Published: 29 August 2024
The following questions can be used as discussion points for peer groups or self-reflection of practice.
It is recommended that the following articles are read before considering the questions:
Each winter brings an influx of patients into primary care clinics with various “cold and flu” symptoms. Recently, COVID-19 has dominated the winter ills landscape, but this year (2024), we are also seeing many people with respiratory syncytial virus (RSV) and Influenza type A, along with the common cold, sore throats and other seasonal illnesses. In most cases, patients can be reassured, managed symptomatically and advised to recover at home. Very unwell patients will present with an obvious urgency to refer for further management. The challenge is in identifying those patients whose symptoms and signs, or other clinical characteristics, put them at greater risk of deterioration and adverse outcomes.
Management of the winter ills season can be pre-empted by encouraging influenza and COVID-19 vaccination to reduce the number of patients who get sick, or the severity of their illness. This is especially important for patients most at risk of adverse outcomes. Some, but not all, of these groups are eligible for funded vaccination; the option of self-funding vaccination should be discussed with other patients who could benefit. Many regions also have community initiatives that support people to get influenza vaccinations if they are not eligible for funding. Ensure everyone in the practice team is familiar with the eligibility criteria for influenza and COVID-19 vaccinations, and other groups for whom vaccination is recommended but not funded.
Parents will often bring children with colds and flu-like symptoms to be assessed in primary care as it is difficult for them to judge the severity, or significance, of these symptoms. There are certain obvious features that if present in a young child, would prompt an immediate referral to secondary care, e.g. decreased level of consciousness, rapid respiratory and heart rate or bradycardia, oxygen saturation <90%. Managing a child with less severe, but still concerning, features is dependent on other factors, such as distance to a hospital and practicality of close follow-up. Children who do not have any concerning features, and are suitable for symptomatic care at home, should still have protective measures put in place so that if they were to deteriorate or if symptoms persist, further health care will be sought. This may include information on warning symptoms and signs, instructions on what to do if the child’s condition changes and an arrangement for follow-up, either in person or via phone.
Pneumonia can occur as a complication of a seasonal winter illness, and it is a significant cause of mortality in children and older people, particularly among Māori and Pacific peoples. Pneumonia can usually be diagnosed clinically, based on the presence of characteristic symptoms and signs, e.g. dyspnoea, tachypnoea, increased respiratory effort, crackles on auscultation, pleuritic chest pain, often accompanied by other symptoms including fever, tachycardia, and less typically, abdominal pain and vomiting; non-specific symptoms may also be present such as confusion in older people and poor feeding in infants. After diagnosis, the next step is to determine suitability for community-based management. The CRB-65 tool (confusion, respiratory rate, blood pressure, age ≥ 65 years) can be used to aid assessment of severity of pneumonia in adults. If the patient is not referred to hospital, antibiotic treatment can be started empirically (usually high-dose amoxicillin). Referral for urgent chest X-ray may be needed if the diagnosis is uncertain or there is underlying respiratory illness or other complications.
General questions for discussion
- What mix of winter illnesses are you seeing in your practice this season? Are there any patterns or themes of illness emerging? Are there any particular features that help you distinguish between causes, e.g. COVID-19, RSV, influenza?
- In your experience, are many patients who may benefit from influenza vaccination but are not eligible for funding, willing to pay for a vaccination? What about for children? What groups of patients do you recommend receive influenza vaccination (other than those eligible for funded vaccination), e.g. childcare/education workers, caregivers of at-risk people, Māori and Pacific peoples?
- Given that influenza vaccination is widely offered outside of primary care practices, does your practice still maintain a recall programme for these immunisations? Are you finding that the Aotearoa Immunisation Register (AIR) is providing accurate information regarding vaccination status? What about following up with patients to see if they are up to date with COVID-19 vaccinations?
- In a young child presenting with fever, what would be “red flag” features that indicate clinical deterioration is possible or likely?
- When recommending observation at home, best practice is to provide specific rather than generic advice, preferably written, and include timeframes for when to seek further medical attention. What is your general approach to giving safety-netting advice?
- What advice do you give about taking paracetamol or ibuprofen? Under what circumstances, if any, do you recommend that they are taken together?
- Do you find that making a clinical diagnosis of pneumonia is usually straightforward? What are some of the atypical features you have seen or other clinical characteristics that have made you less certain about a diagnosis?
- What factors come into your decision regarding whether a patient with pneumonia can be managed at home? Have you used the CRB-65 assessment tool? If so, what has been your experience of this, and if not, would you consider incorporating this into your practice?
