WIT.0001.0038.0001
25 August 2020
The Honourable Jennifer Coate AO Board of Inquiry into the COVID-19 Hotel Quarantine Program PO Box 24012 MELBOURNE VICTORIA 3001
Email: [email protected] Cc. [email protected]
Dear Justice Coate,
Please find below my answers to the questions put to me as a part of the Board of Inquiry into the COVID-19 Hotel Quarantine Program.
1. What is your relevant professional background and work history?
I studied at the University of Melbourne Medical School and graduated M.B.B.S. in 1982. In 1989, I was awarded fellowship of Royal Australasian College of Surgeons and the Royal Australian College of Ophthalmologists. In 2007, I graduated from the Australian Institute of Company Directors and was awarded full fellowship of the Institute in 2008, given my extensive experience as a Director, especially via the Board of a regulated medical indemnity insurance company.
Between 1989 and late 1991, I trained in the United States of America. I received sponsorship for my fellowship training from both the Royal Melbourne Hospital (for Case Western Reserve University and University Hospitals of Cleveland, Ohio), along with the University of Melbourne (for Washington University and Barnes Hospital, St Louis, Missouri) respectively. I was also supported to attend the 8th annual summer program in Epidemiology at the Johns Hopkins School of Hygiene and Public Health during June and July of 1990 where I was trained in epidemiology and biostatistics. I have been involved in research and teaching at the University of Melbourne since 1991 and have held the position of Associate Professor, within the University Department of Surgery since 2005.
In addition to my employment and academic interests, I have been:
Chairman of MDA National (a medical professional indemnity insurance provider); Chairman of Anglican Overseas Aid, a DFAT-accredited foreign aid organisation; and Board member of the Avant Foundation which supports quality, safety and professionalism in health care.
Since 2016, I have served on the Board of the Australian Medical Association in Victoria. In 2018, I became President of the Victorian branch of the Australian Medical Association.
I have also recently been elected Chair of the Federal Council of the national AMA. On Australia Day 2018, I was awarded the medal of the Order of Australia (OAM) for "service to Ophthalmology and to the development of overseas aid". WIT.0001.0038.0002
2. What is the AMA? What is its role and who are its constituents?
The Australian Medical Association is arguably the most influential membership organisation representing registered medical practitioners and medical students in Australia.
The AMA advocates on behalf of its members at the federal, state and territory levels by:
working with governments to increase and maintain provision of world class medical care to all Australians; tracking and reporting government performance on health policy, financing and services; challenging governments on policy that potentially harms the interests of patients; leading the health policy debate by developing and promoting alternative policies to those government policies; providing informed, expert medical commentary on health issues; responding to issues in the health debate through provision of a wide range of expert resources; commissioning and conducting research on health issues.
The AMA therefore exists to promote and protect the professional interests of doctors and the health care needs of patients and their communities.
Consultation of the AMA in relation to the Hotel Quarantine Program
3. When and how did you become aware of Victoria’s Hotel Quarantine Program?
On Friday 27th March, I heard the Prime Minister announce on the radio that national cabinet had agreed on strict new hotel quarantine measures that would apply from midnight on Saturday 28th March 2020. I recall that the Australian Defence Force was mentioned and had been asked to help state law enforcement increase checks on passengers who arrived before the deadline, and who were supposed to self-isolate for 14 days.
4. Was the AMA ever consulted or asked for advice in relation to the development or operation of Victoria’s Hotel Quarantine Program? If so, please provide details, including any relevant documents.
No, we were never consulted.
Role of AMA Members in the Hotel Quarantine Program
5. What role have AMA members played in Victoria’s Hotel Quarantine Program?
I was initially contacted by an AMA Victoria Board member, Dr Sarah Whitelaw early on Easter Saturday morning, 11th April 2020. She expressed concern to me as to the arrangements with hotel quarantine and directed me to speak to Dr Peter Archer who is a Director of AUSMAT who was more familiar with the organisation of the medical care at the Quarantine hotels. I did so I believe later that day or on the following day. I was also called early on Easter Monday (13th April, 2020) by a member, Dr Nathan Pinksier and was informed that his medical deputising company had been contacted on or around March 30th 2020 by DHHS regarding the possibility of providing a medical WIT.0001.0038.0003 workforce (via his Medical Deputising group). This was to be arranged along with other newly recruited doctors to support the medical care of hotel quarantined overseas arrivals. He had arranged for the doctor service to commence on Saturday 4 April at the Crown Hotel sites.
Dr Pinksier’s service was initially a daytime onsite service involving one doctor and three hotels with overnight coverage being provided by the Doctor Medical Deputising Service. I understand that this rapidly expanded into 24 coverage with 6-8 doctors working daily and 1-2 overnight. It had become a sizable logistic operation for this group which became involved in onboarding new doctors on a daily basis. This was managed by the Medi7 group led by Nathan and his AMA member brother, Dr Henry Pinksier, who are specialist general practitioners.
