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Managing pandemic influenza in general practice

Part B - Prevention and preparedness

Preparedness

Last revised: 16 Dec 2019

 

 

As with prevention activities, preparedness activities should be standard in general practices. However, preparedness is more about building the capacity to prevent, protect against, recognise and respond effectively to pandemic influenza (ie to reduce the impact of the disease).

Planning and preparation are not quick processes and need to occur well in advance of a pandemic. In the case of pandemic influenza, being well prepared is likely to minimise the number of people affected, protect critical infrastructure and essential services, and improve the health outcomes of those affected. Lessons learnt from previous disease outbreaks should be incorporated into current plans.

Plans developed for pandemic influenza can easily be used more broadly for other new, highly transmissible or severe communicable diseases.

During the preparedness stage, general practices will need to:

The main strategy for practice preparedness is to develop a pandemic plan for the practice that identifies key risks and key tasks, and clarifies key roles and responsibilities. The plan explains how the practice intends to operate before and during a pandemic.

The most useful plans offer a framework that can be adapted to accommodate pandemics of varying impact.31

A comprehensive and useful pandemic plan:

  • clearly identifies the pandemic leader and pandemic coordinator and outlines the responsibilities for these roles and other practice staff (these two roles may be undertaken by the same person)
  • lists essential pandemic resources including key stakeholders, such as hospitals and diagnostic services
  • describes effective communication strategies to use existing health networks and available infrastructure
  • documents infection control policies and identifies triage algorithms for the management of suspected and known cases
  • identifies contingency arrangements for business continuity, including planning for absenteeism and use of alternative work processes (eg work from home, e-consulting, hospital in the home, flu clinics and re-arrangement of workflow)
  • identifies contingency arrangements for patients with particular needs (eg vulnerable groups, patients with comorbidities)
  • outlines the support the practice will provide for people in home isolation and/or quarantine.

Once the plan has been developed, it is crucial that staff are aware of the plan and receive appropriate education and training.

Strong leadership and good governance are key requirements for effective preparedness.

National arrangements, organisations and committees

The Australian Government provides leadership for overall pandemic coordination and communication efforts, and helps other public and private agencies and organisations by providing guidance and planning assumptions, and by making appropriate modifications to laws or regulations to enable an appropriate pandemic response.1

The federal government collects information on suspected cases of pandemic influenza in a coordinated manner by liaising with state, territory and local governments. It also coordinates appropriate public health responses according to the pandemic plan.

To ensure a comprehensive understanding of the emergency plan and management processes, it is important to firstly understand the roles and responsibilities that the different agencies and organisations play.

For further information about these roles and responsibilities, refer to:

Pandemic coordinator

The first step in preparing for a pandemic is appointing a pandemic coordinator. This person should have a level of experience and knowledge that allows them to act on all practice activities related to pandemic planning. The same person could take on the dual role of pandemic coordinator and infection prevention and control coordinator. Practices may consider appointing a deputy coordinator for back-up.

If your practice is larger, you might choose to appoint a pandemic committee with a chairperson and representatives from other disciplines. This approach means that the source of knowledge does not lie with one person. This is particularly important if there are staff changes or if committee members become unwell or unavailable during a pandemic. If your practice appoints a pandemic committee it is important to hold regular meetings with an agenda, written minutes and action items.

Key activities for the pandemic coordinator include:

  • reviewing relevant and current materials such as the RACGP’s emergency planning and pandemic resources, AHMPPI, and relevant state or territory pandemic plans
  • holding regular practice team meetings to discuss pandemic planning and management
  • developing a flexible plan for the management of pandemic influenza for the practice
  • identifying barriers to an effective response (eg difficulties obtaining PPE and antivirals, or lines of communication between practices and government health departments) 19 Managing pandemic influenza in general practice: A guide for preparation, response and recovery 2nd edition
  • subscribing to and monitoring appropriate communication networks regarding Australian pandemic alerts (eg the RACGP health alerts and the Department of Health website)
  • maintaining close contact with key stakeholders
  • communicating and coordinating with other healthcare and community organisations
  • obtaining regular advice from state and territory governments regarding the management of pandemics
  • maintaining the practice’s stock of PPE
  • providing the practice team with ongoing training regarding the plan, including mini-drills and ‘dry runs’.

The pandemic coordinator may not be the person who takes the lead during a pandemic. Practices may also appoint a pandemic leader to assume leadership during a pandemic response. This role is discussed in Part C – Response.

