Episode 11: Are you Choosing Wisely during the pandemic?

Voiceover:

Welcome to the NPS MedicineWise podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Steve Morris:

Hi, I'm Steve Morris, CEO of NPS MedicineWise. And welcome to another podcast in our series related to COVID-19 issues. In episodes so far, we've heard a bit about what's going on in general practice and a bit of what's going on in the pharmacy environment. Today we're going to hear a slightly different perspective and concentrate on how we make good healthcare decisions during the pandemic in the hospital setting. So I'm joined today by Simon Judkins, who's an emergency physician working in Victoria at one of our Champion Health Service hospitals, and also represents the Australasian College for Emergency Medicine on the representative panel for our Choosing Wisely Australia initiative. Welcome Simon.

Simon Judkins:

Thanks for having me.

Steve Morris:

At the moment it's a difficult time in Victoria. So just maybe give our listeners a kind of sense of the challenges you're currently facing at the minute.

Simon Judkins:

Yeah, so we're right in the middle of a surge in COVID cases within the community as I'm sure everybody is aware. But it's a sort of an interesting time within the hospital system. I think we all knew that this was happening. This was part really of the expected pattern of COVID, that we would see suppression, and then we would see hotspots within the community. Fortunately, we're not seeing the numbers of patients and infections that we're seeing in many overseas jurisdictions. So even though those numbers feel high, I still think they seem to be relatively sort of controllable. And certainly at this point in time, don't seem to be at the point where hopefully they won't sort of overwhelm the healthcare system. I suppose one of the positives about where we are now is that we've had time to really prepare the hospital system for these spikes in activity and case presentations.

And so, there's a good understanding of what we need to do to improve capacity within the hospital system, improve our processes, fast track the right patients to intensive care, arrange directive missions from community into hospitals. So, even though it's a concerning and very sort of anxiety sort of provoking time for staff and patients and their families — we know that there's going to be illness, we know that there's going to be patients who are going to pass away because of COVID — I think having to sort of prepare for this over the last six months has put us in very good stead. And I think looking at, for example, the fantastic resources that Choosing Wisely have had time to put together over the last six months, certainly make sure that clinicians and patients and consumers are really up to date with what the latest evidence shows with respect to treatment of COVID-19.

Steve Morris:

Thanks, Simon. Look just to go further on from what you've mentioned about Choosing Wisely, it might be good just to firstly talk about Choosing Wisely goals and principles for our listeners. So can you just give people a bit of a refresher on what these principles are and whether you think they've stayed relevant during COVID-19?

Simon Judkins:

Yeah, absolutely. So if you look at the basic principles which builds the Choosing Wisely ethos is really about being health profession led, improving quality of care and harm prevention. It's multidisciplinary inputs into healthcare decisions, certainly consumer focused and concentrating on good communication between healthcare workers, health professionals, and consumers, patients and their families. Obviously clearly evidence-based, which is incredibly vital in this sort of pandemic and the management of this pandemic. Because we can certainly see what bad advice can actually do and how it can impact people's understandings of the disease. And certainly transparent in the process and evidence. And again, I would look at how the conversations about the evolution of some of the evidence and the evolution of the process as we learn more about COVID, coronavirus, we adjust. And that's what good science on good evidence is about.

I think one of the strengths in the Australian approach has been the fact that we have had health professionals really leading the preparations and the treatments around COVID-19 with the Australian health care system, and having health professionals standing side by side with political decision makers and really working together to make the right decisions for patients, communities and healthcare systems has been, I think, one of the real strengths of the COVID response in Australia.

Steve Morris:

So some of the principles of Choosing Wisely have really helped inform some of that preparedness, Simon?

Simon Judkins:

Well, I think so. I mean I've reflected to people before that this does — the whole pandemic approach and the way the Australian health system has managed and partnered with both patients and other decision makers, political leaders, consumer groups — has really been a big Choosing Wisely venture. As I said, it's been a lot of the decision makers have been health profession led. So we've had a leading epidemiologist, virologist, infectious diseases, consultants, intensivist, emergency physicians, all collaborating together to come up with the evidence and guiding the process or the plan to manage COVID through the community. It's really about improving the quality of the evidence and harm prevention. I think one of the fundamental principles of the response to the pandemic has been about harm prevention. So the issues around, for example, the physical distancing and the wearing of masks, they've all been about trying to reduce the harm from COVID-19.

And so certainly that really is a Choosing Wisely principle. It's been multidisciplinary, so not only within the medical fraternity, but also other as I said, epidemiologists, other craft groups, including there's clearly our nursing colleagues, our physiotherapists, ambulance services, for example, and other sort of professions or people involved in the delivery of healthcare across communities. So you can see based on those principles, they've been very much embedded in the way that we've been approaching the pandemic. And of course the evidence base, which I think is the most important part of this. And it's really quite interesting to see how we have, the evidence has evolved as and I think everybody's been very clearly very open and honest about this is that, we didn't have a lot of evidence around how to manage COVID-19 as it first developed across the world.

And so we've seen trials based on the use of dexamethasone for example. We've seen the trials based on the antiviral therapies. And now we're saying trials based on obviously the development of a vaccination. All of those clearly evidence-based. All of those are finding positive outcomes for the inclusion of treatments, but also looking at other touted treatments and clearly excluding those as being non-evidence based and not recommending those. So again, clearly following those Choosing Wisely principles.

