Qualiy Care: No. 9, May 2020

Welcome to Quality Care, a monthly update with important information for Ward Governance Committees to discuss at unit, ward and team meetings. Ward Governance Committees are a key part of our response as Monash Health works to move past the first phase of dealing with the challenges of COVID-19. This remains a dynamic situation, and the latest information can be found at http://coronavirus.monashhealth.org/ It remains vital that you share the important information in this edition of Quality News at your unit, ward and team meetings. I encourage you to continue to share the newsletter through your emails, huddles, noticeboards, communications books and tea rooms. If you have any suggestions for content or how we can help you communicate better, please email our Public Affairs and Communications team, or call or email me.

Carlos Scheinkestel Executive Director, Quality and Safety

Hand hygiene We’re continuing our good work with hand hygiene, meeting our target for April and recording over 80% compliance across all sites. Auditors from within Monash Health observe our clinicians, assessing compliance with the five moments of hand hygiene throughout the year. This month’s result is pleasing, given the current context of our work. However, hand hygiene needs to be front and centre of everyone’s mind – always.

When auditors are on the ward, they may take the opportunity to engage with you and provide some coaching around missed moments. Remember to thank anyone who offers you hand hygiene feedback – this is an important part of keeping ourselves accountable and our patients safe. You don’t need to be an auditor or a senior staff member to remind someone on their hand hygiene. We’re a team, and that means working together to make sure we do the right thing or help our teammates or seniors understand the process. You can access hand hygiene training on Latte.

Annual performance appraisal It’s easy!

1. Book in with your Manager for a ‘Give Me Five’ discussion.

2. Log the date you had the discussion in ESS by clicking on the link on the top left of the intranet home page: → logging in → My Details → Performance Enhancement

Targeted training is now live Completing your mandatory and targeted training is now easier than ever. From today, when you login to Latte, the targeted training packages (as well as the mandatory packages) you are required to complete will be automatically assigned to you based on the information in Chris 21.

Mandatory v targeted training – what’s the difference? Mandatory training is for all Monash Health employees to complete. The seven mandatory training packages are:

1. Fire Training

2. iBelong

3. Managing Challenging Behaviour

4. Introduction to Health and Safety

5. Using Social Media

6. Unconscious bias

7. * NEW* Aboriginal & Torres Strait Islander Cultural Awareness

Targeted training is specific to your role. The complete list is below. No-one has to do everything, packages will be allocated to you depending on your role. Targeted training packages

• Communicating with consumers: Teach back method

• Partnering with consumers for exceptional experience

• Open Discussion/Disclosure

• Aseptic Technique

• Hand Hygiene

• Personal Protective Equipment

• Medication Safety

• Allergies and Adverse Drug Reactions

• Single Checking + Administration of Medicines

• Preventing & managing pressure injuries.

• Preventing falls and harm from falls

• Patient identification and procedure matching

• Introduction to Clinical Handover

• Blood Transfusion

• Transporting Blood & Blood Products

• Basic Life Support

This list will be constantly updated and the changes will be reflected in your Latte account. Coming soon are 2 new packages including one on recognising and managing delirium to prevent harm.

How long will the training take to complete? For most employees the training overall takes less than 90 minutes per year. Many of the modules are short and can be completed in bursts. You can pause and return to a training module if required. Training can also be accessed remotely.

What if I haven’t been assigned the correct training modules?

If you believe you haven’t been assigned to the correct training modules, please speak to your line manager. Your manager will look at the role you have been assigned in Position Management as this is used to allocate training.

When do I need to do it by? Successfully completing mandatory and targeted training is a critical part in delivering safe and effective care to our community. You are encouraged to work through the modules assigned to you as soon as possible, all assigned training will need to be completed by 1 July 2020. As training develops, additional programs will be added to Latte and these may be assigned to you, so please make it a habit to check in regularly for any additional requirements. Latte will also send you notifications via email as a reminder when there is something new or when you are due to redo a package.