I understand that the duties and responsibilities of the group included: 1. Providing general medical care to the hotel quarantine guests; 2. Overseeing testing by nursing staff and ensuring the availability of results; 3. Providing mental health support services and escalation via specialist referral where indicated; 4. Ensuring the availability of emergency medicines at each site via an imprest (as some cases of food related anaphylaxis had been reported); 5. Organising the availability of oxygen and resuscitation equipment at each site; 6. Facilitating the recording of clinical information via access to MHR.
Training and Supervision
6. As far as you are aware, what training was provided to AMA members who worked in the Hotel Quarantine Program regarding COVID-19 and how to work in a safe manner?
I am unaware of the training to any AMA members that was provided (if any).
7. To the best of your knowledge, has any Victorian government department or agency provided training to AMA members regarding COVID-19 and how to work in a safe manner in the Hotel Quarantine Program? If so, which government department or agency provided training and what was it?
I am unaware of any training provided to AMA members and/or the agencies that were involved in such training.
8. What onsite supervision was in place for AMA members at each hotel?
I am unaware of the onsite supervision arrangements.
9. To the extent that you are able to comment, was adequate training and supervision provided to AMA members involved in Victoria’s Hotel Quarantine Program?
I am unable to comment as I have no first-hand knowledge of the training and supervision to members involved in the quarantine program.
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Personal protective equipment (PPE)
10. To the best of your knowledge, what PPE (if any) was provided to AMA members by any (and if so, which) government department or agency?
I have no first-hand knowledge of the PPE provided and/or which government department or agency provided this equipment.
11. As far as you are aware, were AMA members at any time required to provide their own PPE for their work at quarantine hotels?
A shortage of PPE was mentioned to me via Dr Nathan Pinksier’s phone call of 13/04/20 and his concerns were repeated in an email from Dr Pinksier to the CHO, Prof Brett Sutton (to which I was copied on 13 April 2020 at 2:17 PM as per attachment 2), although I am unaware of his specific concerns as to the types of PPE that were deficient.
12. What directions or training did AMA members receive about when and how to use PPE, in relation to the Hotel Quarantine Program? Who gave that direction and who provided that training?
I have no first-hand knowledge of any such training.
13. As far as you are aware, was there ever a shortage of PPE at quarantine hotels? If so, how was that shortage managed?
I have no direct knowledge; only the brief mention in the phone call above.
14. To the extent that you are able to comment, was adequate PPE provided to AMA members involved in Victoria’s Hotel Quarantine Program?
I have no direct knowledge.
AMA Reservations
15. Did you (or the AMA) have any reservations about any aspect of the Hotel Quarantine Program at any time? If you did, what were your reservations, and to whom, if anyone, did you (or the AMA) express them? Please provide any relevant documents.
The AMA received complaints from doctors working in several Accident and Emergency Departments (specifically the Royal Melbourne and St. Vincent’s hospitals) about the transfer arrangements for guests attending those hospitals for medical checks. Appropriate ambulance transfer to the hospital occurred but the return journeys were difficult to arrange and consequently guests were most usually returned via taxis, hire cars or private vehicles. I sent text messages to the Chief Medical Officer (as below) seeking discussion and subsequently advised him of my concerns by telephone.
In addition to my text and voice communication, AMA Victoria board member, Dr Sarah Whitelaw (the Australian College for Emergency Medicine representative to AMA Victoria Council) forwarded Prof Andrew Wilson (and others) the attached emails on Wednesday 14 April, 2020 after these WIT.0001.0038.0005 matters were briefly raised under other business by Dr Whitelaw at a meeting between Prof Wilson and the Victorian State Chairs of medical colleges.
Please see the attached emails and the associated file from Dr Sarah Whitelaw to Prof Andrew Wilson of DHHS (Chief Medical Officer). (See Attachment 1)
The advice recommended by Dr Whitelaw was that the State Government should take an operational approach to hotel quarantine.
Operational plans have been developed and applied successfully in very similar circumstances (for example, the management of returned citizens from Wuhan) and there are expert advisory bodies like the National Critical Care and Trauma Response Centre which could have provided advice and assistance. The advice in the email to government was brought together based on consultation with Australian experts in disaster medicine and management.
The email outlined that to set the system up properly, the hotel quarantine system did not need to be developed from scratch. With the email was an attachment which broadly condensed the basic components of an operational plan.
An operational approach involves obtaining advice from disaster management experts and other related experts, considering all aspects and issues that they were likely to encounter and then setting up a system that was ready to respond to those issues.
