Liaison News

Otago
General Practitioners

Issue 25 – March 2011

What’s New
x DHB Website/Community services co-ordination
x TIA Clinic/ Post-Stroke Lectures
x Medical Officer – Mental Health/ Paediatric Dept
x Family Violence Response Tm/ Discharge letters
x Respiratory Failure Support Service
x Insulin Initiation Seminar/ Maternity Services

SOUTHERN DHB WEBSITE

Additions to the website are
o Sexual Health clinic guidelines and treatment protocols
o investigation of thrombophylia

A reminder that the GP part of the website is found under ‘ for Health Providers’ on the
upper right hand , and then ‘GP Liaison Otago’ on the left hand side of the .
The user name is: gpotago and the password is: letmein1
Departmental-specific information is now found under the heading
‘Department/Specific service’

CSCC – COMMUNITY SERVICES CO-ORDINATION CENTRE

This is a reminder that all referrals for SDHB community services within the Greater
Dunedin area, including requests for District Nursing, Community Occupational Therapy
& Physiotherapy, Dieticians etc should be sent to the Community Services Co-ordination
Centre (CSCC).

Referrals should be faxed to CSCC on 4709506.

CSCC is staffed Monday-Friday 0830-1800hrs and

Weekends and Public Holidays 0930-1800hrs and can be contacted on
phone 470 9300 or fax 470 9506.

CSCC staff screen all referrals to ensure that the service requested meets the criteria for
DHB funded community services and that sufficient information has been provided by
the referrer. The referral will then be forwarded to the appropriate service. Any
referrals which do not meet the criteria for DHB services or those that do not contain
sufficient information will not be actioned by CSCC. These referrals will be returned with
an explanation/request for additional information.

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

TIA CLINIC
All doctors referring patients to the TIA clinic are asked to please use the referral form
which is available on the southern DHB website (as above).
This document contains guidelines to aid making a diagnosis of a TIA, and how to
initially manage your patient. It also gives guidance on who should be sent to hospital
for possible admission.

It is important to recognize the ABCD2 score should be considered within the clinical
context. The clinic is seeing some patients who do not have clear signs and symptoms,
but are referred on the basis of ABCD2 scores of 4 and above, accumulated on the basis
that they are over 60 years, have BP over 140/90 and have diabetes but do not have
suggestive symptoms. For example dizziness or staggery gait which lasted and hour will
score 5 which recommends urgent admission if it was a TIA which is highly unlikely.

Patients with very brief (seconds) symptoms and those presenting with sudden collapses
are unlikely to have had a TIA.

It is important to include a covering letter outlining the history, examination findings and
other relevant background material the referral form does not allow room for.

As we try to respond very quickly to referrals it would also be helpful if cell phone
numbers or work or day time phone numbers were included please.

DRIVING after a TIA

Patients you suspect of having a TIA must be told not to drive for at least a month. This
is clearly indicated on the referral guidelines where there are boxes to be completed
indicating what advice patients has been given. We recommend that the fact you have
given driving advice should be clearly recorded in your case notes.

The New Zealand Transport Agency rules encompassed within “Medical aspects of fitness
to drive. A guide for medical practitioners” indicates that after a TIA a patient must not
drive for a month following a single attack. Recurrent or frequent attacks require a three
month stand down.

The current version of the Agency’s book is available at

http://www.nzta.govt.nz/resources/medical-aspects/

POST STROKE EDUCATION LECTURES

The Gibson Community Rehabilitation Service (GCRS) will be providing quarterly
educational sessions to patients, who have recently had a stroke, and their
carers/families. The session will be given by nursing and allied health staff with the aim
of teaching about cause of stroke, general advice for stroke prevention and early
recognition, general rehabilitation principles and how to enjoy life after stroke. Patients
and families will be given advice on how to seek assistance if they have particular
concerns.

