Torres Strait clinicians face deadly dilemma over TB cases in PNG, audit finds

Children with tuberculosis (TB) are dying in the Torres Strait border region after being referred out of Queensland clinics under inconsistent health department policies, an audit has found.

The death of a young girl from Papua New Guinea (PNG) with tuberculosis who had sought treatment at a Queensland health clinic prompted the audit, a doctor involved in the project has confirmed.

A research paper obtained by the ABC detailed and analyzed the results of the audit, which looked at outcomes for PNG patients with suspected TB who crossed the border and sought treatment in PNG facilities. Queensland health between 2016 and 2019.

According to the newspaper, at least six patients, including children, have died after being referred from Queensland Health clinics in PNG for treatment in hard-to-reach and less equipped health facilities.

Two of the six people who died after being returned to PNG had conditions that potentially should have automatically qualified them for evacuation to hospitals in Queensland for treatment, the audit found.

The article was written by leading TB experts, including a senior nurse from Queensland Health.

He suggested there had been “inconsistent application of the aeromedical recovery policy, with patients not transferred for care despite meeting medical severity and urgency criteria”.

“We report a series of poor outcomes in this cohort, including high mortality and loss to follow-up. The policy to avoid such outcomes, particularly the criteria for aeromedical recovery to tertiary facilities, has not been enforced. consistently,” the document reads.

“The study was unable to fully identify the basis on which clinical decisions were made to refer PNG patients presenting to Australian public health clinics to the PNG health system or to medically evacuate them. to an Australian hospital.”

He said health services were expected to provide emergency care “in accordance with human rights”.

Local clinicians had to operate “in a complex healthcare environment constrained by scope of practice, available clinical tools, and expressed and unspoken policies and funding constraints,” according to the document.

“The pressures on clinicians to provide sound clinical judgment – ​​often life and death decisions – while simultaneously avoiding costly care from patients outside of Queensland Health, can lead to suffering silent and a burden of risk for frontline clinicians that may be well beyond their training or experience.”

Queensland Health has defended its management of Torres Strait healthcare, saying all PNG nationals presenting to clinics “are being treated on the basis of clinical need like anyone else and this situation does not has not changed”.

Under Queensland Government policy, PNG nationals with life-threatening emergency health conditions can get treatment if they come to Queensland health clinics.

In some cases, clinics in Queensland are much closer to their home villages than any health facility in PNG, and are better serviced and resourced.

Each year during the study period, dozens of PNG nationals with symptoms of TB presented to clinics, as their home villages in PNG’s Western Province struggled with an outbreak of the disease.

The newspaper says the audit looked at the results of 213 patients from PNG who had signs and symptoms of TB and had crossed the border for treatment at clinics in Queensland.

He said clinicians use observation charts that give each patient a score after assessing breathing, heart rate, oxygen saturation, blood pressure, temperature, level of consciousness, pain and level of distress.

The scores were then used to manage the patients and factored into deciding whether to evacuate them south to a hospital in Queensland.

He noted that according to Queensland Health guidelines, a score of five or more meant that Torres and Cape Queensland Hospital and Health Service were “obligated to ensure that the patient received care in an Australian hospital. by aeromedical evacuation”.

The study found that of the 48 patients who had a score of five or more, 22 were not discharged and two later died.

It also found that five patients under the age of 18 were not evacuated despite scoring five or more.

Of the other 165 patients who presented and were classified as having a health score of four or less, four others were later found to be deceased.

The document highlighted a number of issues, including:

• No recourse under the current system to recall patients requiring further assessment or follow-up as per local policy
• Transport time for patients to the nearest main medical facility in PNG, Daru General Hospital, averaged 120 days between 2017 and 2018
• Delays in transporting patients increase the risk of TB transmission and risk of death and increase Queensland healthcare costs when patients return for treatment at Queensland clinics
• Early warning tools used to identify serious health problems have not been developed to detect serious chronic diseases, including malnutrition and tuberculosis
• Medical decisions can be influenced by non-clinical factors such as high cost

It was also noted that clinicians used a “care cap” procedure to determine whether to limit care. This is normally used in the context of terminally ill patients.

The document made six recommendations, including increased staff training on ethical and medico-legal issues, and a review and improvement of patient health scoring systems.

He also called for care pathways that include documentation of a set of vital signs just before discharge, as well as a medical review of a patient’s health score and ongoing monitoring and evaluation to ensure transparency and Justice.

The cost of outpatient treatment, aeromedical transfer and hospital treatment for a critically ill PNG TB patient from Torres Strait to an Australian hospital was reported at $124,280.

Dr Emma McBryde, who was one of the study’s authors and runs clinics in Torres Strait, and is also employed by Queensland Health, said the audit reflected a massive asymmetry in health care in the international borders.

She said it highlighted the plight of frontline doctors and their ethical conundrum.

“There are concerns that on the front lines between international borders there are all kinds of pressures to keep the funds needed to treat Torres Strait Islanders, but there are ethical obligations to do the best you can. and doctors and nurses are left to navigate this ethical path,” Dr. McBryde said.

“We’re trying to show how this is applied inconsistently.

“The conclusion is not to blame the coal-faced nurses and doctors. The idea is not to criticize the people who make the difficult decision in the heat of the moment – ​​it is to point out the fact that we can do much better with a systems approach to health.”

Dr McBryde said the audit was undertaken following anecdotal evidence of some people making decisions under great pressure that could lead to deaths.

“A young girl has died and an audit has been requested and approved by health authorities,” she said.

Dr McBryde said Australia was seeing “the tip of the iceberg” in terms of TB patients, as PNG’s nearest main colony on Daru Island treated hundreds of cases a year.

She said about a third of those cases involved drug-resistant tuberculosis.

On Friday, Queensland Health released a statement saying it was offering a world-class aeromedical recovery program.

“Any patient referred to Retrieval Services Queensland is managed according to their clinical needs,” Queensland Health said.

“The provision of health services to PNG nationals residing in PNG is the responsibility of the PNG Government and not the Queensland Health System.

“However, all Queensland Department of Health facilities, including those in the Torres Strait, provide emergency treatment in accordance with relevant principles, legislation, regulations and humanitarian agreements, regardless of nationality or personal circumstances. “