This isn’t the approach the Victorian Government took in establishing hotel quarantine. Instead, public servants set up hotel quarantine in a very short period of time. They did not seek input from experts, and so unsurprisingly, when then encountered issues in the ensuing weeks and months, they were not well prepared. It appears that they dealt with issues individually, haphazardly and reactively.
If they’d taken an operational approach from the start, with clear governance and expert involvement, then they would have been prepared for many of these developments. However, instead there seemed a lack of recognition that setting up hotel quarantine is a difficult task and we sensed that DHHS considered that doctors were over-medicalising and over-complicating their approach.
We believe that there was no shortage of experts in Victoria who could have assisted the government with establishing hotel quarantine – but somewhere along the line, the government didn’t view engagement with these types of experts as being necessary.
Overall, there is not a culture within government and within the DHHS of meaningful engagement with stakeholders. There appears to be a lack of appropriate planning, collaboration and two-way communication between the DHHS and its external stakeholders. There needs to be more genuine attempts to seek feedback, test assumptions and ideas, obtain input from experts, and collaborate in planning and understand the experience on the ground.
16. If you expressed reservations about the Hotel Quarantine Program, what response (if any) did you receive? Please provide any relevant documents.
There was no formal response.
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Complaints and concerns raised with the AMA
17. What complaints and concerns (if any) were raised with the AMA (by AMA members or by others) in relation to the Hotel Quarantine Program?
Mainly via the following text messages and associated phone calls to the Chief Medical Officer of Safer Care Victoria, Professor Andrew Wilson:
> Saturday 11th April 1:56pm > > Julian: Would you have a few minutes to chat so that I can give you the heads-up about a looming issue? Thanks, Julian > > Saturday 11th April 4:51pm > > Julian: This guy knows what’s going on in the isolation hotels Andrew. Probably worth a chat with him when you have a moment? > Thanks, Julian > > Attachment: Dr Peter Archer, Director AUSMAT > > AW: Ok sure > > Julian: I think the whole show is being run by the nursing decision makers at DHHS but it desperately needs some medical leadership concerning resources and personnel. > > AW: Got it. I’ll find out who’s involved > > Julian: Good Andrew, I also was told that I would receive a breakdown concerning the recent rise of infections amongst HCW’s. True to form that didn’t happen so i will have no option but to continue a dialogue with DHHS via the media. Why are they so secretive? It seems that they believe in open disclosure for medical staff but not for the department? What a joke! Thanks, Julian > > AW: Who promised? Ill escalate internally as a big issue. We have an scv issues management process that has some traction. > > Julian: Well I spoke to a deputy CHO. > > I spoke to him around 11:30am today concerning the rise in HCW infections - he said that he would try to persuade the team to share the epidemiology but none has been forthcoming. Of course, he may have been busy or the info was hard to collate but maybe they didn’t want to share what was happening? > Thanks, Julian > > AW: Ok. Ill chat to him. It may be hard to make that call on the weekend. Hes usually pretty good and reasonable. > > Tuesday 14th April 9:01am WIT.0001.0038.0007
> > JJululiian: Probably a good iideadea to speak to Prof John WWilsonilson at the AlfredAlfred sometime todaytoday ifif youyou can? ApparentApparentlly they were out of N95 masks inin the CV-19CV-19 Ward lastlast weekendweekend and wwooulduld lliike to discussdiscuss howhow theiir supplliies might be improved?improved? Thanks, JJululian > > BTW AndrewAndrew,, iin a newnew studystudy ofof hospitahospitals inin the US CDC journaljournal (Emerging(Emerging InfectiousInfectious Diseases,Diseases, 10 AprApril 2020)2020) CoronavirusCoronavi rus was found toto be widewidelly distriibuted on ffloors,loors, ccomputeromputer mice,mice, rubbishrubbish bins,, and siicckbedkbed handraililss and was detected inin airair:::4 ::4 m from patiients,ents, withith contamcontamination greater inin ICUsI( Us than general wards. IInn additadditionion,, asas medicamedical staff wallk aroundaround the ward,, the COVID19CO VID19 vviirusrus can be tracked all overover the floor,floor, as indicatedndicated byby the 100% rate ofof positivpositiviityty fromfrom the floor iinn the pharmacy,pharmacy, where there were nono patients. Furthermore, hallf of the samplles from the soleses of the IleuCU medicamedical staff shoesshoes tested posposiitive.tive. Therefore,, the soleses of medicall staff shoesshoes miight funfunctctiioonn as carcarrriiersers - so maybemaybe diissposabposablle bootieses need to be consconsiidered asas inin theatres?theatres? > > Friiday 17th AprApril 12:34pm34pm > > AW: CanCan II ccaallll you later?ater? > > WednesdayWednesday 29th AprilApril 4:02pm02pm > > AW: Can II call youyou later?later? > >Sure> Sure - justjust had a goodgood meetiing withith Terry SymondsSymonds and Siimon Chant w here II think wewe havehave sorted the prpriivatevate contractcontract stuffstuff - but I need to chat aboutabout somesome llingeringering PPE iissuessues when u r freefree?? Thanks,Thanks, JuJulilianan
18. DDidid you or the AMA receive notice of any poor or unacceptable conduct by any person inin connection with the Hotel Quarantine Program?
