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

Someone adjusts the oxygen mask of a tuberculosis patient who is lying in a hospital bed
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Children suffering from tuberculosis (TB) are dying in the Torres Strait border region after being referred away from Queensland clinics under inconsistent health department policies, an audit has found.

The death of a young Papua New Guinea (PNG) girl with TB 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 has detailed and analyzed the results of the audit, which examined outcomes for PNG patients suspected of having TB who crossed the border and sought treatment at Queensland Health facilities between 2016 and 2019.

At least six patients, including children, were found to have died after being referred away from Queensland Health clinics back to PNG to seek treatment at hard-to-access and less-equipped healthcare facilities, according to the paper.

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

The paper was lead-authored by leading TB experts, including a senior Queensland Health nurse.

It suggests there had been “inconsistent application of aero retrieval policy, with patients not transferred for care despite meeting the criteria for medical severity and urgency”.

Headshot of James Cook University infectious diseases physician Professor Emma McBryde.
One of the report’s authors, Emma McBryde, says Torres Strait doctors face an ethical conundrum.(ABC News: Scott Jewell )

“We report a range of poor outcomes in this cohort, including high mortality and loss to follow-up. Policy intended to avert such outcomes, particularly criteria for aeromedical retrieval to tertiary facilities, was not applied consistently,” the paper said.

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

It said it was expected that health services provided emergency care “consistent with human rights”.

Local clinicians were having to function “in a complex health environment limited by the scope of practice, available clinical tools and spoken and unspoken policy and funding constraints”, the paper found.

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

Queensland Health has defended its handling of Torres Strait health care, saying that any PNG nationals who present at the clinics “are treated according to clinical need just like anyone else and this situation has not changed”.

Torres Strait quarantine areas
For some PNG nationals, Torres Strait clinics are closer than PNG health facilities.(Department of Agriculture)

Under Queensland government policy, PNG nationals with emergency life-threatening health conditions can obtain treatment if they present at Queensland Health clinics.

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

Every year during the study period, dozens of PNG nationals with TB symptoms presented at the clinics, as their home villages in PNG’s Western Province have been battling an epidemic of the disease.

The paper said the audit 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 stated that clinicians used observation charts that gave each patient a score after assessing respiration, 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 were taken into account when deciding whether to evacuate them south to a Queensland hospital.

It noted that under Queensland Health guidelines, a score of equal or greater than five meant that Queensland’s Torres and Cape Hospital and Health Service was “obligated to ensure that the patient receives care in an Australian hospital via aeromedical evacuation”.

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

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

People stand on a 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 classified as having a health score equal to or less than four, another four were later found to have died.

The paper highlighted a number of issues, including:

  • No recourse under the current system to recall patients in need of further assessment or follow-up as per local policy
  • The delay for transporting patients to PNG’s closest main medical facility, Daru General Hospital, averaged 120 days between 2017 and 2018
  • Delays in patient transport pose an increased TB transmission risk and mortality risk and add to Queensland Health expenses when patients return for treatment at Queensland clinics
  • Early-warning tools used to identify serious health problems were not developed to detect serious chronic diseases including malnutrition and TB
  • Medical decisions may be influenced by non-clinical factors such as the high cost

Also noted was the fact that clinicians were using a “ceiling of care” procedure to look at whether to limit care. This is normally used in the context of terminally ill patients.

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

It also called for care pathways that included documenting a set of vital signs just prior to discharge, along with a medical review of a patient’s health score and ongoing monitoring and evaluation to ensure transparency and justice.

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

Doctor Emma McBryde, who was one of the authors of the study and undertakes clinics in the Torres Strait, and is also employed by Queensland Health, said the audit reflected a massive asymmetry in international boundary health care.

She said it highlighted the plight of doctors on the front line and their ethical conundrum.

“There are some concerns that at the front line between international borders all sorts of pressures are put to keep funds for treating Torres Strait Islanders, but there are ethical obligations to do your best and doctors and nurses are being left to navigate this ethical path, ā€œDr. McBryde said.

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

“We try to show evidence of the way this is being applied inconsistently.

“The conclusion is not to blame the nurses and doctors at the coal face. The idea is not to criticize people who make the hard decision in the heat of the moment ā€” it is to highlight the fact we can do a lot better with a health system approach.”

Dr McBryde said the audit had been undertaken as a result of anecdotal evidence of some people making decisions under severe pressure that possibly led to deaths.

“A young girl died, and an audit was requested and approved by healthcare authorities,” she said.

Dr McBryde said Australia was seeing “the tip of the iceberg” in terms of TB patients, considering the nearest main PNG settlement on Daru Island dealt with hundreds of cases a year.

She said about a third of these cases involved drug-resistant TB.

On Friday, Queensland Health issued a statement saying said it delivered a world-class aeromedical retrieval 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 Queensland’s health system.

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

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