Risk assessment and management

Risk identification and management is a fundamental aspect of a high-quality, resilient and sustainable practice. This applies to all aspects of the practice including infection protection and control.

When planning for a pandemic the risk factors regarding the disease should be taken into account. This includes transmission, virulence, morbidity and mortality. Further, the vulnerabilities and risk factors particular to each practice should be taken into account. This includes size of the practice team, patient cohorts, access to additional resources, patient flow within the practice, and financial restraints. Additionally, practices should work to address extraneous risk factors which commonly include inadequate hand hygiene, poor respiratory etiquette, lack of effective triage protocols and increased workload, which may result in stress and fatigue.

Together, these provide the context of the risk.

The disease-specific factors will not be known until the time of the outbreak (and may change rapidly during the outbreak). Potential areas of risk in terms of practice systems and processes can be identified during the preparedness phase and reviewed in the event of a pandemic threat.

During the preparedness phase, it is recommended that the pandemic coordinator undertake an assessment of all the possible risks to the practice and identify appropriate strategies to manage them. Once risks are identified, they are analysed for their magnitude of impact and their likelihood of occurring.

Doctors and other health professionals may have different opinions about risk and may therefore disagree about the appropriate approach to mitigate that risk. Professionals should engage in discussions before an event to decide and agree on a consistent approach. Developing policies founded on evidence-based guidelines can help address any difference of opinion regarding risk.

Risks are then evaluated and prioritised. This includes determining which risks need to be actively managed (why and how) and which risks will be ‘tolerated’ (ie what risk a practice believes is minimal).
Once all relevant risk and other factors have been identified, practice staff should implement the actions identified to mitigate risks. For example, place alcohol-based hand sanitiser in all patient care areas to improve hand hygiene and reduce cross-infection.

All protocols and procedures to manage risk should be documented, monitored and regularly reviewed.

Execution of mini-drills could be conducted (depending on time and human resource availability) to investigate the practical and logistical barriers of some of the actions proposed. Consider scenarios of pandemics with various severities and formulate some options and innovative solutions for handling these scenarios.

Refer to the RACGP’s Infection prevention and control standards (5th edition) for further information regarding risk assessment and management.

A pandemic business continuity plan sets out how to prepare for a pandemic and continue to operate during and after the disaster. General practices require the capacity to respond to the health needs of patients while ensuring both the protection of staff and business continuity – which may include periods without any external assistance or supplies. In the event of a pandemic, it may be days before any information, advice, assistance or awareness of an issue occurs and is acted upon by authorities.

As part of pandemic planning, the pandemic coordinator should schedule a meeting to develop the business contingency plan. The plan needs to consider:1

  • the critical functions that need to be sustained (including periods without supplies)
  • the personnel, supplies and equipment vital to maintain critical functions
  • staff absenteeism and how to mitigate its impact on critical functions
  • clear command structures, delegations of authority and orders of succession
  • the stockpiling of strategic reserves of supplies, material and equipment
  • any services that could be downsized or closed
  • assigning and training alternative staff for critical posts
  • establishing guidelines for priority of access to essential services
  • the training of staff in workplace infection prevention and control, and communication of essential safety messages
  • ways of reducing social contact (eg working from home and reducing the number of physical meetings and travel) • the need for family and childcare support for essential workers
  • the need for psychosocial support services to help workers to remain effective
  • a plan for the recovery phase
  • strategic planning of financial obligations
  • how the practice will run during a pandemic and communicating this to staff, patients, clients and the community.

General practices need to identify their ‘break point’ – the point where an organisation can no longer maintain available services in a safe manner due to identified risk in workplace health and safety. This could be due to insufficient staffing levels through absenteeism or the disruption of services or resources on which the practice depends.

Human resources management

Practices need to develop practice-specific policies to support human resource management and the provision of safe healthcare to patients. When planning a pandemic roster, practices should factor in changes in situation for employees. This may include:

  • heightened distress during a pandemic
  • pregnancy
  • restrictions on travel
  • staff absenteeism due to schools closing and lack of childcare.

Other factors, such as availability of PPE, vaccinations and antivirals, also affect the willingness of staff to continue to work through a pandemic.32–34 A high proportion of general practice respondents to an Australian study into attitudes to pandemic influenza indicated that they would need access to vaccines and antiviral medication for themselves and for their families, in order to consider treating patients.33
Workplace absenteeism due to staff illness and other factors during a pandemic is inevitable.

