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GP Liaison Newsletter

Issue 10 - February 2017


Welcome to our first Newsletter of 2017 and a happy new year to everyone! I hope you all had a great summer break. Please forward this newsletter to any GP who you think should be receiving this.

Dr Damian Tomic, Clinical Director Primary & Integrated Care

Damian.Tomic@waikatodhb.health.nz

Map of Medicine


Our Midland regional clinical pathway initiative is going from strength to strength with our new project manager and lead editor. I encourage you all to have a look and let us know if you need help remembering your user name or password.. 

Click here to read the latest newsletter
 
What is it?
A free app available to our population and our doctors, nurses and allied health professionals including GPs primarily to address health access issues that we have in the Waikato and New Zealand.

What does it do?
Patients can access useful health information, ask the databank questions and get answers and talk to a NZ registered doctor for free in the evenings and weekends before travelling to an in person face to face out of hours service. Patients can also have an online outpatient appointment from home if clinically appropriate to stop unnecessary travel.
SmartHealth team at Waikato University during orientation week signing up students!
GPs and specialists can chat to each other using a messaging function, can video consult with their own patients (GPs can charge for this service) if this is desirable, be part of patient care teams allowing the sharing of clinical notes, do CME and peer review your own or others interesting cases.

SmartHealth is continuing to integrate with Medtech and we look forward to the discussions with Indici soon. 

We have about 120 GPs now signed up to the app, if you want to do the same to have a look round or start connecting with local specialists or have any other questions please let me know or speak to your PHO.
Hauraki PHO practices will also be receiving further support in the near future.

Damian.tomic@waikatodhb.health.nz
 

Advance Care Planning

Advance Care Planning (or ACP) has been developed over six years by a committed NZ-wide cooperative (formed by clinicians across New Zealand) to ensure that all people in New Zealand will have access to comprehensive, structured and effective advance care planning.

ACP is about setting goals for how we want to live, how we would like care given to us if something happened and options of how and where we would like our end of life care given. It helps to make sure that our needs and wishes are known, and our personal beliefs and values are respected.

It is a guide for clinicians regarding treatment options if the patient becomes incapable of making decisions for themselves.

Click here to read more

 
Related to this we have now made it clearer whether the patient in CWS has an Advanced Directive.

- See the screenshot showing the red “AD” button.
- Click on the AD button to read the Advanced Directive.

Electronic Discharge Summaries and Electronic Clinic Letters

The transmission of discharge summaries electronically to GPs is going really well but let me know if you are not receiving them or there is some other issue. I am happy to announce that we should start transmitting clinic letters electronically to GPs towards the end of March.  

Damian.tomic@waikatodhb.health.nz

 

GP and Community Access to CWS

I am leading Waikato DHB's endeavours to share hospital patient information with community providers.. The DHB funds everything in this section, no cost to general practice. We aim to support our community specialists in the best way possible by giving them easy quick access to patient information.
  • The majority of General Practices within our District have either ‘One Click’ or Web Portal access to Clinical Workstation (CWS). There are only 4 Waikato general practices who have not requested access. We receive over 400 hits a day from General Practices to our CWS.
  • A number of General Practices, Community NGOs, EDs, & public/private sector providers (including hospitals – predominantly those we have outsourcing arrangements with) have access through PACS Extended Imaging solution to Radiology images. I know that it can take a long time to receive a radiology report. Please let me know if your practice wants this also.
  • We hope to be able to give Indici practices similar “one click” access to CWS in the future
  • Our Secondary clinicians have access, through CWS, to Hauraki PHO patient data
I am also interested in hearing from Pinnacle medtech practices who would like to give DHB clinicians access to their patient data. Sharing patient information with another clinician who is treating your patient is fundamental to safe patient care, remembering that many patients turn up at Waikato hospital unannounced.

