This generic procedure, based on the Massive Transfusion Protocol (MTP) provided by the National Blood Authority of Australia (NBA), needs to be modified for each site according to local practice (e.g. notify the Laboratory or Nurse manager), local Laboratory and blood test availability, local blood product availability and Royal Flying Doctor Service (RFDS) resources.
This generic template, based on the Massive Transfusion Protocol (MTP) provided by the National Blood Authority of Australia, needs to be modified for each site according to local practice, local blood test availability and local product availability.
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
To ensure the safety and treatment of all patients attending WACHS Emergency Services for treatment, this policy outlines the process of management and review for those patients who did not wait for treatment after triage and the WACHS duty of care for the presenting patient.
This guideline identifies the way in which a complaint or concern about a medical practitioner (MP) is to be handled in the WACHS. It grades a response according to the seriousness of the issues raised from a review at a local level to a formal investigation to referral to external agencies including the Medical Board.
This procedure covers all elective surgical and obstetric patients. It describes the process to ensure the safe management of obese and morbidly obese patients scheduled for elective surgery.
This procedure has been developed to provide a standardised foundation for the management of inpatients in WA Country Health Service (WACHS) who no longer require acute or subacute care and are waiting in a public hospital bed for Aged Care Services. It is for all WACHS staff involved in the care and discharge planning of older patients. Aged Care Services includes Commonwealth funded permanent residential aged care, Home Care Packages (HCP) and the Transition Care Program (TCP). Young people with disabilities under the age of 65 years are also included if they require permanent or respite care in a residential aged care facility when there is no other appropriate option in the disability sector. Patients requiring residential respite care and patients of Multi-Purpose Services (MPS) are excluded.
This procedure limits the availability of potassium ampoules and requires local guidance regarding access to these, especially outside of pharmacy hours.
This procedure provides managers and staff with practical guidance on how to manage health and safety risks associated with hazardous chemicals and dangerous goods in their workplace.
The WA Country Health Service aims to resolve all safety and health issues quickly and effectively in accordance with statutory obligations imposed by the Occupational Safety and Health Act 1984 and has developed this procedure to enable prompt effective action in the event a WorkSafe Notice (WIN) is issued by a WorkSafe inspector or a Provisional Improvement Notice (PIN) is issued by a qualified safety and health representative (SHR).
The WA Country Health Service (WACHS) aims to resolve all safety and health issues promptly and effectively in accordance with statutory obligations imposed by the Occupational Safety and Health Act 1984. This procedure enables prompt effective action in the event of a site visit by a WorkSafe inspector and any issue of an Improvement Notice.
The publication of the WACHS Maternal and Newborn Care Strategy has resulted in the WACHS maternity services policy no longer being relevant except for the maternal and newborn care capability section and relevant appendices.
This document (formerly Appendix 4 of the WACHS Maternity and Newborn Services Policy) provides an indicative guide of the most appropriate clinical settings for women and babies with complications of pregnancy, birth, the postpartum and neonatal periods. The guide is neither an exhaustive list of possible clinical scenarios, nor is it meant to be prescriptive.
Ths policy has been developed to ensure the appropriate channels are followed to achieve safe and timely resolution to any conflict of clinical opinion which may arise between health practitioners involved in the care of a maternity client.
This policy deals specifically with the safe management of the obstetric and anaesthetic risks associated with the obese pregnant client or those with a history of bariatric surgery.
This procedure is to look at the normal operating procedure of maternity, the increased protocols when there is an active Code Black and the protocols when patients need to be admitted outside the maternity unit.
The Visiting Midwifery Service (VMS) is a home visiting service for postnatal women and neonates requiring the ongoing care of a Registered Midwife. This procedure is to ensure that all women and neonates receive appropriate care and follow up postnatally for a minimum of five days postpartum upon leaving the hospital.
This contingency plan is to be invoked in the event of both lifts being inoperative when a decision has been made that a women is required to be transported to theatre for a non-elective caesarean section.
This procedure aims to ensure that staff are aware that meal times can be a time of increased risk of incidents and that additional care is to be taken when preparing for and observing meal times.