It is important to establish contingency plans for continuation of critical business processes at less than full capacity. It is recommended that businesses plan for staff absences of 30–50% during a pandemic.35 Identify the functions that are critical for practice survival and which staff members provide these functions.

A key to successfully navigating a business through a disaster is having some flexibility in the sharing of roles and tasks. Practice owners should consider:

  • identifying staff members who can multitask to replace staff lost through absenteeism
  • training staff in alternative roles
  • flexible worksite (eg working from home) and flexible hours (eg staggered shifts)
  • identifying additional human resources such as local hospital casual staff, recently retired GPs and nurses, and volunteers through local/state public health and emergency services.

Establish policies for employee compensation and sick leave absences unique to a pandemic, including policies on when a previously ill practice staff member is no longer infectious and can return to work. Practice owners should ensure there is a clear policy on the payment of staff who elect not to work during a pandemic. Practice owners should also ensure that staff are not discriminated against for choosing not to work during a pandemic, and conversely for electing to work and potentially being viewed as infectious.

Practices also need to consider how to manage practice staff who have been exposed to pandemic influenza, are suspected to be ill or become ill in the practice (eg infection control response, immediate mandatory sick leave). Practices should consider how they would manage employee evacuation.

Strategies to maintain procedural workflow

Practices should plan for possible practice modification during a pandemic. Strategies include:

  • eHealth technologies (eg e-consultation, e-prescribing, e-referrals)
  • postponement of non-essential/routine procedures/consultations.

Relationships and sharing resources

Providing healthcare and managing a business during a pandemic requires coordination and collaboration. Where available, practices could develop arrangements with other local practices and businesses. For example:

  • local pharmacists, to ensure continuity of prescriptions for patients during a pandemic, particularly for patients living in residential aged care facilities
  • local hospitals
  • pathology services
  • allied healthcare professionals
  • local veterinary hospitals, which could provide additional PPE during shortages. These arrangements may be formal or informal, depending on local need.

Financial resourcing

The principle of ‘as low as reasonably practicable’ (ALARP) is a risk management concept that may be useful when assessing the optimum level of financial resourcing to allocate to preparedness activities (refer to Figure 5). This requires a vigorous risk assessment.

Large-scale emergencies such as pandemics require cooperation and communication between a number of agencies, groups, staff and individuals. Pre-established communication channels and positive working relationships allow orderly and organised flow of useful information.

Where staffing numbers permit, practices may consider appointing a communications coordinator in addition to the pandemic coordinator.36 The communications coordinator would be responsible for developing a pandemic communications policy and reviewing communication plans periodically.

The plan should include:

  • identification of key contacts (with back-ups)
  • the chain of communication (including suppliers and customers)
  • processes for tracking and communicating business and employee status.

Communicating with patients

All practices should prepare a list of vulnerable patient groups. This should be regularly updated and be readily available for use in case of any type of emergency.

Practices should plan and prepare for open, realistic and continuing communication with the public.37 Patients need to know that their general practice is a reliable source of accurate, clear and concise, balanced and up-to-date information. The communication should also be consistent with reputable public health organisations such as the federal and state/territory health departments and the WHO.

Practices should clearly communicate to patients:

  • what is known
  • what is unknown
  • what is being done
  • when the next update will be released.

Methods of communication will vary depending on the practice and patient groups. By selecting a range of different communication methods during a pandemic, patient reach will be maximised and the load on more direct methods of communication such as phone and email will be lessened.

Examples of different communication methods include:

  • posters and signs at the entrance to the practice and in the waiting room (refer to posters contained within the Pandemic influenza toolkit)
  • fact sheets and brochures (health department literature given to patients at reception may help manage expectations)36
  • attachments to patient receipts
  • waiting room videos
  • podcasts played over an audio system in the waiting room
  • bulk emails
  • postal mail outs
  • information on practice website
  • credible websites with relevant information
  • social media
  • on-hold telephone call waiting messages
  • phone answering machine message
  • external building signage
  • internal building signage such as a pandemic ‘notice board’ dedicated to pandemic planning and updates.

Communication topics include home care, how to prevent infection, when to call for an appointment, when to go to the emergency departments and when not to go, frequently asked questions, community-based resources and practice policies. Communications may also be used to provide regular updates that describe what we know, what we don’t know, what we are doing and when the next update will be released.