Update from the Communicating for Safety Committee Ensure you and your team are familiar with the following updated PROMPT procedures:

Bedside Communication Boards (new)

Our patients tell us that how we communicate with them is important. Some areas have bedside communication boards available to complement verbal communication facilitating information sharing between clinicians, patients and their families. The board is located at the patient bedside and is visible to the patient, staff and family. The board is only useful if it is up to date. All clinicians are encouraged to update the board during handover. The Point of Care audit is used to monitor use of bedside communication boards

Patient Clinical Alerts (revised) The EMR Banner Bar communicates critical information about each patient. What do we class as critical information? Information that could have a considerable impact on their health, wellbeing or ongoing care (physical or psychological) and includes allergies, adverse drug reactions (ADRs), Patient Clinical Alerts and Goals of Care. Ensure you check the alerts for your patients and add any additional alerts required.

Patient Identification (revised)

All patients must be correctly and appropriately identified:

• On registration and admission;

• When care, medication, therapy, diagnostic imaging and other services are provided;

• When undergoing a procedure, and;

• When clinical handover, transfer or discharge documentation is generated.

The EMR Banner Bar must be checked to identify critical information specific to the patient, such as allergies, Adverse Drug Reactions (ADRs), Patient Clinical Alerts and Goals of Care. Regardless of the area, patient identification must be checked against three identifiers. Generally these are:

• Patient’s Family and Given Name

• Date of Birth

• Unit Record Number

But ensure you are familiar with the required identifiers for your area.

Why use two, when ONE will do? New blood management procedure: Monash Health has implemented a new Single Unit Red Cell Transfusion (Adult) Procedure across all sites.

What do I need to know?

• The new procedure has been developed to improve clinical practice and patient outcomes through alignment with the national Patient Blood Management Guidelines “Where indicated, transfusion of a single unit of red cells, followed by clinical reassessment to determine the need for further transfusion, is appropriate”.

• It aims to improve the safety and efficacy of red cell transfusion by confirming every unit transfused results from a clinical decision where the expected benefit outweighs the risks.

• Applies to adult patients with clinically significant anaemia who are stable, normovolaemic, and who do not have clinically significant ongoing bleeding.

• Exceptions to single unit transfusions include patients with active bleeding, haematology and oncology patients, patients in operating theatre, and those in whom surgery is planned with expected significant blood loss.

• An adult red cell transfusion guide and single unit pathway flowchart is included within the procedure.

• Unless the patient has an underlying haematological disorder, is in theatre, has a preoperative request, or the clinical notes or “transfuse reason” state “bleeding” only one unit of red cells will be reserved and released at a time in the above setting.

What do I need to do?

• Familiarise yourself with this procedure.

• Know that each red cell transfusion is an independent clinical decision based on the risk, benefits and available alternatives.

• Do not base the decision to transfuse on haemoglobin alone but also on assessment of the patient’s clinical status.

• Transfuse one unit at a time and only when clinically indicated, based on the need to relieve clinical signs and symptoms of anaemia.

• If a second unit is required after clinical assessment make a second request in EMR or on the Blood Bank Request Form (MRL28).

What should I not do? In the last month, there have been 8 different episodes in which the commencement of a blood transfusion was delayed after the blood had been released from Blood Bank but the blood was not stored correctly and so was unable to be transfused. The blood had to be discarded. Blood is a precious product. When blood arrives for transfusion, either put it up or return it to Blood Bank promptly. Don’t delay!

Further information

• Further information is available on the transfusion service intranet homepage.

• Includes Internal Communication and PowerPoint presentation summarising the key information.

Case Study Note the patient’s name and some details have been changed.

Preventable pressure injury Bill is 91 years old. He was admitted following a stroke causing balance issues and nystagmus. He has a past history of ischaemic heart disease (with bypass surgery in 2007), atrial fibrillation (on warfarin) and type 2 diabetes.

On admission his Braden score (pressure injury risk assessment tool) is 13 (considered a moderate risk) and his skin is documented as intact. He is transferred to the rehabilitation ward after a week in an acute ward. On admission to rehabilitation:

• His skin assessment is normal;

• His Braden score is 14 (moderate risk);

• He is nursed on a pressure relieving mattress, and;

• He ambulates with a four wheel frame.