The use of mechanical bodily restraint is governed by the Mental Health Act 1996 sections 121 - 124, however the GS Mental Health management team is adamantly opposed to the use of mechanical restraint within the authorised inpatient unit. There are always other methods to be used in the situation in which mechanical restraint might be considered. If a patient is difficult to contain, the nursing staff are to discuss with the treating psychiatrist, suitable and safe options available for containment.
WACHS Communications is the focal point for all contact with, and comment to the media, to ensure that we deliver a consistent and timely message to all sections of the media. This includes mainstream print, radio and television, as well as health-specific media. All media inquiries and calls from journalists must be referred to WACHS Communications.
This procedure details the requirements for clinical staff (doctor/nurse/midwife/pharmacist) to ensure correct and complete reporting, notification and documentation of medical alerts (adverse drug reactions, anaesthetic alerts and medical alerts). It also details the integration between the clinical process and the Health Information Management (HIM) processes that are to occur within WA Country Health Service - South West (WACHS-SW), including the review of alerts by designated relevant responsible officers. The principles of this procedure are based on the Department of Health WA Clinical Alert (Med Alert) Policy Operational Directive OD 0511/14.
This process has been simplified to streamline the actioning of alerts and inputting them on the PAS. All alerts are to be sent to WACHS-WBPatientAlerts@health.wa.gov.au.
The purpose of this guideline is to provide guidance to regional health service executives, administrative staff and medical practitioners about the responsibilities and processes for credentialing and defining a scope of clinical practice for Medical Practitioners working at WACHS sites, and to ensure that the appropriate credentialing and compliance requirements are met.
The purpose of this policy is to describe the actions required to minimise these risks specific to medical equipment procurement. This policy should be used in conjunction with the relevant procurement policies issued by the State Supply Commission and Director General.
The purpose of this committee is to manage the WA Country Health Service Medical Equipment Replacement Program (MERP) in accordance with the Department of Health Medical Equipment Working Party (MEWP) guidelines.
The model of medical care at the Albany Hospital is a shared care model. The purpose of this procedure is to outline the medical governance arrangements for post-operative surgical patients and their continual care for the Great Southern region.
This document describes the management of radiation safety at WA Country Health Service (WACHS) sites. It lists the regulatory publications, guidelines and general policies that are applicable to radiation safety and is intended to be read by any person responsible for any aspect of radiation safety across WACHS.
This procedure outlines the impact of a disruption or failure of WAPACS PACS/RIS and the associated workaround (downtime) procedure for key personnel to undertake to facilitate the viewing of diagnostic images performed in WACHS sites without the ability to transmit images to WAPACS for viewing.
This information applies to all medical practitioners holding appointments or clinical privileges at WACHS facilities however they are paid, and compliance with them is a condition of the grant of clinical access.
The Telephone Communication Record (TCR) must be utilised by all nursing staff to document all telephone communication with a medical officer when there is a request made for clinical review of an acute inpatient or resident in the Residential Care Unit, Blue Wren Lodge (BWL).
This document outlines how incidents in which there is a potential for compensation or medico-legal proceedings are to be referred within the WACHS Kimberley region.
This policy is for application across WACHS health sites (adult and paediatric), and including hospital in the home, community health and public health settings, sub acute care, mental health and aged care facilities, and remote area nursing posts.
This document provides an outline of the required minimum standards for the involvement of unregulated health workers (UHW) in the support and/or administration of client medication. The guideline has been developed to ensure a standardised approach, safety and quality for consumers and staff.
Bedside storage of medications is to be the usual practice in Wheatbelt hospitals. This procedure provides further information about how bedside medication storage is to be implemented, and the likely exceptions.
This policy provides a framework for the timely, safe and accurate assessment and care of people seeking MH care by non-MH staff within WACHS EDs and on general hospital wards, and in obtaining specialist MH care. It provides specific guidance for the assessment and care of people who present at risk of suicide.
New policy to detail the key principles of effective case management and describe the roles and responsibilities of performing case management within WACHS MH Services.