WeWe cannot iidentiify poor or unacceptabunacceptablele conductconduct byby any personperson invoolvedlved withith the HotelHotel Quarantine Program.Program.
19. As far as you are aware, have any AMA members involvedinvolved in the Hotel Quarantine Program tested positive for COVID-19? IfIf so (without providing informationinformation that would identify such persons specifically) please provide the details of how you became so aware, includingincluding the dates, and any hotel(s) at which such AMA members had been rostered prior to testing positive:
No,No, we have no knowwlledgeedge of any member involvedinvo lved wwiithth the programprogram testingtesting posposiitivetive forfor COVID-19.ID-19.
Yours sincerely
AssociateAssociate ProfessorProfessor Julian Raiit OAMOAM AMA VICTORIA PRESIDENT WIT.0001.0038.0008
Attachment 1: Please note that these emails are timed as if being sent from a US time zone.
From: sarah Whitelaw < > Sent: Wednesday, April 15, 2020 1:50 AM To: CP ; 'Andrew Wilson (DHHS)'
Subject: Re: Meeting with Prof Andrew Wilson and Committee of Chairs of Victorian Medical Colleges
Dear All,
Please find attached a document that contains an operational approach to hotel quarantine. I think many of these principles will also apply to medihotels or step down residential or discharge programs that may be developed at a local Health Service level, so may be of use to some of you and worth being aware of.
The large numbers of returned travellers requiring quarantine in Vic have presented a huge learning opportunity for refinement of a safe, efficient and effective response for residents, staff and all of the stakeholders involved.
I think there are a number of outcomes:
The first is that there are significant differences from in home quarantine, including mental health, complex psychosocial issues, lack of medication supplies for chr medical conditions, food allergies and intolerances, access to health assessment, nursing and medical support for management of COVID19 symptoms and complications, fear and anxiety among limited hotel staff, PPE, security and waste management issues, drug and alcohol and smoking addiction and withdrawal, testing, communication, discharge criteria, transport and documentation etc etc.
The second is the absolute requirement for health staff involvement and support and escalation – nursing and medical – even in a cohort of pretty well/minimal symptomatic people who could “otherwise manage at home”
The third is the essential requirement for an operational approach. Fortunately there are both operational plans that been developed and applied successfully in very similar circumstances – eg management returned citizens from Wuhan – and expert advisory bodies like the https://www.nationaltraumacentre.nt.gov.au/ can provide advice and assistance. No need to develop de novo! WIT.0001.0038.0009
NCCTRC | National Critical Care and Trauma Response Centre COVID-19. The National Critical Care and Trauma Response Centre (NCCTRC) is currently experiencing the impact of COVID-19 and in recognition of the evolving situation is suspending all education and training courses effective immediately. www.nationaltraumacentre.nt.gov.au
I have distilled the basic components of the operational plans (attached) that have been developed by a collaboration of Australian experts in Disaster Medicine, who have very generously peovided multiple resources. Obviously at a Vic State/DHHS level the detail for each component is much more specific - the information is available but I haven't included it in the document so that it could be useful as a beginning template for other states or other residential circumstances, and the contact details will change for different geographic (regional vs rural vs metro) locations and depending onc urrent case definitions and testing criteria etc.
I understand there has been an enormous amount of effort from the Emergency Services and Health Minister through the Departments, The CHO and CMO and Safer Care Vic and the multidisciplinary staff involved at a direct residential care level (over 5000 returned travellers in residential quarantine) over the last few weeks in adjusting the approach to residential quarantine management, and that there has been much national scrutiny on the issue. I think it is very worthwhile making sure the huge quantity of work is acknowledged, and that the succesful outcomes and learnings are made available to assist other states and programs that may require a similar operational approach.
Very happy for feedback and refinement!
Regards,
Sarah Whitelaw
Sent from Outlook
Attached to the above email was the following document:
Operational Approach to Hotel Quarantine – many principles likely to translate to MediHotels
NB Consider Operational Plans that have been utilised successfully including those developed by, and advice from https://www.nationaltraumacentre.nt.gov.au/
Consider Application of Hotel Zones:
Red zone: confirmed Covid+ve Residents – will require SOP for Resident arrival, care in the Red zone and discharge criteria
Orange zone: Quarantined Residents – monitored for development of symptoms for maximum incubation period. WIT.0001.0038.0010
Also applies to contacts of suspected cases. Should be managed with contact precautions if there is likely to be a delay in confirming or excluding COVID19 infection in the suspected case (eg delayed test).