Sessions will be held in Community House, Moray Place, Dunedin and Mosgiel Abilities
Resource Centre. Dates/venues for 2011:
19.5.11 Community House Dunedin 2-4pm
18.8.11 Community House Dunedin 10-12
17.11.11 Mosgiel Abilities Resource Centre 10-12
16.2.12 Community House Dunedin 2-4

Information pamphlets on dates/venues will be given to patients on leaving DPH and by

the Stroke Field Officer. A poster advertising the lecture will be sent to GP practices. If
GPs know of patients who have suffered from CVA in the more distant past and may
benefit from attending the lecture then please contact GCRS via the usual CSCC referral
form so that a pamphlet may be sent to them.

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

MEDICAL OFFICER- MENTAL HEALTH SERVICES
Wakari Hospital, Dunedin
Full time/Fixed term

Our Mental Health Service is seeking applications for the role of Medical Officer.

A full-time fixed-term (12 months) position exists for a suitable experienced Medical
Officer to meet the physical health needs of patients of the Mental Health and
Intellectual Disability Services at Wakari Hospital. This is an exciting new Monday to
Friday position working with multi-disciplinary teams across a number of varied clinical
settings. Applicants must demonstrate a commitment to providing optimal physical
health assessment and treatment with consideration of the holistic needs of people with
mental health and intellectual disabilities. In addition, we would like to recruit someone
who has an active interest in health promotion. An opportunity also exists for the
applicant to participate in the Mental Health and Intellectual Disability Services after
hours on-call roster (with additional remuneration for these duties).

To be successful in this role you’ll need to be flexible, committed to quality service

delivery and development, and able to work effectively within a multidisciplinary team.

Closing Date: 13 March 2011

Please attach an updated CV and Cover Letter and apply online. For more details
contact Nigel Copson, Recruitment Advisor,
Phone: 03 470 9605 or Email: nigel.copson@southerndhb.govt.nz

PAEDIATRIC DEPT
The Children’s Health Service is short of one SMO (clinician) this year and the number of
referrals to Paediatric OPD continues to rise. In order to cope with this and to continue to
see referrals within a reasonable time, we would like to remind our General Practice
colleagues of some of the measures we have been taking. These include:

1) making sure that any follow up appointments that are appropriate for GPs are
directed there

2) redirecting referrals that are more appropriate for another service to another service
such as CAFS or YSS for urgent/severe mental health issues or where the patient is
already known there.

3) redirecting new referrals for children/young people not already involved in our
service with a chronic health issue who are older than their 15th birthday to the
appropriate adult service.

4) remaining willing to respond to questions by phone, letter or email in a way that may
avoid the need for a referral.

We are happy to discuss any of these issues further.

If you have any enquiries about the paediatric dept, please contact
John Clarkson Consultant Paediatrician or
Pam Markby Unit Manager Paediatric Outpatients.

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

FAMILY VIOLENCE RESPONSE TEAM - FVRT
The Southern District Health Board (Otago) has a relationship of collaboration with the
Family Violence Response Team (Dunedin) – a coordination group working in the area of
Family Violence. The core group of the FVRT comprises Police, Child Youth and Family
and Women’s Refuge (Te Whare Pounamu). Working with this core group are other
services – Corrections, Southern District Health Board, Prosecutions and Stopping
Violence Dunedin.

On a weekly basis the core group and this wider FVRT group reviews Police Family
Violence call-outs and other family violence concerns from the member organisations, to
support coordinated safety planning, intervention for victims, and interventions for
offenders to encourage behaviour change.

The Southern District Health Board (Otago) works with FVRT through an agreement to
share information with the Violence Intervention Programme (VIP) of the SDHB.

Working with the GP representative on the Otago Child and Youth Mortality Review
Committee and the Otago Family Violence Mortality Review Committee, the combined
committee has recommended information sharing with the relevant GP practices where
there are significant concerns about victim safety and support. FVRT has supported this
sharing of information through the SDHB role on the FVRT.
The client is not told at the time but the process of sharing information to support safety
is not secret

It is proposed that this information sharing will take the form of a letter to the relevant
GP, outlining the core information known to the Police, or other agency, in relation to the
concern. The GP may seek further information from the Coordinator, Child Protection
Service, VIP – contact details below.

There are times when contact, or GP, information for patients may be inaccurate – e.g.
the GP named as providing care for the patient may not be the current GP. If that is the
case could the GP either return the information to the Coordinator, Child Protection
Service, VIP, or forward to the relevant GP if known.