WACHS strongly recommends all clinical staff, involved in the delivery of direct care to Mental Health consumers, to be engaged in a process of clinical supervision for a minimum of one hour per month. The aim is to support the clinician in their professional environment with the goal of improving clinical practice and improving patient outcomes.
This procedure describes the Mental Health Consultation and Liaison service that is provided by the Great Southern Mental Health Service (GSMHS) to the Great Southern Region.
In accordance with the WA Chief Psychiatrist's Standards for Clinical Care 2015, WA Country Health Service (WACHS) is committed to working with consumers and carers to prevent, reduce and eliminate the use of restrictive practices. Early intervention, assessment, crisis management, deescalation and other alternatives to restraint are preferred interventions of choice in managing patient care and safety. WACHS recognises however that there are circumstances where restraint may be necessary to minimise imminent risk to the patient, visitors and/or staff.
Road transfer of mental health clients carries potential risks for both clients and staff and deserves an appropriate level of consideration, planning and collaboration to make the situation as safe as possible for all involved. This document sets out the process around how this is achieved for staff and clients from within the catchment area of the Great Southern Mental Health Service.
Mental health clients have the right to safe transport that minimises interference with their rights, dignity and self-respect and that reduces the likelihood that they will experience the transport as a traumatic event. These rights must be balanced with the need to protect the safety of all involved and the active management of risks identified.
In accordance with the WA Chief Psychiatrist's Standards for Clinical Care 2015, WA Country Health Service (WACHS) is committed to working with consumers and carers to prevent, reduce and eliminate the use of restrictive practices. Early intervention, assessment, crisis management, de-escalation and other alternatives to seclusion are preferred interventions of choice in managing patient care and safety. WACHS recognises however that there are circumstances where seclusion may be necessary to minimise imminent risk to the patient, visitors and/or staff.
The shift coordinator is responsible for supervising, monitoring, delegating, and communicating all operational processes involving the provision of safe and effective nursing care. The shift coordinator would generally not be directly allocated patients.
The Goldfields Mental Health Service is a specialist service that provides inpatient and community care to mental health patients in the Goldfields region. Triage Officers are based at the Community Mental Health Clinics in Kalgoorlie and Esperance with a regional CAMHS Triage Officer based in Kalgoorlie. This procedure outlines the role of Triage Officers within the GMHS to prioritise care based on clinical urgency/risk, and to assist consumers to access effective and appropriate support (from either GMHS or another service provider). This procedure does not apply to Emergency Triage or Disaster Triage.
This process has been simplified to streamline the actioning of alerts and inputting them on the PAS. All alerts are to be sent to WACHS-WBPatientAlerts@health.wa.gov.au.
A Structured Administration and Supply Arrangement (SASA) is a written direction of the WA Country Health Service (WACHS) that authorises a midwife, under Part 6 of the Medicines and Poisons Regulations 2016, to administer or supply a medicine to any patient in specified circumstances. A SASA enables midwives to administer certain medications, for specified clinical indications in accordance with endorsed clinical guidelines, without a medical prescription or order. A SASA cannot be used for Schedule 8 medicines.
A resident is considered missing when they are absent and the facility is unaware of any reasons for the absence. A missing resident may also include a resident who has not returned from leave at the specified time. This procedure outlines the processes to be followed and is to be read in conjunction with the WACHS Consumer Identification Policy for Community Health Settings and Residential Aged Care.
The WA Country Health Service (WACHS) is committed to providing for the safety and wellbeing of patients and to minimise potential harm to the public. WACHS owes a duty of care to all patients admitted to any of its facilities. This duty includes the responsibility to protect and care for people who because of illness, may come to harm by leaving a health site and potentially wander off into unfamiliar surroundings. For guidance on missing or suspected missing mental health inpatients refer to the MP 0012/16 Missing Person Policy - WA Public Mental Health Services.
The purpose of this policy is to ensure WA Country Health Service mobile device assets are uniformly and appropriately procured, provisioned and managed, to implement a uniform and consistent approach to device security and to ensure that all users of WA Country Health Service mobile devices are aware of their responsibilities.