Residents in the orange zone are required to maintain social distancing at all times to prevent contact from others who are quarantining as all residents may be infected with COVID-19 and not yet be symptomatic.
Green Zone: staff area All other areas of the site that are not Red and Orange are Green and classed as COVID-19 free. Universal precautions and close attention to hand hygiene are applicable in this area. Cough etiquette, maintaining social distancing of 1.5 meters and staff to refrain from close greetings and hand shaking. Consider PPE required for Zones – for staff and for patients. These need to match hospital care for nursing and support staff, eg:
Red Zone / Positive residents - Full Airborne transmission precautions (vs contact), including routine use of a P2/N95 mask, disposable gown, gloves, and eye protection for clinical staff. Support staff cleaning to wear full PPE as clinical. Meal drop requires a surgical mask and no gown meals dropped outside residents’ rooms. No resident contact. Orange Zone / Quarantine - Full Airborne transmission precautions for clinical direct patient contact. P2/N95 mask for CONTACT Nurse and a surgical mask for the clean nurse. Support staff cleaning P2 mask, Gloves and glasses, no gown. Meal delivery surgical mask, gloves. All staff entering the red zone should practice hand hygiene on entry & exit. Green Zone - Universal precautions including close attention to hand hygiene. Cough etiquette. No hand shaking, maintain social distancing.
PPE training and monitoring: Donning, Doffing + waste bags and Hand sanitiser at stations each floor
Staff clothing SOP: eg: change to scrubs on arrival closed footwear, scrubs to be removed prior to leaving at end of shift
Develop PPE Infection control and Zone FAQs
Referral Pathway for Medical Transfer eg Referral pathway for onsite healthcare staff when residents require escalation of care ED/Hospital admission eg Ambulance Service to list Hotel as an “area of concern” in case of independent calls and may/will ask onsite healthcare staff to assess need for Ambulance attendance and transfer in case of low acuity calls
Develop minimum criteria for transfer to Hospital
Designate Hospitals for transfer Adult and Paediatric
Keep log of issues encountered on shift by staff: eg: WIT.0001.0038.0011 no of symptomatic patients Medical issues requirements for prescription Stores utilised and resupply requirements Any operational issues Other issues eg – to be addressed early am and mid-afternoon for actioning
Designate Pharmacy/ies for supply of medications required for residents + process for prescription and transfer
Designate testing SOP re process for updated case definitions/testing criteria, equipment required, request authorisation, transfer to designated lab, re-stocking, results notification
Rubish Removal/clinical waste eg biohazard bags in each room and doffing areas on each floor
Fire Evacuation SOP eg as per Facilities plan – clinical staff wil be required to attend evacuation in PPE if required
Security/Evaluation SOP
Communications eg Notification to residents bd re any changes to systems eg utilise food drop times to remind residents of required actions (eg reminders to place their mask on before opening the door) Translation into appropriate languages Residents to have an emergency 24/7 contact number Training and signage re PPE utilisation and donning and doffing requirements Staff communication numbers for – nurse (eg 24/7), medical (off site, daily visit), Mental Health support service, Pathology Courier, Pharmacy, business centre, EM managers, PH manager, Health Department –other necc contact details as required, additional Hotel/s numbers
NB Phones in red/orange zones in ziplocked bags and decontaminated on doffing
Initial Health/medical screening on Arrival and Daily eg over phone re medical history, medications, allergies and initial and daily COVID19 screening questions
SOP re if symptomatic – eg in-room assessment in PPE with temperatureas per medical screening tool SOP re consideration/criteria for COVID19 testing eg 24/7 onsite nurse + escalation to medical support +/- hospital transfer as appropriate
Role Onsite Nurse: +/- Data collection and recording current residents,numers, names, room, details, ID eg intial and subsequent COVID19 screening questions, initial medical assessment Receive calls from reception re medical needs WIT.0001.0038.0012
Assess need for medical review via phone triage In room assessment if required in PPE Move patients Orange to Red if COVIDswab returned +ve Request Medical support via phone or in-person, 000 for medical emergencies and transfer Consider ensure appropriate supply regular medication for chronic medical conditions and escalation to medical support as per prescription requirements and fulfilment prescription/transfer from pharmacy as per SOP
Resident Satisfaction Survey eg weekly
COVID19 Test SOP: eg swab procedure including PPE, labelling, technique, correlating pt details, packaging, decontamination, doffing, waste disposition, communication, storage and transfer/transport test, restocking, security
Security SOP eg: to accompany all in room assesments, PPE, 2 staff to assist residents to allocated rooms
