urgency should be deferred 4-12 months at the clinician’s discretion. This is subject to further review and amendment.
  • All elective cataract surgery must cease.
  • All nasolacrimal procedures (nasal syringing, lacrimal surgery and nasal endoscopy) should cease unless absolutely medically indicated (attempt medical therapy first) due to the high risk of COVID-19 infection from the nasopharynx.
  • Whenever possible, telehealth is preferred. Most conjunctivitis can be managed by telehealth.

Please NOTE: As per Directive from SA government, and effective as of 11:59pm, 1 April the only surgery allowed in South Australia is Emergency Surgery and Non-Emergent Urgent Surgery clinically indicated within 30 days (fitting with RANZCO’s high urgency category in the Triage Guidelines).

Please find this media release: Colleges call out Government on Elective Surgery

What about Intravitreal anti-VEGF injections?

Intravitreal injections can be continued to prevent vision loss and preserve sight.   Given that a large majority of patients undergoing intravitreal therapy are in high risk categories (age and comorbidities), COVID-19 Triage Guidelines recommend minimising unnecessary investigations and establishing maximal treat and extend intervals. A mask should be worn by the treating physician and any assistants.

 

How do we deal with potentially high risk COVID-19 patients presenting at a private practice?
  • Review the specific definitions of suspected and confirmed cases of COVID-19 in Australia and New Zealand.
  • Make yourself aware of local public assessment and testing facilities. Many new facilities of this type are expected to be set up in the very near term. For suspected COVID-19 cases in New Zealand, call your local public health unit on DHB switchboard and ask to speak to the Medical Officer of Health for advice.
  • In Australia, and usually in New Zealand, patients coming to you would be expected to have a referral. If their presentation is for follicular conjunctivitis, and they fall under the definition of a ‘suspect case’, they should be asked to present to a COVID-19 dedicated testing site and have a negative result prior to review.  If you are asked to review a known positive case, you should do so only if you have the appropriate PPE.  In the absence of appropriate PPE you should make arrangements for a patient to go to a centre that can accommodate the patient requirements. You should liaise directly with that centre to ensure they are aware of the patient status.
  • Consider putting measures in place for immediate identification of suspect cases as they may present to clinics and private practices. Note that conjunctivitis may be a presenting symptom of COVID-19. Where suspect cases are identified and do not require emergency eye care, RANZCO recommends that these are isolated from other patients and instructed to proceed immediately to the nearest public assessment and testing facility.
  • Do not send suspect cases to general hospital EDs unless there is no alternative public assessment at a testing facility.
  • Do not send suspect cases to dedicated eye hospitals unless there is a clear and specific ophthalmic necessity. In such cases, the eye hospital must be notified in advance of transfer.
Should I stop seeing patients or close my clinic?

This is your choice and RANZCO encourages you to follow the government advice in Australia and New Zealand that only Category 1 and exceptional Category 2 elective surgery be carried out.

If you are seeing a ‘suspect’, ‘confirmed’ or ‘probable’ COVID case, you should be using full PPE. In this scenario, it is likely to be impractical to use a slit lamp. You may wish to consider using indirect ophthalmoscope as a light source and 20 dioptre lens as a magnifying aid and in this scenario, no direct contact with the patient is required. Detailed examination is not likely to be possible until the patient is declared COVID free and the aim is to exclude any imminent sight- or life-threatening condition.

Should I stop seeing elderly or patients from nursing homes?

No. Cases who have not had any exposure to COVID-19 can be seen as normal. However, you should advise elderly patients or those with comorbidity to defer non-urgent appointments.

It is also important to screen all patients prior to their appointment to ascertain if they have risk of COVID-19 as per the recommendations on pre-screening on this site.

If you are seeing cases from nursing homes known to have been exposed (suspect cases), they should be managed as per the advice for a ‘suspect’ case. That will entail triaging to ascertain urgency. Non-urgent cases should be rescheduled until declared clear.

How do I effectively clean my equipment between patients?

Regular (minimum daily) environmental disinfection of office spaces, ophthalmic equipment and computers with appropriate disinfectants is recommended. 70% alcohol, 0.5% hydrogen peroxide and 0.1% sodium hypochlorite are all suitable.

If you have seen a ‘suspect’, ‘confirmed’ or ‘probable’ COVID case, a two-step clean of the room and equipment is required as per the information disseminated in our clinical guidelines.

There are concerns that we could be unknowingly treating asymptomatic cases. How do I know if I'm seeing an asymptomatic case?

Unfortunately, there is no sure way of screening all possible asymptomatic cases. However, the advice from WHO is that the pre-symptomatic period for COVID-19 is short and therefore asymptomatic spread is less likely.