Other work planned or underway:


Work that is plamned or underway to expand the integration with our primary, community, & hospital partners includes:
  • Access for our ED clinicians to the St John inbound ambulance information electronically in CWS.
  • Community pharmacists access to CWS.
  • Access enabling LMC’s to access selected patient data and to view & acknowledge results
  • Access for St John ambulance officers and 111 triage nurses to the CWS.
  • Development of One-Click functionality enabling GP practices using the Best Practice Premier solution to access CWS
  • ‘One Click’ access between BoP DHB & Waikato DHB’s enabling staff at each DHB to access patient records held at the other DHB
  • ‘One Click’ access between Taranaki DHB & Waikato DHB’s enabling staff at each DHB to access patient records held at the other DHB
  • One click access for Hospice clinical staff to access CWS.
Over time, aligned to our strategic priority of working towards closer integration with our partners, it is planned that we will extend the user base to include Community Labs (eg PathLab), Community Radiology, Community Mental Health, private providers (eg organisations such as Southern Cross and Braemer), etc.  We are in the process of establishing a System Integrator forum to encourage this to occur.  In discussions with these partners we are encouraging them to provide DHB clinicians with access to the health information for patients they hold.
 

Acute Referrals to Waikato Hospital

I draw your attention to the following updated specialty referral guidelines which help guide you when making an acute referral to Waikato Hospital. Please use them when unsure as just referring to ED can lead to unnecessary delays for your patient. We are in the process of integrating these guidelines into ereferral making them much easier to use.

I hope to be announcing further improvements to the acute referral process for GPs in the near future following on from the GP engagement  evening we had with the emergency Department.

Department of Emergency Medicine Updates Specialty Referral Guidelines

K’Aute Pasifika

K’aute Pasifika’s Program for Pacific peoples suffering from knee joint arthritis and/or gout.

This service is called Mobility Action Program (MAP), and is a Ministry of Health initiative that will see about 350 eligible clients in Hamilton and Tokoroa, being provided with comprehensive health services in their home and their communities.


Click here to read more

 

The Memory Service

The Memory Service is looking at ways in which we can improve.

As part of this we are asking our colleagues in services which may refer to us to complete the attached 10 point questionnaire.

We are aiming to provide a service which is straight forward, efficient and will meet the needs of people who may access us.

We value your honest opinions and feedback, and welcome the opportunity to listen to what you think works well and what you think requires improving.

If there is anything you wish to discuss further please do not hesitate to contact us on 07 839 8603 or email Heather.Chase@Waikatodhb.health.nz

Thank you for your time, we look forward to your feedback.
 
Here is the link to the questionnaire:
https://www.surveymonkey.com/r/NYLFCW7
 
Kind Regards
The Memory Service
 

Updates from GP Liaisons


Fiona Campbell


Work continues on the Map of Medicine Pathway and e-referral for Sleep Disorders in particular obstructive sleep apnoea. The goal is to ensure our referrals provide the information needed to correctly identify patients requiring FSAs and those who can go straight to a sleep study. This will streamline the patient journey and reduce waiting times.
 
And some Waikato Hospital Lab information:

"The Waikato DHB lab is currently updating guidance for diabetes care amongst inpatients at Waikato DHB. The first protocol and guidance to be implemented will be regarding the Hyperglycaemic Hyperosmolar Syndrome (HHS, which was previously known as HONK). As part of this guidance we use a 'corrected' or adjusted sodium - as sodium appears to fall in hyperglycaemia which is erroneous. This can be adjusted for with a calculation that we have arranged to be done automatically through the laboratory. All patients with HHS must be admitted to a high dependency unit, however primary care clinicians will also see a corrected sodium result which will automatically be calculated in all patients aged over 15 years with a blood glucose level >17 mmol/L. This would apply to samples processed through the Waikato DHB system and not those processed at Pathlab or Southern Community labs. This change will be in place from Wednesday 1st February 2017."
 
We are always really pleased to receive any feedback from you around any of the work we are doing or any suggestions you have for improvement to services. We are also very happy to follow up any queries on your behalf regarding hospital services/ DHB referrals.

Fiona.Campbell@waikatodhb.health.nz

Angela Fairweather


Within the next month the colonoscopy template for direct access to colonoscopy will be launched on BPAC. This is very exciting and should allow faster cancer diagnoses for those patients who are deemed high risk. The criteria for risk stratification are taken directly from the ministry guidelines and are reflected in the suspected bowel cancer map in the Map of Medicine .Those patients with symptoms who do not meet the criteria for direct access can still be referred for consideration of colonoscopy via outpatients clinic as usual. The template also allows referral for surveillance colonoscopy in those patients whose family or personal history warrants screening.