Medical Assessments SOP eg Red Zone with mild symptoms – medical review within 24/24 of arrival Diagnostic equipment required eg thermometer, 02sats probe, pen – storage and decontamination requirements for these Deteriorating patient pathway – eg; 000/Ambulance transfer eg unwell, SOB , hypoxic 02sats <95% considered for transfer
Resident Daily Care: Red zone: Daily health check symptoms with chart tick box (fever sore throat, cough, fatigue, SOB) HR reg/irreg, RR, Temp Psychosocial conversation, identify any other medical concerns 24/7 phone line for emergencies for residents Required to wear masks at all times Orange Zone: Daily Health check tick box (symptoms) If symptoms – management symptoms + testing as per SOP Identification sign – awaiting results – recorded/ process for receiving results Recreational activities as enabled if not symptomatic – NB if possible facilitate sometime outside – supervised, appropriate PPE, rostered timeslots and traced, security, hand hygiene and decontamination Psychosocial conversation and identify any other medical concerns eg afternoon telephone review
NB Discharge SOP including timing of swabs, number of swabs, resolution symptoms/signs, transport arrangements and certification
NB After hours medical support contact details – will be required for nursing support 24/7 NB Medical support may be combination primary care/urgent/emergency care 24/7 Mental Health support/triage/assessment contact details WIT.0001.0038.0013
NB Advice and SOP re smoking/drug and alcohol addiction/withdrawal and exercise plan NB Designate Office/administrative onsite space NB identification needs complex families/psychosocial NB SOP re food allergies and intolerances and alternatives NB Develop Transfer Medically Unwell SOP, Medical screening form, Testing SOP
References: WHO https://www.who.int/emergencies/diseases/novel-coronavirus-2019 CDNA SoNG https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel- coronavirus.htm National Critical Care and Trauma Response Centre: AUSMAT Operational Plan | Howard Springs February 2020. Australian Health Sectors Emergency Response Plan for Novel Coronavirus (COVID-19) https://www.health.gov.au/sites/default/files/documents/2020/02/australian-health-sector- emergency-response-plan-for-novel-coronavirus-covid-19_2.
The following email was also sent from Dr Sarah Whitelaw to Professor Andrew Wilson on that day:
From: Sarah Whitelaw Sent: Wednesday, April 15, 2020 7:09 AM To: 'Andrew Wilson (DHHS)' Subject: Residential Quarantine
Dear Andrew,
Thank you so much for your time this afternoon on the Vic Faculty Chairs of Medical Colleges zoom call. I 'm not quite sure how you're doing it, and we appreciate the 24/7 access that many of the Departmental staff and SCV have provided. The extraordinary amount of work you're doing and that is being generated is so very much acknoweledged and appreciated by AMA Victoria and I know by so many across the medical profession, who will likely never get to tell you how grateful they are. As you highlighted this afternoon, I suspect the COVID19 related strategic and operational response is significantly more challenging in Vic than in the smaller more centralised states, who have a much higher Department of Health staffing ratio, and it makes the succesful response to date and the sesmic shifts that have taken place even more notable.
Re the issue of residential quarantine for returned travellers, we are aware that there has been an enormous amount of work down from the Emergency Services and Health Ministers' through the relevant Departments, our CHO and PHOS and yourself and SCV, and the multidisciplinary staff directly looking after the residents.
I am also aware that there's a fair bit of national scrutiny on Victoria on this issue currently, and I think that means a good opportunity for Victoria to promote it's experiences and learnings to assist other states, and also other programs where the principles will also be similar - eg medi hotels, step down discharge programs like resp rehab, other residential quarantine programs for vulnerable patients that might be set up by individual health services in Vic or elsewhere. WIT.0001.0038.0014
Based on some veryve ry generous resourceresourcess sharesharedd by a cocollaborationllaboration of AustraAustralianlian DDisasterisaster MedMedicicine experts,experts, II havvee attached a ververy rough document that iiss a bit of a checkchecklistlist of the prinicpnicplesles - many of which havehave come out of the VVicic eexperiencexperience to datedate, that miigghtht be of use for thothosese dedevevelolopping or monitoriing similarsimilar programs or the ViVicc programs gogoinging forward. I know yyoou havehave had some preprelimliminarnaryy conconversationsversations with Julian Rait on tthehe iissuessue of quarantine management and IfIf youyou have any feedbafeedbackck or there are aspects that yyouou think aren''t useful eevenven at this earearllyy stage iit wwooulduld be very much appreciatedappreciated,, but alsoalso compcompletelyletely understand iiff it 's's not anywhereanywhere near makiing itit on to yyouourr radar.