This information is provided to the GP to assist the GP to provide relevant support and
treatment, following on from the management of any immediate safety or health needs
at the time. The aim is to keep the GP informed to assist them in understanding the
family context should support etc be needed in the future. If there are other issues /
concerns / follow-up that the GP needs to arrange, that would be explicitly asked for.

Regards

Gerard Kenny
Nurse Coordinator, Child Protection
Violence Intervention Programme
Southern District Health Board (Otago)
Private bag 1921 Dunedin

DD: 470 9564

gerard.kenny@southerndhb.govt.nz

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

DISCHARGE LETTERS from DPH
Currently there is an investigation of referral mechanisms into Dunedin hospital, and as
a side-line of that, GPs have voiced concern about discharge summaries being received
after a patient’s admission or out-patient review.
The issues include incorrect medication lists, the use of acronyms that the registrar
might understand but which leave the simple GP none the wiser, promptness of
discharge letters being received in the community.

I would like to hear from you about any particular problems you have had with discharge
letters recently.
Please email me (Anne Worsnop) to the address below.

RESPIRATORY FAILURE SUPPORT CLINIC

Who:
Patients with end stage respiratory failure, usually but not always due to COPD.
What:
An exploration of end-of life issues in relation to palliative treatments and future care.
This will include discussion of Advance Care Plan if appropriate.
Referral threshold:
Patients will usually have had several admissions for exacerbations of COPD. They will be
disabled by their respiratory failure. Such patients will benefit from a consultation if you
think the answer to the question “Would it be a surprise to you if this patient were to die
within the next 6 months?” is “No”.
Staff:
Respiratory Nurse Specialist, Debbie Hannah, Lynda Paris or Carol Fitzgerald AND a
Respiratory Consultant (Professor Robin Taylor, Dr. Colin Wong or Dr. Ben Brockway)
will be in attendance for the Consultation.
When:
Tuesday afternoons
Where:
4th floor Outpatient Clinic, Dunedin Hospital. But initial contacts are made by telephone
and/or home visit (nurse specialist).
How to refer:
Call Debbie Hannah or Carol Fitzgerald via Dunedin Hospital switchboard (03 474 0999)
Read more:
please see attached outline below

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

ADVANCE CARE PLANNING
Dying well with COPD:
Patients with end stage COPD often experience a number of hospitalisations during the
last phase of life due to exacerbations of respiratory failure, and the approach to
management is almost always based on an “acute care” model, designed to achieve a
“curative” outcome. The idea that the exacerbation might represent an end-of-life event
is not often embraced at the time, and the patient sometimes receives aggressive and
for that reason, inappropriate, treatment. This is not always in keeping with the patient’s
wishes.
The situation contrasts with that of patients with a diagnosis of lung cancer, for whom
the “acute care model” is set aside in favour of a palliative approach at an earlier stage,
and inappropriate or unwanted treatments are less likely to be given.
In most cases, clinicians do not offer COPD patients and their families the opportunity to
discuss and plan for their future care. Why is this? Studies indicate that the hopes and
desires of COPD patients are very similar to patients with lung cancer, but are neglected
because there is uncertainty about the prognosis, and clinicians are uneasy that they
might rob the patient of hope. In fact studies show that the opposite is the case.
The Respiratory Medicine Unit in Dunedin Hospital has recently established a
“Respiratory Failure Support Clinic”. The aim is for a Nurse Specialist and a Respiratory
Consultant to meet with the patient together with family or whanau members as
appropriate. Issues relating to prognosis, anxiety and depression, palliative care
treatments, levels of physical and spiritual support, death and dying, and what the
patient would like to be done in the event of acute exacerbation are addressed in a 45
minute meeting.
The idea of a future care Plan, based on the “Preferred Priorities of Care” model, but
modified for end-stage respiratory disease, is introduced, though not always at the first
visit. Pressure to draw up a Plan is never applied. The Preferred Priorities of Care Plan
outlines the patients informed choices regarding their treatment in the event of future
deterioration. It may include where the patient would wish to die.
Referral to the Supportive Care Clinic is based on the “Surprise Question” (“Would you
be surprised if this patient were to die within the next six months?”) and a brief
screening visit by the Nurse Specialist prior to the initial consultation. Follow up is
arranged where appropriate.
To date, patients’ responses to this strategy have been varied but very encouraging. Our
overall experience is that patients and their families appreciate the time and attention
given to issues which, under our present model of health care delivery, do not receive a
great deal of time and attention. If you would like to consider referring a patient to the
Clinic, please contact Debbie Hannah, Respiratory Nurse Specialist, at Dunedin Hospital
(474 0999, pager 6395) or Carol Fitzgerald (pager 6816)