This document ensures the Funeral Director (or their employee) requesting the deceased holds a current Funeral Directors Licence (FDL) prior to the release of the deceased.
The objective of this policy is to provide the foundation for improved management of the WACHS passenger and light commercial fleet, ensuring optimal and effective fleet management practices are in place.
This procedure identifies the minimum requirements for participation in the Senior Officer Vehicle Scheme (SOVS), in compliance with the WA Government Fleet Policy and Guidelines (WAGPFG)
Chronic Condition Alert form for use by clinical staff as a prompt to identify eligible patients with a chronic condition, and to activate appropriate care pathways, inform discharge planning and referral to primary health services for self-management and support.
This form supports the WACHS Administration of Fluoride Varnish by Non-Dental Practitioners Policy by providing both the checklist for oral health assessment and the consent and administration sign off requirements.
The CARE Call Clinical Review Record is to be completed and placed in the patient's medical record as soon as practical following a CARE Call. Forward a completed copy to the appropriate Regional Safety and Quality Team and to WACHS Area Office Safety and Quality at wachs.safetyqualityperformance@health.wa.gov.au
The MR149 WACHS Neurovascular Observation Chart is to be utilised for all patients (adults and paediatrics) requiring neurovascular observations and assessment in WACHS.
Track and trigger blood glucose monitoring, ranges within this chart are in accordance with obstetric ranges rather than general population ranges allowing for appropriate identification of hyperglycaemia in pregnancy and management.
This chart is mandated for restricted use in mental health units as this is the only setting where clozapine will be commenced and monitored under the direct supervision of a psychiatrist.
This form supports the effective monitoring of clozapine patients in the maintenance phase of clozapine (beyond 18 weeks) ensuring clinical consistency, optimal patient safety outcomes and reduced risk of harm.
The intent of this form is to avoid duplication of information and possible transcribing errors and to remain predominantly free-text with guidance to minimum data set. This is not an exhaustive list of required information, and additional pages may be required, as well as the inclusion of supporting documentation and clinical forms i.e. MR170 NIMC Medication Charts, and Observation Charts.
This Resident Handover form serves a dual hand-over function as it accompanies the resident when they are transferred to and from an acute area (ED or ward). This form is to be printed double sided with both pages completed.
Effective handover is vital in protecting patient safety. Both neonates and paediatrics are specialist areas requiring additional considerations prior to transfer and in handover of care. This document is designed to ensure all relevant clinical information has been considered and handed over appropriately.
Strictly orderable - iProc Order number 149007B. MR172 Tenecteplase Kit which contains - MR1B Emergency Chest Pain Assessment and MR1B ACS Guide inserted in the middle.
This formfacilitates the appropriate clinical care and management for sexual assault clients in our Emergency Departments and directly links in with the State SARC supports. In the event of alleged/suspected sexual assault, contact Sexual Assault Referral Centre (SARC) ASAP for advice on sample collection and storage. Phone (08) 6458 1828 (24 hours/7days)
This form is to be completed giving due consideration to the 'Consent to Treatment Policy for the Western Australian Health System'. iProc order number 190447R
This consent form is to be used for infusion of: Packed Red Blood Cells (PRBC), Platelets, Fresh Frozen Plasma (FFP), cryoprecipitate (cryo) and / or other.
This form is for the documentation of a patient's choice to refuse blood products, and/or certain products that are derived from blood and/or certain types of procedures involving the administration of blood.
Any person who wishes to leave the hospital against medical advice is to be requested to sign a written declaration (MR36 WACHS Discharge Against Medical Advice form) that he or she is leaving the hospital against medical advice.
This form (along with the WACHS Review of Death Procedure) assist health practitioners to navigate the mandatory and statutory obligations that arise following the death of an inpatient.
The FRAMP is a tool to guide and document falls risk screening, risk assessment, minimum and individualised interventions for patients in compliance with Operational Directive OD 0579/14 Falls Risk Assessment and Management Plan (FRAMP). iProc Order Number 154600B
Parenteral Nutrition (PN) support refers to the delivery of intravenous nutrition formula into the blood stream. PN is considered only when it is not possible to meet an individual's nutritional needs by enteral or oral route. Prescribing PN requires special considerations by Dietitians, Pharmacists and Medical Officers. Hence, this form is for completion by these health professionals only to ensure the appropriate formula, rates and additives are prescribed for the patient.