Alarmist framing of health threats may be counterproductive.38 When confronted with respected health authorities responding with alarm, people may panic, feel overwhelmed or lose respect for authorities if the threat does not materialise. These responses all prevent effective ongoing communication and action.

Patients should be informed of how they can obtain information and how they can protect themselves and their families if a pandemic should occur in their locality, what symptoms to look for, when to seek help, how to access home quarantine and isolation support services, and the use and availability of antiviral medications and PPE  (as appropriate).

Ensure all communication methods with your patients take into consideration:

  • cultural backgrounds (language differences) and cultural diversity
  • vision impairment
  • hearing impairment • lack of literacy and numeracy
  • technological capabilities.

Also consider patients who might be outside the usual systems, such as the homeless.

Social media

Social media includes social networking sites, blogs, forums and podcasts (live video and audio). Social networking has made significant contributions to emergency response and recovery in global disasters (eg information alerts and warnings). Australia’s per capita use of social networking is among the world’s highest.39

Practices could investigate how social media can help communicate with patients during a pandemic. Note there are significant considerations regarding the use of social media, including privacy issues; consequently, any use of social media should be well planned and assessed for risk before implementation.

For more information, access the RACGP’s Guide for the use of social media in general practice.

Communicating with other healthcare providers, agencies and authorities

Engaging with local agencies and services during the pandemic planning phase should help develop positive working relationships during an outbreak of infectious disease. Develop lists (electronic and hard copy) of important local contacts such as:

  • state and territory health departments
  • Primary Health Networks
  • general practices
  • community health services
  • hospitals and pharmacies
  • laboratories
  • social support groups (including mental health support services, Aboriginal and Torres Strait Islander organisations, and culturally and linguistically diverse support groups and peak bodies).

The contact list should be available in both electronic form and hard copy (in case of an IT outage). Some organisations may not have the capacity to operate during a pandemic. This may mean an increase in workload for general practices that do continue to operate. Planning for this enables practices to factor in potential patient surges. Conversely, temporary flu clinics may be established in some areas during an influenza pandemic, which may decrease the practice’s caseload.

Plan the type of communication strategy you will have with these organisations (eg emails, phone) and list the points of contact in each.

Practices must coordinate planning for pandemics with state and federal governments. The Australian Government has developed a coordinated and consistent communications strategy for the health sector regarding pandemic influenza. The communications strategy is designed to be flexible (to adapt and expand to accommodate new policy measures, or developments in the disease threat) and to ensure communications effectively address changing information needs. In addition, state and territory health authorities will communicate with the public and general practices about local arrangements such as flu clinics and vaccination services.

General Practice Round Table

The General Practice Round Table is a group made up of relevant professional groups and healthcare organisations. The group meets twice a year and:

  • informs and provides advice to the Office of Health Protection on the role of primary healthcare in emergency preparedness and response management
  • establishes agreed expectations of members and what they can and cannot do together
  • develops the potential roles of GPs and general practices in different health emergency situations and how they can be best supported in these roles.

Preparing to manage cases of pandemic influenza

GPs play a major role in influenza epidemics and pandemics. Most people with an influenza-like illness are treated in general practice or by primary care doctors on duty in out-of-hours services.6
All staff need to be able to identify patients with possible influenza and institute the necessary alerts and patient management protocols. General practices may be the first to see a suspected pandemic influenza case.

Laboratory diagnosis is important in the early phase of a pandemic to determine the strain of influenza. Clinical staff need to know the processes of confirming cases of pandemic influenza, such as swab collection protocol. Discuss with the local pathology laboratory what processes the clinic staff need to know. This will include a review of collection and referral processes.

Point-of-care testing may become more useful as current technology (eg real-time polymerase chain reaction assays40) become more widely available and cost effective. If point-of-care testing is to be used, staff will need training in collecting samples and running the test.

Clinical staff should demonstrate an understanding of the roles of seasonal, candidate and customised pandemic vaccines during a pandemic, as well as the role of antiviral medication.
During a pandemic, clinical staff may be required to deliver vaccinations from a multidose vial. The pandemic coordinator needs to ensure that the pandemic plan includes policies around safe delivery of vaccines from a multidose vial. Guidelines for the use of multidose vials will be released by the Department of Health and the RACGP during the pandemic. The policies should consider principles of infection control, cold chain, anaphylaxis and cross-contamination.

Preparing to manage vulnerable groups and patients with comorbidities

General practices will need to manage much more than influenza during a pandemic. Patients who might otherwise be managed in hospital or at other specialist facilities may not be able to access medical care as usual during a pandemic for reasons of increased caseload, quarantine or travel restrictions.