On day 2 of his rehab stay his medical record states his skin is intact but he is noted to have a red sacrum and protective creams are applied. On day 11 the medical team prescribe full length TED (thromboembolism deterrent) stockings. A heel wedge is also utilised to protect his heels from pressure. On day 12 and 14 Bill is reviewed by the Medical Team, with an order to continue TEDS. Nursing staff have documented the presence of the TED stockings however there is no documented skin assessment. On day 15 Bill complains of a painful left big toe. A referral is done to Podiatry querying an ingrown toenail. Podiatry review and inform the medical team that Bill has sustained deep tissue injuries (DTI) to toes on both his feet. The medical team document to remove TEDS. The wounds deteriorated, increasing in size and progressed to black eschar requiring second daily dressings. These injuries were likely preventable. For Bill they resulted in:

1. Pain that woke him up when sleeping and decreased his participation in physiotherapy, and

2. Reduced mobility - he required modified footwear (Darco shoe) for ambulation to remove further pressure on toes. This altered his gait and confidence when ambulating.

Learnings

• The Venous Thromboembolism: Risk Assessment and Prevention Guideline was revised in 2019 removing graduated compression stockings. These are not be routinely used at Monash Health.

• Document and communicate the assessments done and the interventions in place so the team focus on prevention of these debilitating injuries.

• All hospital acquired pressure injuries (except stage 1) require a RiskMan incident to be entered. Refer below for a guide on entering Stage 3, Stage 4 and suspected deep tissue injuries.

Entering hospital acquired pressure injuries on RiskMan Stage 3, Stage 4 and suspected deep tissue injuries require referral to ongoing services, such as wound services, podiatry and even surgery. For this reason, ‘Advanced treatment’ is to be selected when rating the incidents. This calculates to an ISR 2, as below. Carefully consider the ‘Degree of Impact’. These injuries can result in permanent harm. This would result in an ISR 1 and potentially require reporting by the Quality and Safety Unit to Safer Care Victoria as a sentinel event.

Policy procedure and guideline update

New Procedures

Acute Medicine, Sub Acute & Community: De-activation of ICD for Inpatients receiving End Of Life Care

Patients with Thyroid Cancer requiring Thyrogen Injections before Radioactive Iodine (RAI) HITH

COVID -19 Inpatient Admission

Transfer of Patients during COVID-19 Pandemic

Blood Management Committee:

Single Unit Red Cell Transfusion (Adult)

Capital and Infrastructure:

Asset Management Policy

Communicating for Safety Committee:

Bedside Communication Boards

Diagnostic Imaging:

Monash Imaging Communication of Non- Routine Image Findings

Radiation and Pregnancy Flowchart

Radiation Safety for Pregnant Patients

Mental Health:

Mental Health Inpatient Ligature Point Assessment and Management

Mental Health Inpatient Ligature Point Assessment and Management

Sensory Interventions: Use of Weighted Modalities

Monash Children's:

COVID -19 Paediatrics

Paediatric Patient 'Call Now' Criteria

Monash Newborn Referral to Paediatric Respiratory Medicine for the Home Oxygen Program Checklist

Medical Services:

Medical Staff Undertaking Exposure Prone Procedures (EPP)

Nursing and Midwifery Services:

Family Violence Services List

OHS:

OHS Access to Roofs and Windows

OHS Isolation of Services

OHS Permit to Work - Confined Space Entry

OHS Task Based Risk Assessment Form

Operational Services:

COVID -19 Hospital Care for Adult Patients with COVID 19

Patient Information:

Flutter

MRI - Magnetic Resonancy Imaging MRI brochure

ADaPPT Adolescent, Drug and Psychosocial Pregnancy Team

Blood pressure measurements from home

Breastfeeding expressing colostrum in pregnancy

Progesterone pessaries in pregnancy

Symphyseal fundal height measurements from home

Preparing for your bowel surgery AM version

Preparing for your bowel surgery PM version

Low Risk Febrile Neutropenia Program: Home Observation Form

Tips for mums with Coronavirus - helping to keep your baby safe

Pharmacy:

Single Patient Use Request: Inpatient use of PBS- Funded Medicines

Compounding Services - Aseptic and Cytotoxic Preparation Hand Hygiene

COVID-19 Administering Patient's Own Medications Workflow

COVID-19 Non-Imprest Inpatient Medications Supplied to Ward Workflow

COVID-19 Patient's Own Medications Handling and Storage Workflow

COVID-19 Return of Patient's Own Medications on Discharge Workflow

Quality and Safety Unit:

Sentinel Event and In-Depth Review

Specialist Consulting Clinics:

COVID 19 Screening Clinics

Surgical and Interventional Services:

Audiological Assessment - Otoacoustic Emissions

Same Day Percutaneous Coronary Intervention (SDPCI)

Women's and Newborn:

2019 Novel Coronavirus (COVID-19) in Neonates

Coronavirus (COVID-19) Infection in Pregnancy

Monash Women's and Monash Neurology Partnership

Admission to Maternity from a Non-Maternity Area

Consultative Council on Obstetric and Paediatric Mortality and Morbidity Reporting

Prediction and Prevention of Preterm Birth

Telehealth Monash Women's

Nipple Shields

Revised Procedures

Acute Medicine, Sub Acute and Community: Alcohol intoxication Short Stay Unit/ Extended Care Unit Admission (Adult)

Allergic reaction admission Short Stay Unit (Adult)

Allied Health and Social Support Short Stay Unit Admission (Paediatric)

Allied Health and Social Support Short Stay Unit/ Extended Care Unit Admission (Adult)

Ambulance Offload Mandatory Alert Criteria

Asthma Short Stay Unit/ Extended Care Unit Admission (Adult)

Back Pain Short Stay Unit Admission (Paediatric)

Back Pain Short Stay Unit/ Extended Care Unit Admission (Adult)

Biliary Colic Short Stay Unit/ Extended Care Unit Admission (Adult)

Bleeding in Early Pregnancy Short Stay Unit/ Extended Care Unit Admission (Adult)

Blood Transfusion Short Stay Unit/ Extended Care Unit Admission (Adult)

Bronchiolitis Short Stay Unit Admission (Paediatric)

Cardiac Monitoring Short Stay Unit/ Extended Care Unit Admission (Adult)

Cellulitis Short Stay Unit/ Extended Care Unit Admission (Adult)

Croup Short Stay Unit Admission (Paediatric)

Deep Vein Thrombosis (DVT) Short Stay Unit/ Extended Care Unit Admission (Adult)

Drug Overdose Short Stay Unit/ Extended Care Unit Admission (Adult)

Emergency Department Short Stay Unit Admission and Operational (Adult)

Epistaxis Short Stay Unit/ Extended Care Unit Admission (Adult)

Evaluation of Possible Myocardial Injury or Infarction Short Stay Unit Admission (Adult)

Gastroenteritis Short Stay Unit Admission (Paediatric)

Gastroenteritis Short Stay Unit/ Extended Care Unit Admission (Adult)

Head Injury Short Stay Unit Admission (Paediatric)

Hyperemesis Gravidarum Short Stay Unit/ Extended Care Unit Admission (Adult)

Hypertensive Emergencies Short Stay Unit/ Extended Care Unit Admission (Adult)

Hypoglycaemia Short Stay Unit Admission (Paediatric)

Hypoglycaemia Short Stay Unit/ Extended Care Unit Admission (Adult)

Investigation or Results Short Stay Unit Admission (Paediatric)

Left Ventricular Failure (Mild) Short Stay Unit/ Extended Care Unit Admission (Adult)

Migraine Short Stay Unit Admission (Paediatric)

Migraine Short Stay Unit/ Extended Care Unit Admission (Adult)

Paracetamol Poisoning Short Stay Unit/ Extended Care Unit Admission (Adult)

Pneumonia Short Stay Unit/ Extended Care Unit Admission (Adult)