GPs are soon going to be sent an acknowledgement of any internal referral generated within the hospital, once it has received and prioritised by the referral centre. The acknowledgment will be sent back to the patient’s usual GP via BPAC and will we marked as having been generated within the hospital.

Work is nearing completion on the Hyperemesis map and  is awaiting review prior to publishing .I am starting work on a map for the management of tongue tie, which will be a collaborative process involving lactation consultants ,midwives and specialists and will highlight what is best practise in the treatment of tongue tie.

Angela.Fairweather@waikatodhb.health.nz

Sheril-Ann Wilson


I am working with ED to update the Acute e referral BPAC form to include quick links to Primary Options ( which ED feel are sometimes underutilised) and simpler ED guidelines. DO you realise that at present your patients may wait for 4-6 hours in ED to see the registrar whom you have done an acute service referral too. ED will of course organise any acute management/pain relief or investigations needed during this time. If you have not designated a specific acute service and just directed the referral to ED the patient can wait 4-6 hours to see the ED doctor and then another lengthy wait for the speciality registrar.
 
Renal colic Map of Medicine imaging updates are awaiting publishing. The major change is the initial investigation for women under the age of 35 presenting with symptoms suggestive of renal colic is an ultrasound which can be arranged acutely via the Waikato Hospital Radiology Department. Only 20% of women < 35 year of age presenting will have a renal stone and there are concerns re radiation levels for young women when CTU is performed.
 
Please feel free to contact me or one of the other team members if you have any comments or issues of concern.

Sheril-Ann.wilson@waikatodhb.health.nz

Simon Shingler


By the end of the year the Raising Healthy Kids Target requires that ‘By December 2017, 95% of obese children identified in the Before School Check programme will be offered a referral to a health professional within general practice for clinical assessment and family based nutrition, activity and lifestyle interventions’. To assist, we have developed an appropriate algorithm to ensure that referrals are made accordingly, and extensive work has gone in to developing the Childhood Obesity Map of Medicine support tool & preparing the necessary services for anticipated increased utilisation. In conjunction with paediatrics, ENT and varied allied health professionals, this tool aims to equip the GP (or other health professional) to structure the required consult and meet expectations. Next more we aim to have more information to you on this.

We are in the closing stages of revising the constipation map to make it more user friendly and to enable primary care providers to use appropriate treatment regimens in the community with more confidence.

A recent discussion held with the paediatric team also gave rise to a few requests:
  • Please make use of resources such as the NZF (http://www.nzfchildren.org.nz/) or local pharmacist when wishing to discuss paediatric dose calculations, to free up the acute registrar OR non urgent advice request via BPAC if query unresolved.
  • For ALL referrals, but particularly those with reference to growth problems: i.e. short/tall stature; growth faltering or obesity referrals: please make available ALL available growth data & ideally parental measurements. This assists to allocate the appropriate triage category. Options available:
    • Access clinical work station and enter the details under the ‘Growth Chart’ link, either by GP or colleague in practice
    • Send the data within the BPAC referral free text (since screening values do not auto-populate)
    • Consider use of the Microsoft ‘snipping tool’ to make an ‘image copy’ of relevant screening values and this can be attached to the BPAC e-referral (if I receive sufficient requests, a simple guide can be put together).
  • For referrals regarding behavioural concerns e.g. ADHD or ASD, please attach copies of any school reports or relevant questionnaires such as the strength and difficulties questionnaire (SDQ) at the B4SC where possible.
  • If you come across any complications of tongue tie/lip tie procedures that have been performed in the community – please send an advisory update via BPAC to paediatrics. Please note we are developing a tongue tie clinical pathway to establish best practice in this area.
  • In event of suspecting NAI (Non accidental injury) or CSA (child sexual abuse)” the first port of call is the acute paediatric medical registrar/consultant 
As a result of the Development Dysplasia of Hip map being temporarily unavailable from the UK and some uncertainty regarding referral to orthopaedics vs acquiring community imaging first, we sought clarity from Richard Willoughby with thanks:
 