Dietitians often need to provide special tailored meal plans for admitted patients to ensure the diet provided meets their nutritional needs. This form will allow Dietitians to document special diets/ meal plans on a medical record form to be filed with relevant documentation for the patient's admission. This form is to be used by catering services to provide the requested meal plan.
This MR form supports completion of the Dysphagia Screening in line with the WACHS Adult Dysphagia Screening and Assessment Clinical Practice Standard and is only to be completed by staff who have undertaken training.
All episodes of qualified non-acute care must have a formal assessment of functional ability using this Resource Utilisation Group - Activities of Daily Living (RUG-ADL) clinical assessment tool. The tool measures the level of functional dependence of a patient for four activities of daily living and provides an indication of what a person actually does, rather than what they are capable of doing.
The Montreal Cognitive Assessment (MoCA) is a cognitive screening test designed to assist Health Professionals in the detection of mild cognitive impairment. The standard format of is available MR format (MR 66.6, MR 66.6.1, MR 66.6.2). Two additional formats of the MoCA have now been added: (1) MoCA Test Blind - version of MoCA without the visual elements (2) MoCA Basic - version of the MoCA for people who are illiterate or with low education.
The Montreal Cognitive Assessment (MoCA) is a cognitive screening test designed to assist Health Professionals in the detection of mild cognitive impairment. The standard format of is available MR format (MR 66.6, MR 66.6.1, MR 66.6.2). Two additional formats of the MoCA have now been added: (1) MoCA Test Blind - version of MoCA without the visual elements (2) MoCA Basic - version of the MoCA for people who are illiterate or with low education
This document provides a standardised inpatient antenatal care plan that ensures midwifery care aligns with the KEMH clinical guidelines for antenatal inpatient admission. This is a low volume use form that is to be printed on hospital site as required.
A more robust patient consent section has been added. Written consent to be only completed for the first administration and verbal consent for following administrations if required. Initial instructions to remain at top of first page and repeated instructions prior to each administration removed. Tick boxes added to 'Indications' section and 'Comments' section with free text.
This document is designed to ensure the midwife providing antenatal care identifies all risk factors and refers the woman to the appropriate services. t ensures that the risk assessment is completed on a umber of ocasions throughout her pregnancy. It will also aid in the development of a documented antenatal, intrapartum and postnatal plan of care based upon the identified risk factors.
This form is an addendum - page 5 of the MR75 WACHS Newborn Care Plan (to support the requirement for any additional single sheet feeding charts for longer stay babies).
This form is designed to support the staff to work with the woman to design a breastfeeding plan to ensure consistency in the advice provided when managing breastfeeding issues. It also ensures advice provided is in line with latest evidence based practice and KEMH guidelines.
This nationally consistent client-held pregnancy record, is for use by all Australian women to ensure reduction in local variations in service and practice. Women can move between different jurisdictions and professionals during their pregnancy; taking their records with them ensuring the history taking process is not repeated with each new health professional. This promotes improved communication and improved risk management in maternity care provision. iProc order number 100319K. The WACHS NWHPR antenatal sticker can be ordered separately via iProc UCN 186367R (one roll has 250 stickers).
The WA Country Health Service (WACHS) Multiple Chemical Sensitivity / Chemical Hypersensitivity Guideline has been provided to minimise the effects of common hospital and health care incitants on people who identify as having MCS and require treatment in a hospital setting or need to visit a person close to them, who is in the hospital.
This manual applies to all WACHS staff who have been authorised to access the MHR system, clinicians that provide document content to upload to the MHR, system administrators and training/support staff that facilitate the Consent Management Protocol for MHR and those that interact or oversee staff that interact with patients that may have a MHR. This manual also applies to any contracted service provider of WACHS who has been authorised to access the MHR system or the HI Service on behalf of the WA health system and/or WACHS.