Pneumothorax (spontaneous) Short Stay Unit/ Extended Care Unit Admission (Adult)

Poisoning/Toxicology Short Stay Unit Admission (Paediatric)

Poor Feeding/Observation of Feeding Short Stay Unit Admission (Paediatric)

Post Seizure Short Stay Unit/ Extended Care Unit Admission (Adult)

Pylonephritis Short Stay Unit/ Extended Care Unit Admission (Adult)

Renal Colic Short Stay Unit/ Extended Care Unit Admission (Adult)

Tonsillitis Short Stay Unit/ Extended Care Unit Admission (Adult)

Transfer to home/Accommodation or other Hospital Short Stay Unit/ Extended Care Unit Admission(Adult)

Transfers from MMC to Dandenong or Casey Hospital Short Stay Unit Admission (Paediatric)

Transient Ischaemic Attack (TIA) Short Stay Unit/ Extended Care Unit Admission (Adult)

Urinary Retention Short Stay Unit/ Extended Care Unit Admission (Adult)

Viral Meningitis Short Stay Unit/ Extended Care Unit Admission (Adult)

Clinical Gait Analysis Referral and Admission Addition of GP Health Summary (where possible) to accompany specialist referral. Documentation about referral acceptance as part of documentation in SMR

High Dose Insulin Euglycaemic Therapy (HIET) for Calcium Channel Antagonist and Beta-Receptor Antagonist Poisoning

Identifying Unstable Patients Waiting for AV Offload

Trauma Response (Adult) Emergency Department Further details added to injury pattern criteria in line with State Trauma system guidelines including obstetric and neuro-trauma

Trial of Void Management Plan Residential In Reach Wording updated to remove ambiguity and template update

Trial of Void Residential In Reach

Ferric Carboxymaltose Infusions HITH Adult

Hospital in the Home Breast Surgery Discharge Pathway Removed inpatient physiotherapy review as deemed not relevant by AHLC

Monash Health Community - Assessment and Care Planning Added section on 'Clinical Risk Screening and Assessment' in addition to minor word changes

Natalizumab (Tysabri®) Hospital in the Home (HITH)

Allied Health:

Videofluoroscopic Swallowing Study (VFSS) Inclusion of relevant acronyms, improved definitions, and updated hyperlinks. Inclusion of new processes, updated and correct reference list.

Conducting Family Meetings

Hydrotherapy Pool Update of Dandenong Hospital hoist weight limit to 250kg from 130kg. Added Extreme heat policy in section 8 to provide instruction of when pool sessions need to be cancelled based on temperature

Cervical Spine Hard Collar Care: Maintenance, Cleaning, and Patient Education Removal of health care students (deemed not within scope of practice). Removed references to 'smart moves training' and update to relevant procedure. Updated content and blurb to note change in Monash Health

Cervical Spine Hard Collar Measurement and Application in the Hospital Setting Removal of health care students (deemed not within scope of practice). Removed references to 'smart moves training' and update to relevant procedure. Updated content and blurb to note change in Monash Health

Meal Assistance Identifier

Nutrition Risk Screening (Adult)

Blood Management Committee:

Refractoriness to Platelet Transfusion Definitions to Refractoriness to Platelet Transfusion added

Transfusion Collecting Blood Products from Blood Bank Expanded scope to include collecting all blood products for example, albumin, intravenous immunoglobulin, red cells and platelets.

Transfusion: Red Cell (Adult) Information related to red cell transfusion given during haemodialysis

Communicating for Safety Committee:

Patient Identification Added reference to patient identification process for same day dialysis patients. Added reference to EMR Banner Bar for idenfication of allergies, ADRs, Patient Clinical Alerts and Goals of Care. Defined unkown patients utilising a red patient ID band until an allergy/ADR has been established. Included reference to WebPas alongside iPM. Removal of outdated patient identification flowchart for mental health patients (processes and EMR references described within document.)