Certain patient groups are at higher risk. This might include people with chronic disease, Aboriginal and Torres Strait Islander peoples, people who take immunosuppressive medication, overweight and morbidly obese patients,41,42 pregnant women and young children.43

Practices will need to identify at-risk patients and develop strategies to prevent infection and manage concurrent illnesses and conditions, should infection occur.

It will be important to ensure patients taking medications for chronic conditions have adequate supplies. This may mean providing prescriptions for more medication or organising alternative methods for repeat prescriptions.

Other healthcare providers such as antenatal and maternal health clinics and Aboriginal Health Services may not be able to provide patient care during a pandemic.

Practices could consider using telehealth services or phone consultations with other providers (eg other specialists and allied healthcare providers such as psychologists) to ensure continuity of care.

Preparing to manage patients at home

All practices should have a policy for the management of home visits. This should include:

  • how the practice identifies its ability and willingness to provide patients with home visits during a pandemic
  • under what circumstances and in what geographical area the practice will perform home visits
  • which practice staff will attend to home visits (eg doctor or practice nurse)
  • what equipment and PPE supplies will be required for a home visit bag
  • how to manage disposal of clinical waste
  • who will be responsible for checking and restocking the home visit bag
  • how details will be recorded in the patient file.

Antivirals

The role of antivirals (if any) will be established once a pandemic has emerged and more knowledge is gained as to the particular virus strain.

The benefits and risks of antivirals in treating pandemic influenza should be carefully considered. Antiviral drugs given after patients show influenza symptoms may lessen symptoms and shorten the time of illness by one to two days. Antiviral drugs can have side effects and can become ineffective. There are also ethical considerations around the use of antivirals; for example, if antivirals are in limited supply, who should receive them?

During a pandemic, practices are advised to refer to the AHMPPI produced by the Department of Health for recommended treatment options.

The Australian Government has developed a stockpile of antivirals to be used in the event of a pandemic. The WHO and Australian Government will provide advice regarding recommended treatment options.

Generally, whether or not antivirals are used depends on:

  • the likelihood that an individual with pandemic influenza disease will experience a medical benefit if provided antiviral medication1
  • the effectiveness of antivirals in preventing infection (including any evidence of antiviral resistance)
  • the effectiveness of candidate and customised pandemic vaccine
  • the protection offered by natural infection
  • the availability of resources
  • the anticipated length of time until the customised pandemic vaccine will become available.

During a pandemic, practices can obtain up-to-date information regarding new antiviral medications from state and territory health departments, the Department of Health and the RACGP.

Pandemic influenza vaccination

Pandemic influenza vaccination is unlikely to be available early in an outbreak. It is recommended that practices implement a system for checking with the Department of Health and state and territory health departments when a vaccine becomes available for distribution, as well as immunisation strategies.11

It is important to know where and how to order supplies and any security issues for storage. Practices should consider their storage capacity for vaccines. If practices do not have capacity, it is suggested that they explore alternatives for safely storing and transporting vaccines within the safe temperature range of +2 °C to +8 °C (ensuring cold chain management).

A vaccine that gives good protection against a pandemic influenza virus can only be developed after the new strain of virus appears. It may take several months to produce a specific vaccination (called a customised pandemic vaccine) and initially it will be in short supply.

Early in a pandemic, a candidate pandemic vaccine may be used. Candidate vaccines are based on a viral strain thought to have ‘pandemic potential’. The virus strain from which these types of vaccines are made is unlikely to be an exact match to the strain that eventually causes the pandemic. However, they may provide enough crossprotection (or ‘priming’ of the immune system) to prevent infection, decrease the severity of illness or reduce the number of doses of customised vaccine required.

The use of seasonal influenza vaccine can reduce the incidence of circulating seasonal influenza virus. This means that the risk of diagnostic confusion and demands on the health system during a pandemic may be reduced. When a pandemic arrives in Australia, the availability of seasonal influenza vaccine may be limited. At this stage it will be necessary to prioritise the remaining stocks of seasonal influenza vaccine to high-risk groups.

Systems for data collection

During the planning stage, the pandemic leader should be responsible for establishing and maintaining systems to collect influenza data within the practice. The pandemic leader should also ensure other clinicians and practice staff are educated about the process for collection of this data. Data collected will help provide an overall picture of affected areas and identify high-risk areas. This information may also help to assess if current supplies are adequate and if additional supports are required.