Thank yyouou again for the enormous amount of woworkrk that iiss beiing done bbyy yyourseourself and SaferSafer Care VVic.ic. II knoknoww as an Emergency MedMedicineicine PhysicianPhysician at RoyaRoyall MeMelbournelbourne HospHospiitall that we allll feelfeel vveryery fortunate to be woworkrkiing iinn ViVictoctorria at this t ime. HappHappyy toto helphelp inin any way that can be useful,, partiiculcularly inin communcommunicatingicating the wwoorkrk that the Department aandnd SCSCVV iiss doing,, and inin facilitating clinclinicaicall representation and iinput.nput.
Sarah WhWhiitelaw (board member AMA Victorctoriaia and ofVDHP,ofVDHP, and incomincominging EmergencEmergencyy MedMedicineicine Craft Group Rep to AMA Federal,l, FACEMFACEM RMH)
Sent from Outllooookk WIT.0001.0038.0015
Attachment 2:
From: Nathan Pinskier Date: Monday, 13 April 2020 at 2:17 pm To: Prof Brett Sutton Cc: Pinskier Henry Julian Rait Subject: COVID-19 Hotel Dr arrangements
Hi Brett,
You might be aware that two weeks ago I was contacted by DHHS regarding the possibility of providing a medical workforce via Medical Deputising and other doctors to support the medical care of hotel quarantined overseas arrivals.
The doctor service commenced on Saturday 4 April at the Crown Hotel sites. What was initially a daytime onsite service involving one doctor and three hotels with overnight coverage being provided by the Doctor Doctor Medical Deputising Service has rapidly expanded into 24 coverage with now 6-8 doctors working daily and 1-2 overnight. It has become a sizable logistic operation which has involved onboarding new doctors on a daily basis.
The service is being coordinated by my medical administration arm Medi-Admin via Drs Nathan & Henry Pinskier. We have been in regular communication with DHHS regarding the clinical requirements and the associated levels of resourcing and other support required. The DHHS team have all been very accommodating and supportive as best as possible however given the speed at which the service has been established there are a number of issues that require further consideration some of which are of a high priority.
These include (in no particular order):
1. The testing protocols and availability of results. Some COVID-19 tests are being sent to VDRL and some to Melbourne Pathology. The VDRL results are taking up to 5 days to arrive and are communicated to the doctors only if they ring up VDRL and are then sent to the hotel by fax. VDRL has refused to provide the results to the doctors over the phone. This is complete contrast to normal clinical communications practices for both urgent and routine results. This is placing individuals at risk. Test results should be provided in a timely manner and preferably be sent by a seamless electronic solution not fax with a direct call to the doctors and nurses for all COVID-19 positive results as son as they are available.
2. Mental Health Support services and escalation protocols. This has been identified by the doctors as a significant issue. Henry has personally briefed Martin Foley yesterday re this issue.
3. Availability of emergency medicines at each site via an imprest. There have apparently been a few cases of food related anaphylaxis.
4. Availability of oxygen and resuscitation equipment at each site.
5. The recording of clinical information. To date doctors have been recording clinical notes on paper as to have the nurses. This is clearly not ideal so we have addressed this for the doctors by requesting our IT providers to set up over the weekend a hosted version of Best Practice (this was approved by DHHS in conversation with Neville Board). BP has gone live today however the nurses who are provided by DHHS are still using paper. They also need to be added to the system so that they can access the doctors notes and instructions and also add clinical indication to the record. We are also installing the Melbourne Pathology secure messing software Fetch for pathology result downloads. I’m unclear whether this is available for VDRL. We are also aiming to setup access to MHR.
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To support the electronic record data capture we will require some administrative support which includes provision of the names of all quarantined persons so they can be added to BP as required. We will also need to sort out the the process for the long term storage of both the paper and electronic clinical records.
6. The quarantine protocols and 14 day rule needs clarification. The doctors have advised that persons are being sent home from quarantine after 14 days irrespective of their COVID-19 status. Could you please clarify?
7. A private working area for the doctors is required at each hotel
8. Indemnity cover. Despite efforts to have this addressed it remains unresolved. We require VMIA and/or Crown coverage for both the company and the doctors to be provided and confirmed immediately in writing with cover provided from the date of commencement of the service - Saturday April 4 2020.
9. PPE availability (I appreciate that this is an issue for all healthcare providers).
Please note that I have been in touch with Julian Rait (cc’d) this morning and he suggested that I contact you directly.
I would appreciate a call back today if possible to discuss the above.
In anticipation
Best
Nathan
Dr Nathan Pinskier MBBS, FRACGP, FAAPM, FAAQHC, Dip Prac Man, CPM
On 13 Apr 2020, at 3:33 pm, Brett Sutton (DHHS) wrote:
Hi Nathan,
Thanks for raising these issues and reaching out. I appreciate that you and the service team have come to this role with no advance notice and have rapidly adjusted to the requirements of a large cohort of individuals requiring assessment and care.