How do I minimise the spread of COVID-19?
  • The highest standard of hygiene will help slow the spread of infection.
  • All high-risk staff, including doctors, should self-isolate according to government guidelines.
  • Screen patients with appropriate questions prior to their arrival and exclude any meeting of the high-risk criteria (i.e. returned from overseas or been cruising in the last two weeks, been in contact with a confirmed carrier).
  • Defer non-essential appointments.
  • Have less patients in waiting rooms by deliberately under-booking.
  • Consider what appointments can be done via tele-medicine.
  • Where practical, doctors, staff and patients should wear masks. This may be very difficult given the limited availability of masks.
  • Doctors and staff should use gloves when seeing patients.
  • Provide hand sanitiser for patient use.
  • Remove all magazines and other frequent touch items from waiting rooms and offices.
  • Install signs and ask patients to sit at least 1.5m apart where possible and reconfigure waiting rooms accordingly.
  • Ask patients to have the minimum number of people possible with them in waiting rooms (e.g. drivers wait in cars, do not bring children to appointments).
  • Observe the five points of hand washing.
  • Disinfect head and chin rests, contact lenses, joysticks or other touch points, including face shields where in use, using alcohol-based wipes or 10% sodium hypochlorite or 3% hydrogen peroxide on ALL devices between patients.
  • Pay close attention to routine cleaning and disinfection of surfaces.
What are the new Australian COVID-19 temporary MBS telehealth item numbers?

COVID-19: temporary MBS telehealth item numbers

  • From 13 March 2020 to 30 September 2020 inclusive, new temporary MBS telehealth items have been made available to help reduce the risk of community transmission of COVID-19 and provide protection for patients and health care providers.
  • The previous restrictions on eligibility have been removed. All Medicare eligible Australians can now receive these temporary MBS telehealth services.
  • All of the new temporary MBS telehealth items must be bulk billed.
  • In ophthalmic practices, these items are to be used only for the purposes of specialist ophthalmic consultation and are not applicable to teleconferencing or telephone calls made by any persons other than ophthalmologists.
  • This and other RANZCO documents / guidelines related to COVID-19 are living documents and it is the responsibility of ophthalmologists to keep abreast of this rapidly evolving situation. RANZCO will update this advice as the situation unfolds.

 What are the temporary MBS telehealth items?

 The items relevant to ophthalmologists are as follows:

Service
Existing Items
face-to-face
Equivalent COVID-19
Telehealth items
video-conference
Equivalent COVID-19
Telephone items
- for when
video-conferencing
is not available
Initial specialist attendance
104
91822
91832
Subsequent specialist attendance
105
91823
91833

When are the temporary MBS telehealth items in effect?

  • From 13 March 2020 to 30 September 2020 inclusive, new temporary MBS telehealth items have been made available to help reduce the risk of community transmission of COVID-19 and provide protection for patients and health care providers.

Under what circumstances can RANZO fellows use the temporary MBS telehealth items?

  • A service may only be provided by telehealth where it is safe and clinically appropriate to do so.
  • The safety, clinical appropriateness and extent of telehealth consultations are at the discretion of the individual clinician, considering a standard judged reasonable by the majority of their peers.
  • Videoconferencing services are the preferred approach for substituting a face-to-face consultation. Where video is not available, there are telephone items as listed above.

Are there any restrictions on which patients can access the temporary MBS telehealth items?

  • The previous restrictions on eligibility have been removed. All Medicare eligible Australians can now receive these temporary MBS telehealth services.

How are the temporary MBS telehealth items billed?

  • All of the new temporary MBS telehealth items must be bulk billed.

Is a referral required?

  • As with a standard face-to-face consultation, a valid referral is required.

How do patients assign their right to a Medicare benefit?

  • Where practicable, each individual provider should make efforts to obtain a patient’s signature in whichever way is appropriate to their needs.
  • There are several options available to providers performing these services:
    • Provider to post the completed assignment of benefit form to the patient to obtain their signature and return.
    • Request assistance from a supporting practitioner (when there is one and possible).
    • Email agreement between the provider and patient.
  • The Department of Health’s position is that, under these exceptional and temporary circumstances, for the new temporary MBS telehealth items only, the practitioner’s documentation in the clinical notes of the patient’s agreement to assign their benefit as full payment for the service would be sufficient.

 Are there geographical restrictions?

  • Unlike existing telehealth items, here are no geographical restrictions on the use of these temporary telehealth item numbers.

What are the record-keeping requirements for telehealth consultations?

  • The new temporary MBS telehealth items have the same record keeping requirements as the face-to-face MBS items currently claimed.

Where can I obtain more information?

  • Fellows should refer to the links below so that they are aware of all the conditions relating to the use of these COVID-19 telehealth items.
  • Please continue to check the RANZCO website for updates.
  • Media release from the Health Minister (29 March 2020) regarding the above telehealth items.
  • New temporary telehealth item numbers overarching fact sheet.
  • Specific information for specialists regarding the above telehealth items.
  • Telehealth items general provider FAQs.

 

Last updated: April 3, 2020

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