The RACGP and the Australian Government would like to see a system where adequately resourced general practices use the appropriate coding in their practice software to flag patients with influenza-like symptoms. During the standby stage, it is suggested that practices use this data to create weekly reports which are de-identified (only numbers are required) and report to their RACGP state/territory faculty office on a weekly basis. The faculty can then collate this information and report to the relevant state or territory health department, who would report to the Federal Government.

Infection prevention and control outside the practice

Practices need to ensure that provisions for these precautions are made for patients seen offsite (ie in home visits or visits to residential aged care facilities). Home visit kits must be appropriately stocked to manage patient needs and staff protection (eg with clinical waste disposal equipment).

Personal protective equipment

PPE is a first line of defence against the spread of viral infection, and an integral component of quality healthcare.13,44

What PPE is required?

PPE is not a substitute for hand hygiene and cough etiquette and should be used in conjunction with individual, organisational and environmental measures.

The SARS outbreak demonstrated the importance of basic infection control precautions in healthcare facilities. Failing to take standard precautions can lead to transmission of disease.44

Communicating with staff about PPE

All members of the practice team should be informed that PPE is available and where it is stored, as availability of PPE may influence the likelihood of work attendance during a pandemic.32

Staff should know how to order more supplies and should establish contingency plans where primary sources become limited.

These communications might include:

  • ensuring staff and patients understand how to put on, take off and dispose of PPE
  • scheduling a team meeting and getting staff to fit and check P2/N95 masks
  • consulting with local state or territory health departments about access to potential stockpiles, or communicating with alternative sources of PPE (eg veterinary hospitals).

The PPE appropriate for a pandemic includes:

  • gloves
  • disposable plastic aprons
  • surgical masks
  • P2/N95 masks (respirators)
  • goggles/glasses
  • face shields
  • gowns.

Disposable PPE should be used because the influenza virus can remain infectious on surfaces for long periods of time.

General principles for PPE selection and use are that PPE should be:13

  • appropriate to the occupational risk
  • acceptable and usable by healthcare personnel in their daily tasks
  • practical regarding issues of cost, time and training to use.

From a patient perspective, approaching someone wearing PPE can be very confronting. The use of PPE should aim to minimise negative interaction with or effects on patients and their families.13

Past events indicate that during a pandemic there is an increased demand for PPE, often resulting in a shortage of essential equipment. Where possible, practices should have appropriate stocks of clinical and non-clinical supplies to ensure continued provision of essential patient services and staff safety in the event of a pandemic.

How much PPE should a general practice have in stock?

Practices are responsible for sourcing and providing PPE for staff and patients within the practice. While there is a medical stockpile of PPE held by the national, state and territory governments, supplies are limited and access to the stockpiles should not be assumed.

Practices might consider maintaining a supply of hand-hygiene products, tissues and PPE for staff for the duration of a pandemic wave (approximately four weeks). This may be costly, so practices should factor this in during their preparations.

Practices need to consider if they have sufficient storage space to house the PPE. If necessary, they may consider relying on existing networks (eg a local pharmacy) to store supplies until required.

Stocks need scheduled checks, as some items are perishable. For example, P2/N95 masks have perishable elastic and an expiry period of five to seven years.

The focus of pandemic preparedness and response is typically on physical health. However, disease outbreaks can cause anxiety and stress and affect the mental health of patients and staff. Practices should also prepare to respond to the mental health and psychological needs of patients and staff during a pandemic.

As well as the disease itself, factors such as travel restrictions, school closures, requirement to take carer’s leave, supply shortages and financial strain can exacerbate mental health issues. Further, people may experience difficulty accessing medical support due to high demand for services which may exacerbate anxiety.

Anxiety and stress can lead to changes in behaviour of staff and patients. Anxious and stressed patients may place extra demands on clinical and non-clinical staff in both the practice and home-care environments. Providing staff with training in the management of difficult and anxious patients is recommended. Staff will also have their own needs and concerns during this time. Providing care to infectious patients presents a range of potentially hazardous exposures for general practice staff.

Identify patient groups and staff who may need psychosocial support in preparing for a pandemic and prepare a document with links to the support organisations that could assist. These links might include home nursing services, meal services and social support services. Identifying referral pathways to culturally appropriate social services is also important.

The Australian Psychological Society tip sheets provide information about how to psychologically prepare for a disaster.

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