Comprehensive Care Committee:

Wound dressing selection guide Revised for clinician ease of use and alignment with wound dressing selection products available for use at Monash Health

Deteriorating Patient Committee:

Adult and Paediatric Resuscitation Trolley Merged Adult and Paediatric resus trolleys procedure together and included several implementation tools as an appendix.

Deteriorating Patient Recognition and Management (Operational) Updated reporting and auditing (generic KPIs are listed in the committees TOR). Incorporated DP training requirements (BLS/ALS)

Adult Clinical Observations and Response

Adult MET and Code Blue

External Code Blue

Adult and Paediatric Resuscitation Trolley Minor changes to include additional locations of resuscitation trolleys in relation to the COVID 19 response

Diabetes:

AVIVA® and InsuLinx® bolus calculators

Diabetic medication before and after elective surgery or endoscopy (Adult) Pre-operativel, SGLT2 inhibitors can be withheld on the day of the procedure for gastroscopy or day procedures (as opposed to for 3 days). Update following recent updated Australian Diabetes Society guidelines

Insulin Dose Adjustment (Adult)

Type 2 diabetes pre and post procedural medication management Updated following recent updated Australian Diabetes Society guidelines

Diagnostic Imaging: Monash Imaging Insertion of a Tunnelled Port Catheter

Communication of 2nd and 3rd Trimester Obstetric Ultrasound Results

Finance:

Treasury, Investment and Credit Risk management

Infection Prevention:

2019 Novel Coronavirus (COVID-19)

Animal Visitations

Clinical Equipment Cleaning

Personal Protective Equipment (PPE) - Application and Removal Updated to align with new department of health guidelines as to order of PPE removal

COVID -19 (Novel Coronavirus) Reference Document

Seasonal Influenza Updated to align with COVID 19 procedure, changing N95 mask use to Surgical mask for all NPA swabs

Medical Services:

Monash Doctors -Senior Medical Staff (SMS) & Dental Appointments Updated in line with EBA, Medical Workforce Strategy and People and Culture

Credentialing and Defining Scope of Practice Senior Medical Staff

Deceased Person Management Updated Precautions/Contraindations to include the applicationof standard precautions when managing the deceased person. Reference has been made to labelling of the mortuary bag with regard to COVID 19

Mental Health:

Mental Health Client Missed Appointments

Sensory Assessment

Sensory Interventions

Monash Children's:

Bronchiolitis (Paediatric)

Croup (Laryngotracheobronchitis) (Paediatric)

Diabetes (Paediatric) Continuous Glucose Monitoring System

Discharge process for Infants with chronic neonatal lung disease on home oxygen therapy Reference in procedure to a new checklist which needs to be completed as part of referral process to help guide cliniciancs for referring patients

Entonox® administration for paediatric patients for procedural pain management

Formula Preparation in Formula Room After Hours

Gastroenteritis (Paediatric)

Central Venous Access Device Management (Paediatrics)

Monash Children's at Home: Referral to Hospital and Post Acute Care

Tracheostomy Management for Paediatrics Changes regarding tracheal tube sizes and EMR process incorporated. Emergency management flowchart amended to specify 'Paediatric Code Blue'

Nursing and Midwifery Services:

Medical Falls Risk Assessment

Restraint (excluding Mental Health and Residential Aged Care Services) Revised to align with the current operationalisation and best practice processes for the prevention application and removal restraint.

Occupational Health, Safety:

OHS Working from Home Self Assessment Checklist

OHS Working Alone or in Isolation

OHS Asbestos Based Works

OHS Chemical Management

OHS Chemical Spill Risk Management

OHS Confined Space

OHS Consultation and Communication

OHS Contractor Hazard Identification Site Induction Checklist

OHS Contractor Management Procedure

OHS Extreme Weather

OHS Extreme Weather Alert Checklist

OHS Forklift Unloading -Monash Medical Centre Loading Dock

OHS Hazardous Building Materials

OHS Health Monitoring

OHS Hot Work

OHS Issue Resolution

OHS Manual Handling

OHS Movement of Beds and Patient Trolleys

OHS Noise Risk

OHS Office ergonomics and workspace

OHS Permit to Work -Access to Roofs and Windows

OHS Permit to Work Fire Sprinkler and Hydrant Isolation

OHS Permit to Work Hot Work

OHS Permit to Work Services Isolation

OHS Plant and Equipment Lock Out Tag Out

OHS Plant and Equipment Maintenance Form

OHS Plant and Equipment Risk Assessment Form

OHS Plant and Equipment Risk Management

OHS Register of Employees Approved to Work Alone or in Isolation

OHS Risk Management

OHS Site Local Induction Checklist

OHS Traffic Management

OHS Traffic Plan Template

OHS Training and Induction

OHS Working at Heights

Operational Services: Patients Clinical Alerts Extended description of patient clinical alerts. Added Australian Commission on Safety and Quality in Health Care definition of Critical Information. Appendix 1 updated to capture the changes (since August 2019) to the overarching list of Patient Clinical Alerts.

Visiting Monash Health Minor content changes to reflect alignment with National Standard.

Patient Information: Visiting at Monash Health information sheet (patient information)

Devices for people with hearing impairment (patient information)

Mental Health Consumer & Family/Carer Resources

Statement of Rights - Assessment Order - Mental Health (external)

Statement of Rights - Court Assessment Order - Mental Health (external)

Statement of Rights - Court secure treatment order - Mental Health (external)

Statement of Rights - Electroconvulsive treatment (ECT) - Mental Health (external)

Statement of Rights - Forensic Patients - English - Mental Health (External)

Statement of Rights - Neurosurgery for mental illness - Mental Health (external)

Statement of Rights - Non-Custodial Supervision Order (NCSO) - Mental Health (external)

Statement of Rights - Secure Treatment Order - Mental Health (external)

Statement of Rights - Temporary Treatment Order - English - Mental Health (External)

Statement of Rights - Treatment Order - English - Mental Health (External)

Skin prick testing for inhaled allergens (patient information)

Basic Life Support children over 12 months resources for parents and carers

Basic Life Support children over 12 months with tracheostomy resources for parents and carers

Basic life support children under 12 months resources parents and carers

Basic life support children under 12 months with a tracheostomy resources for parents and carers

Middle ear aeration techniques (patient information)

Vocal hygiene and vocal behaviour strategies (patient information)

Sodium Glucose Co-transporter 2 (SGLT2) inhibitors

Blood pressure measurements from home

Symphyseal fundal height measurements from home

Tips for mums with Coronavirus - helping to keep your baby safe

Pathology:

Pathology results verbal communication Updated critical limits which will be phoned to clinicians

People and Culture:

People and Culture - Complaints

People and Culture Bullying and Harassment (Operational)

People and Culture Equal Employment Opportunity

People and Culture Fitness for Work (non-work related illness/injury)

Pharmacy:

Compounding Services - Aseptic and Cytotoxic Preparation Entry, Gowning and Degowning

Compounding Services - Aseptic and Cytotoxic Preparation General Principles of Cleaning

Compounding Services - Aseptic and Cytotoxic Preparation Suite Cleaning

Medication Dispensing by Authorised Prescribers Updated to describe the process and legalities invloved in supplying medicines to a patient for later use by an authorised prescriber at a time when a Pharmacist is unavailable. Labelling requirements clarified for scheduled medicines in the Emergency, Inpatient and Outpatient Setting.

Respiratory Infections (Adult) New version of national guidelines (Therapeutic Guidelines: Antibiotic) released in 2019. There were a number of changes, including: dose of ceftriaxone in all pneumonia types combined facility acquired pneumonia with community acquired pneumonia. Added penicillin hypersensitivity terminology section. Added links to PROMPT documents for penicillin delabelling and seasonal influenza procedure

Surgical Antibiotic Prophylaxis -peri and post-operative (Adult)

Alteplase (for unblocking central venous access devices) Adult and Paediatric Medication Profile

