Clinical management and comorbidities

During a pandemic, general practices may see an increase of potential cases, contacts and worried people. Practices risk being overwhelmed due to the challenges of sick patients with other chronic and complex diseases, and staff absenteeism from sickness, fear or family care needs.

Referral pathways may also change during a pandemic. Suspected cases may be sent to designated hospitals and patients who might usually be referred may need to be cared for in primary care.

Consider designating a practice nurse to manage worried or anxious people who are not ill. Having clear patient education materials available across a number of platforms may reduce anxiety based on the unknown.

Point-of-care testing may not always be reliable but it may be useful for managing the worried well.

During a pandemic, it might not be possible to care for all patients at the practice location. This may be due to illness, frailty, disability, quarantine or anxiety about becoming exposed to pandemic influenza at a practice. Some of these patients may require additional support from social services such as mobile meal services or mobile mental health services.

State and territory health authority planning will differ between jurisdictions. Each jurisdiction will nominate a level of service delivery and healthcare to patients within their own home. Practices need to know what assistance will be delivered to their patients.

There are established hospital-in-the-home (HITH) services across many parts of Australia that provide domiciliary acute care as a substitute for traditional inpatient care. These services may have a specific role during a pandemic. This may include assisting non-influenza-related conditions or managing some patients with influenza and its associated complications. Services are commonly linked to public hospitals and community health services with some private services in operation in metropolitan areas. Some general practices already play a role within these services, and familiarity with HITH may provide GPs with additional support during the response and recovery phases.

Patients with pandemic influenza may be avoided by their family and friends and therefore require additional support. This may depend on the clinical severity of the pandemic as well as other factors such as irrational fears. During the H1N1 pandemic in the United States, H1N1 was the most stigmatised disease: more so than cancer or HIV/AIDS.⁵³

Telephone follow-up could be used to manage patients with mild symptoms at home.

Management will largely depend on:

• the clinical severity of the virus (eg a mild virus may require treatment similar to seasonal influenza, whereas a severe virus may mean immediate referral to a designated setting)
• any present comorbidities, such as COPD
• the role of antivirals.