As these issues are being raised with me for the first time, I’ll require some time to check in with various individuals in DHHS to understand some more detail and what, if anything, might already be in train to address them. I’m sure you’ll appreciate that some of the issues flagged are not in the direct control of DHHS but I am of course happy to explore solutions as soon as possible.
I’ll call you tomorrow once I understand the issues in more detail – is 10am a possible time for a call?
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Regards, Brett
Adj Clin Prof Brett Sutton MBBS MPHTM FAFPHM FRSPH FACTM MFTM Victorian Chief Health Officer Victorian Chief Human Biosecurity Officer Regulation, Health Protection & Emergency Management Department of Health & Human Services I 14/14 I 50 Lonsdale St
Please note that I work from home on Thursdays and am contactable on the numbers aboveabove..
From: Nathan Pinskier··········Pinskier •••••••••• Date: Tuesday, 14 April 2020 at 5:50 pm To: Prof Brett Sutton REDACTED
Subject: Re: COVID-19 Hotel Dr arrangements
Dear Brett and Annaliese,
Thanks for calling us today to discuss the various issues documented in my email yesterday.yesterday. As per our discussions I note the following:
1. COVID-19 Testing: To streamline the process and turnaround time it is preferable that all COVID-19 test specimens including those ordered and undertaken by the duty nurses be sent to Melbourne PathologyPathology.. DHHS will advise the nurses of such.
In the event that tests are sent to VIDRL the protocol for releasing results to the doctors needs to be changed so that results are provided by phone call as they become available and also electronically (if possible).
2. Clinical Care Pathways and escalation protocols: You advised that there are a number of teams on the ground at each hotel providing different care services and that DHHS is working to coordinate and streamline their various activities. DHHS is also establishing a central database to coordinate and track activities and actions. I understand that the doctors will be provided access to this database.
In addition, clinical care pathways and escalation protocols need to be confirmed both for general care and mental health issues.issues. Furthermore it would be of advantage if the doctors can be provided with direct priority access to senior hospital duty doctors where required.
33.. Availability of emergency medicines at each site via an imprest: Given the number of quarantined persons at each hotel, it is unworkable to expect the doctors to continue to personally supply emergency medicines, of which they are only supplied a limited quantity each month via the doctors bagbag.. Yesterday we established a locked imprest at each hotel containing a small number of medicines which have been supplied by the DOH contracted city pharmacy.pharmacy. This list requires review to ensure it's appropriateness. A daily monitoring and handover process will be establishedestablished..
44.. Medical Equipment: WIT.0001.0038.0018
Essential medical and medical resuscitation equipment needs to be available at each hotel. At a minimum, this includes a pulse oximeter, bag and masks and AED (if not already present). It needs to be confirmed as to how these will be provisioned.
5. Recording of Medical Notes: Best Practice is now fully operational and being used by the doctors. As discussed we will now need to provide some administrative support in order to scan into BP the doctors paper records created over the past 10 days. Do we need to have the funding for this resourcing confirmed by Camilla McDonald or are we good to proceed?
6. The Quarantine protocols and departure protocols: You advised that DoH is working on refining the hotel quarantine and departure protocols. We are looking forward to receiving the update so that we can circulate it to all the doctors.
7. A private working area for the doctors is required at each hotel: Please advise as to how this is best progressed?
8. Indemnity cover: As discussed this remains unresolved. This is a unique situation whereby the doctors are providing a service to DHHS under legislation enacted by National Cabinet. In discussions with Avant, it remains unclear as to whether the doctors are covered by their existing medical defence indemnity insurance. Our company entity appears not to be covered by its existing policies. This is a risk we cannot continue to be exposed to. We therefore repeat our requirement that VMIA and/or the Crown provide coverage for both the company and the doctors immediately with confirmation of such in writing and cover provided from the date of commencement of the service - Saturday April 4 2020. As a further point, I note that all the primary care pop up COVID clinics established by the Commonwealth have been provided with Crown indemnity. We require equal consideration and identical indemnity arrangements.
As a final matter not raised in the teleconference. Parking Tickets: I understand that several of the doctors have received parking fines Incurred outside the hotels. We would appreciate that consideration be given to waiving these fines as they were incurred as the direct consequence of the provision of medical services. The same process should apply as per the waiving fines incurred by health professionals parking outside hospitals announced by the Premier over the long weekend.
Thanks for your ongoing consideration
Best
Nathan
Dr Nathan Pinskier MBBS, FRACGP, FAAPM, FAAQHC, Dip Prac Man, CPM