Steve Morris:

Yeah. Look it’s good to hear that those principles have had such a benefit in terms of helping to identify some solutions to some really difficult issues.

Simon Judkins:

Well, we can certainly say some of the, and fortunately we have seen obviously people and there's obviously there's very prominent politicians in other parts of the world who have made clearly unsubstantiated, unevidenced based comments about treatments and clearly that can lead to adverse outcomes and that clearly can be dangerous. So I think it's incredibly important that we focus on where the evidence is. And there are thoughts about whether a specific treatment might be helpful. We're clearly seeing a very rapid engagement from the scientific community to either support or refute any treatments.

Steve Morris:

And beyond the broad principles, Simon, obviously Choosing Wisely has also issued some almost pandemic specific guidance. Five key messages for health professionals, as well as a version of principles for consumer pandemic guidance. So can you tell me about this specific guidance and how maybe these messages can help with peer to peer and doctor to patient conversations about the risks and benefits of care and what care is truly necessary during the pandemic?

Simon Judkins:

Yes. So again, I think the Choosing Wisely principles for both health professionals and consumers, are very, very clear and very, very supporting documents. So, looking at encouraging patients to seek their usual care for existing medical conditions is one of the first guiding principles. And I think that again, incredibly important that we want to make sure that patients realise and understand that maintenance of their health and all their other healthcare conditions is vital during this time. Because obviously we're clearly trying to prevent COVID infection and COVID spread, but we can't do that by sacrificing other maintenance of healthcare. So people with their kidney disease, diabetes, their cardiac failure. In short, we need to make sure that people have access to their GPs and their specialists to maintain their health, using health care resources judiciously again.

And I think we're seeing that within the healthcare system that people, clinicians, and patients have adopted, for example, or embraced telehealth and video conferencing around accessing their healthcare needs. So ensuring that the right resources are being used and we're using them effectively and efficiently. And I think that'll be one of the big changes that we may see through the pandemic that we change a lot of the ways in which health care is actually delivered. In fact, one of the early conversations I had at the start of this year was about the people embracing video conferencing and teleconferencing for outpatients.

And one of the leading haematologists said to me, "I realised that all this time I've been practicing doctor centred care instead of patient centred care by expecting people to get in their car, drive for 45 minutes, come to find park, come to hospital, see me for 15 minutes, and then I send them back home again. And it takes a whole day." So, clearly changing the way we access and deliver health care is, I think, one of the positives that we'll see, or one of the ongoing benefits we'll see out of this sort of evolution or forced evolution, I suppose, of healthcare.

Steve Morris:

It's certainly one of the things that's come out of our other podcasts, Simon, how you build some of these changes in a sustainable manner in an ongoing basis.

Simon Judkins:

Yeah, and this is the next step. The next step is maintaining all of this. And I think the fact that it's multidisciplinary as well. So we're seeing it from GPs. We're seeing it in mental health. We're seeing it in our outpatients. So I think this change will be embedded in the way people access, and as I said, deliver healthcare. Resource stewardship has been incredibly important. And probably as a front line health care worker, the issues around, for example, the use of personal protective equipment or PPE has been one of the most, I suppose, discussed and pressing issues around resource stewardship. Again, our personal protective gear, face shields, mask, etc, an incredibly important piece of the protection for both healthcare workers and patients.

And so certainly following the evolution of those PPE guidelines and how everybody has shown an amazing level of responsibility to ensure that those resources are fair and equitably spread across the system, I think has been quite amazing. Because I think your initial response as a health care worker would be give me everything. I want to put everything on. But everybody understands that they have a role to ensure that everybody has access to that equipment when and where it's needed. So that's again, been quite an amazing experience to watch people understand where the evidence is and really try and follow the evidence and ensure that we don't burn through something as important as our PPE gear to ensure that we have it for the longer term.

Steve Morris:

Yeah. Thanks Simon, you give a very good overview of the importance of those Choosing Wisely and evidence-based principles. Are there any final comments you have for our listeners?

Simon Judkins:

Oh, look, I think for the listeners really, I think on both sides of the equation, both for the clinicians, but also for consumers, patients and their families and their supporters is this is more than ever a time that we need to engage. We need to listen to and understand the evidence. You need to ask appropriate questions. And really, I think, and understand even outside of your own personal space and family about what the system is trying to achieve. There's always going to be differing views. There are always going to be different websites and people out in communities who are saying controversial things. But I think if you can go to a trusted source for your evidence, and certainly the Choosing Wisely source, the website there with the information that it's got on there, certainly are considered a very highly, highly trusted source. And I think if you have any questions about the pandemic guidance for both health professionals and consumers, I would strongly suggest that you go to the Choosing Wisely website and get your information from there.

Steve Morris:

Okay. Thank you, Simon.

Simon Judkins:

Okay. No worries. Thanks for your time.

Steve Morris:

And thank you for listening. And as always everyone, you can find additional details around COVID-19 as well as Choosing Wisely on our NPS website, nps.org.au. Okay. Thank you for listening.

Voiceover:

For more information about the safe and wise use of medicines, visit the NPS MedicineWise website at nps.org.au.