Orthopaedics:
  • Are happy to see any child where there is concern about Development Dysplasia of Hip
  • Don’t have the resources to screen every child and so…
  • Suggest they should screen any child with risk factors (Breech, family history, clicky hips, twins, uneven skin creases)
  • Are happy to discharge on the strength of a normal USS after 6 weeks of age (BUT those require more experience to interpret as it is not always on the numbers alone)
  • X-rays can be used beyond 5 months of age (roughly).  If the growth centres have formed and the rest of the X-ray is normal then that is also adequate to reassure parents that the hips are normal
  • In terms of the examination, somewhere between 6 and 12 months of age the sensitivity of clinical examination becomes less as children get much stronger
  • While clinical examination is still important to do the X-ray is ‘probably’ more reliable
  • If there is not any clinical concern and a normal X-ray then if a GP is happy, orthopaedics do not feel the referral is required.
(As a reminder, all Development Dysplasia of Hip referral should be prioritised URGENT and ideally addressed to Development Dysplasia of Hip clinic)

After recent discussion with paediatric ENT services:

GPs are kindly reminded to view the ‘tonsillitis-suspected’ map & particularly ‘threshold for tonsillectomy’ which will ensure that all information required to triage a referral has been included. The same applies to grommet referrals as per below.

This is preferable to attaching copies of consultation notes.
  • The following information is required in ALL referrals for consideration of tonsillectomy.
  • number of tonsillitis in last three years
  • number of tonsillitis in last year
  • size of tonsills (graded 1-5), see grading chart
    • During an attack of tonsillitis
    • Between attacks of tonsillitis
  • any evidence of Obstructive Sleep Apnoea (OSA)?
    • if yes,please complete OSA-18 score sheet
    • if yes, audio or video recording should be brought to ENT appointment
  • any life threatening or severe complications associated with tonsillitis?
  • any family history of bleeding disorder? If so, please do coagulation screen before ENT referral
  • any allergies? 
The following information is required in ALL referrals for consideration of grommet insertion
  • How many infections in the last 6 months
  • Any perforations
  • Any hearing loss?If so when was it 1st noted?
  • Any OME? If so duration.
  • Dates of documented Type B tympanograms in last 6 months
  • Any retraction of tympanic membranes?
  • Any balance problems?
  • Any associated problems with ears that would make treatment more urgent?
  • Did child pass neonatal screening?
  • History of past grommets/adenoidectomy?
  • Nasal function?
  • Mouth breather?
  • Snorer?

Simon.Shingler@waikatodhb.health.nz

Mark Taylor


Welcome to the New Year. I hope all had some summer sun and relaxation.

This year brings some very exciting innovation that will hopefully help both us and our patients. Firstly, Waikato DHB will soon be starting a pilot for tele-dermatology. While I have been promising this for a long time, we have finally had the go ahead. This should change the way we manage skin cancers and will give both shortened time to diagnosis and also more convenient and cheaper care for our patients. More details will come out, but I’m happy to answer emails or phone calls on the subject.

Further to this, we are pleased to announce that Pathlab now have a dedicated email address for sending dermatoscopic photos to them, when requesting histology on an excision biopsy for ?melanoma. This will significantly improve the accuracy of melanoma histology, which can often be very difficult.

Please send all photos, with the patients NHI number only, to pathologyimages@pathlab.co.nz

The other new change will be with iron infusions. Initially, these will be initiated from anaesthetists for patients needing major surgery who have iron deficiency. Those practices that have signed up, will receive a request from the Patient Blood Management service to give an iron infusion for a particular patient, which will automatically be couriered out to the practice by hospital pharmacy, much like the cellulitis protocol. This will attract a Primary Options service fee to be claimed. This should be great for our patients.

Even better is the news that we are also very close to being able to give funded iron infusions to our own patients, who we deem require them. This will require the following of the Map of Medicine pathway to meet certain criteria. However, it will be both funded and attract a Primary Options fee to be claimed. So watch this space.

Enjoy what’s left of summer!

Mark.Taylor@waikatodhb.health.nz
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Damian.Tomic@waikatodhb.health.nz

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