D. Robin Taylor
Consultant Specialist and Professor of Respiratory Medicine.

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

INSULIN INITIATION SEMINAR
This is an advance notice of a meeting that will be held in Dunedin in May. The aim of
the seminar is to provide GPs and Practice Nurses with an overview of diabetes (Type 1
and 2) with an emphasis on insulin initiation in the practice.
To register your interest, please email: Laina.Etuale@sanofi-aventis.com

Insulin Leadership Summit.

Agenda
Saturday 14th May 2011 Dunedin Public Art Gallery

8.00 am -8.50 am Registration

8.50 am-9.00 am Welcome and introduction Sanofi-Aventis

9.00 am-10.00 am Diabetes type 1 and 11 Prof Patrick Manning

10.00 am-10.45 Breaking down the barriers to Prof Patrick Manning

am insulin use

10.45 am-11.15 Morning tea

am

11.15 am-12.15 Workshop 1 Prof Manning/DNE Mr Gavin

pm Insulin initiation and titration- Hendry
KISS

12.15 pm-1.15 pm Lunch

1.15 pm – 2.00 Workshop 2 Prof Patrick Manning/DNE
pm Insulin switching Mr Gavin Hendry

2.00 pm – 3.00 Workshop 3 Prof Patrick Manning/DNE

pm Practical management Mr Gavin Hendry

3.00 pm – 3.30 Afternoon tea

pm
3.30 pm – 4.15 Q&A Panel Prof Patrick Manning/DNE
pm Mr Gavin Hendry

4.15 pm – 4.30 Wrap up and close

pm

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz

MATERNITY SERVICES in NZ
The Ministry of Health has chosen the Southern District Health Board to be one
of four demonstration sites for clinical quality improvement activities for maternity
services.
A multi disciplinary team has been established across both Otago and Southland
sites to meet the project objectives.
The work of the DHB demonstration sites will be used to develop national
approaches and guidance for other DHBs.
The selected sites will be demonstration sites and are expected to implement
innovative approaches to ongoing local clinical review of maternity services, so
that issues in local services will be proactively identified and addressed. This will
include:

x More visible and broader clinical quality improvement activities in

maternity services. This will involve building on the quality improvement
activities already in place (such as local mortality reviews and reviews of
serious and sentinel events) and broadening the scope of review to
include a wider range of matters that impact on the quality and safety of
maternity services, as well as matters that are of concern to local
practitioners and consumers;

x Stronger clinical leadership across both hospital and community-based

maternity services, so that leaders across the midwifery, general
practice, obstetrics and paediatric professions work together to drive
clinical quality review activities;

x Local maternity networks, so that practitioners working in maternity

services across the community and hospital settings are brought
together via a co-ordinated network;

x Effective mechanisms for consumer engagement in the implementation

of maternity quality improvement activities. There will be a particular
emphasis on consumer participation from high-need populations
including Maori, Pacific and young mothers.

In addition to the above a joint project between Prof Gauld’s department at Otago
University and Dr Andre Smith, Medical Director of Women’s Health Otago, is being
carried out to further investigate the current provision of maternity services in NZ. Andre
is interested in hearing from a few GPs who would be interested in forming a small
working group to further the discussion around quality and help shape a study that will
run alongside and beyond the MOH project.
If you have experience with maternity services over the last generation and would like to
be part of the group, please email me, as below.

Dr Anne Worsnop, GP Liaison, Email: anne.worsnop@southerndhb.govt.nz