Antiemetic Medications (Adult) Emergency Department

Calcium Chloride Adult Medication Profile

Calcium Gluconate Adult Medication Profile

Critical medicines

Digoxin Adult Medication Profile

Hyperkalemia Treatment

Idarucizumab Adult Medication Profile

Iloprost Intravenous Infusion Adult Medication Profile

Intravenous Lidocaine (Lignocaine) Infusion For Migraine Treatment Adult Medication Profile

Isoprenaline Medication Profile

Medication Imprest Review

Medication initiation by Registered Nurses, Midwives and Pharmacists

Medications for Adult Patients Declining Blood Products

Potassium Adult Medication Profile

Potassium Paediatric Medication Profile

Rivaroxaban Adult Medication Profile

Tirofiban Adult Medication Profile

After Hours Medication Transfer

Daptomycin Intravenous (IV) Adult Medication Profile

Esmolol Monash Newborn Medication Profile

Fentanyl Monash Newborn/NeoMed Medication Profile

Ferric carboxymaltose (Ferinject ®) Paediatric Medication Profile

Glucagon Monash Newborn/NeoMed Medication Profile

Medication Expiry Date Checking

Medication Imprest Integrity Checklist

Medication Requisition Book Application Form

Medication Supply

Milrinone Monash Newborn/NeoMed Medication Profile

Noradrenaline (Norepinephrine) Monash Newborn/NeoMed Medication Profile

Sildenafil Monash Newborn/NeoMed Medication Profile

Quality and Safety Unit:

Clinical incident management, including open disclosure Extensively revised to reflect current practice

Speciality Medicine, Cancer and Critical Care:

Iron Sucrose Infusion Adult and Paediatric(Intravenous Infusions for Haemodialysis)

Collecting Dialysate Sample for CFU and ENDOTOXIN form 4008 and 5008 Haemodialysis Machine Frequency of dialysate sampling for the haemodialysis machines changed from 3 to 6 monthly

Surgical and Intervenional Services:

Beta Blocker Administration for CT Coronary Angiogram Content changes to clearly delineate agreed workflows in ED vs Ward patients

Monash Heart - Elective DC Cardioverson (DCR)

Atrial Septal Defect Closure /Patent Foramen Ovale with Amplatzer or Occlutech OccluderDevice

Pancreatitis (Acute) Assessment and Management Inclusion of importance of intensive fluid resuscitation, allocation of patient to appropriate medical team and hospital location as well as inclusion of BISAP score criteria.

Radial TR band following sheath removal from the radial artery

Temporary Epicardial Pacing Management

Pregnancy visit schedule for shared maternity care

Telehealth Monash Women's Clarifying a couple of points, 1. Shared Care schedule to include consideration to maintaining a 16 week visit that may be face to face or telehealth. 2. Women attending for ultrasounds at Monash Health can also have a blood pressure colected to facilitate subsequent telehealth consultations.

Medical and Neonatal Nurse Practitioner attendance at births (Resuscitation skill Levels) Incorporates Neonatal Nurse Practitioners

Metabolic bone disease of prematurity

Neopuff ™ (Infant T-piece resuscitator) pre-use set up checking Incorporates Neonatal Nurse Practitioners

Nova StatStrip Glucose /Ketone Meter Addition of instructions for use of Nova Statstrip connectivity meter and quality control testing. Updated pictures from manufacturer

Palivizumab for respiratory syncytial virus (RSV) Monash Newborn

Thyroid function tests for neonates

Transcutaneous jaundice meter Revised to reflect updated information on daily operational check of equipment and measurement site to be used for device

Women's and Newborn:

Admission priority of any infants <28 weeks gestation following birth Minor changes to nursing workflow in procedure

Maternity Teams booking descriptors and schedules No longer prioritising booking Dari, Farsi, and Punjabi languages to Friday. Amethyst and Opal have exclusive booking only in speciality to ensure space for the later transfers into these teams

Pack Count (Maternity) Revised title. Added a qualifier at the time of birth to the point that gauze swabs not permitted in birth rooms.

Water birth: immersion in water during labour and/or birth Maternal temperature must be taken hourly whilst immersed in water. Midwife or support person must remain with the woman at all times to maintain safety whilst the woman is immersed in water.