Audit reveals Torres Strait clinicians face deadly dilemma in PNG spillover of tuberculosis cases

Children suffering from tuberculosis (TB) are dying in the Torres Strait border region after being turned away from Queensland clinics under inconsistent health department policies, research has revealed.

The death of a young girl from Papua New Guinea (PNG) with tuberculosis who was seeking treatment at a Queensland Health clinic prompted an investigation, said a doctor involved in the project.

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

At least six patients, including children, were found dead after being transferred away from Queensland Health clinics and returned to PNG to seek treatment in hard-to-reach and under-equipped health facilities, according to the paper.

Two of the six who died after being repatriated to PNG had conditions that would have made them eligible to be flown to Queensland hospitals for treatment, research has revealed.

The paper was written by leading TB experts, including Queensland’s chief public health nurse.

It suggested that there was “consistent application of the aeromedical recovery policy, with patients not transferred to care despite meeting the criteria of medical difficulty and urgency”.

An article by James Cook University infectious disease doctor Professor Emma McBryde.
One of the authors of the report, Emma McBryde, says doctors in the Torres Strait are facing an ethical dilemma.(ABC News: Scott Jewell )

“We report a number of negative outcomes in this cohort, including high mortality and losses that should be followed up. The policy aimed at avoiding such outcomes, especially the method of repatriation by air to institutions of higher education, was not implemented consistently,” said the paper.

“The study was unable to fully identify the basis on which clinical decisions were made to refer PNG patients presenting at Australian Public Health Clinics back to the PNG health system or to discharge them to an Australian hospital for medication.”

It said that the health workers are expected to provide emergency assistance “in line with human rights”.

Local doctors had to work in a “complex health environment limited by scope of practice, available clinical tools and by spoken and unspoken policy and financial constraints”, the paper found.

“The pressures on doctors to provide sound clinical judgment – often life-and-death decisions – while at the same time avoiding costly care for patients who fall outside the Queensland Health remit, may result in silent suffering and a burden of risk for front-line nurses who may be beyond their training or experience.”

Queensland Health has defended its management of Torres Strait health care, saying any PNG residents attending clinics are “treated for clinical needs like everyone else and this situation has not changed”.

Torres Strait Islands
For some PNG people, Torres Strait clinics are closer than PNG health facilities.(Ministry of Agriculture)

Under Queensland government policy, PNG residents with life-threatening medical emergencies can receive treatment at Queensland Health clinics.

In some cases, Queensland clinics are closer to their homes than any of PNG’s health facilities, and are better served and resourced.

Every year during the study period, a large number of PNG people with TB symptoms presented to the clinics, as their communities in the Western Province of PNG have been fighting an epidemic of the disease.

The paper said the study examined the outcomes of 213 PNG patients who had signs and symptoms of TB and had crossed the border to seek treatment at Queensland clinics.

It said doctors use observation charts that give each patient a score after checking breathing, heart rate, oxygen saturation, blood pressure, temperature, level of consciousness, pain and stress level.

The scores are then used to manage patients and are taken into account when deciding whether to transfer them south to a Queensland hospital.

It noted that under Queensland Health guidelines, a score equal to or greater than five meant that Queensland’s Torres and Cape Hospital and Health Service was “responsible for ensuring that the patient receives care in an Australian hospital by aeromedical discharge”.

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

It also found that five patients under the age of 18 were not discharged despite having five or more points.

People stand on the walkway outside the hospital building.
There are significant delays in transferring patients to PNG’s Daru hospital, the paper noted.(ABC RN/Jo Chandler)

Of the other 165 patients who presented and were described as having a health score of four or less, four were later found to have died.

This paper highlighted a number of things, including:

  • There is no benefit under the current plan to recall patients who need further testing or follow-up according to local policy
  • Delays in transporting patients to PNG’s closest medical facility, Daru General Hospital, averaged 120 days between 2017 and 2018.
  • Delays in patient transport increase the risk of TB transmission and mortality and add to Queensland Health costs when patients return for treatment at Queensland clinics.
  • Early warning tools used to identify serious health problems have not been developed to detect severe chronic diseases including malnutrition and tuberculosis.
  • Medical decisions can be influenced by non-medical factors such as high costs

It was also noted that physicians were using the “care ceiling” process to determine whether they were limiting care. This is often used in terminally ill patients.

The paper made six recommendations, including more training for staff in relation to ethical and medical and legal issues, and the review and development of patient health scoring systems.

It also called for measures of care that include the recording of a collection of vital signs just before discharge, as well as a review of the treatment of the patient’s health outcomes and continuous monitoring and evaluation to ensure transparency and fairness.

The cost of providing outpatient care, aeromedical transfer and inpatient management of a critically ill PNG TB patient from the Torres Strait to an Australian hospital was reported to be $124,280.

Dr. Emma McBryde, who was one of the authors of this study and who practices clinics in the Torres Strait, who is also employed by Queensland Health, said that the study shows a large disparity in health care at the international border.

He said it highlights the plight of leading doctors and their moral dilemma.

“There is concern that on the front line between international borders all kinds of pressures are being put to save money to treat Torres Strait Islanders, but there are moral obligations to do your best and doctors and nurses are left to walk in this manner,” said Dr McBryde.

A sign at a health center in Daru warns of the importance of wearing a mask.
Daru Hospital in PNG deals with hundreds of TB patients a year.(ABC RN/Jo Chandler)

“We are trying to show evidence of how this is done inconsistently.

“The conclusion is not to blame nurses and doctors at the coalface. The idea is not to criticize people who make a difficult decision in the heat of the moment – to highlight the fact that we can do much better with health. a systemic approach.”

Dr McBryde said the audit was carried out because of anecdotal evidence of some people making decisions under severe stress that could have led to death.

“A little girl died, an investigation was requested and it was approved by the health authorities,” he said.

Dr McBryde said Australia was seeing a “hot spot” in terms of TB patients, considering PNG’s nearby settlement on Daru Island was experiencing hundreds of cases a year.

He said about one-third of these cases involved drug-resistant TB.

On Friday, Queensland Health released a statement saying it had launched a world-class aeromedical retrieval system.

“Any patient referred to Retrieval Services in Queensland is treated based on their clinical needs,” Queensland Health said.

“The provision of health services to PNG residents living in PNG is the responsibility of the PNG Government and not the Queensland health system.

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

Source

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