A NSW Government website
SCHN Policies
C
To guide the use of the C-MAC in retrieval intubations To ensure appropriate cleaning and maintenance of the device
To appropriately inform necessary clinicians and recognise the importance of deterioration for patients on non-invasive ventilation including CPAP or BIPAP
To adequately prepare and manage children undergoing cardiac catheterisation & EPS in order to enhance recovery and minimise post-operative complications.
To guide clinicians across the network on the correct care and management of paediatric patients requiring cardiac pacing.
To provide a guideline that is based on current best practice regarding the care of a post-op cardiac patient
These practice guidelines are based in the International Liaison Committee on Resuscitation (ILCOR) and the Australian Resuscitation Council (ARC) recommendations. They reflect current teaching of Cardio Pulmonary Resuscitation Training at the Sydney Children's Hospitals Network. The guidelines provide staff with the necessary knowledge to initiate and sustain an effective and efficient response to a medical emergency at SCHN.
Define criteria and processes for the Care by Parent Model of Care
All children presenting at the SCHN are entitled to high quality care, in line with the hospital’s vision and values. The purpose of this document is to ensure that children in immigration detention receive safe, effective and person-centred care and that staff from immigration detention should not adversely affect the patient's health care, the working environment of the ward and hospital, other patients, other children, their parents or SCHN staff. The high-level guiding principles contained within this document aim to deliver person-centred care which is respectful of and responsive to the preferences, needs and values of patients and consumers. The widely accepted dimensions of person-centred care are respect, emotional support, physical comfort, information and communication, continuity and transition, care coordination, involvement of family and carers, and access to care (Australian Commission on Safety and Quality in Health Care).
Middleton Day Surgery Unit encompasses a Pre-operative admission area Post Anaesthetic Care Unit (PACU stage 1 ) and a Stage 2 PACU Discharge Lounge for Day Only patients. Middleton Unit is the Admission unit for over 95% of all planned and unplanned SCHN-Westmead Surgical Admissions This Practise Guideline document reflects what is currently regarded a safe practise .
To educate and support staff in the procedure of catheterisation in all its forms.
This is a practice guideline relating to the operation of the cell salvage device used in the operating theatres at CHW.
To guide management of central diabetes insipidus in SCHN inpatients not requiring vasopressin infusion.
Guide clinicians within SCHN on managing any patient with a Central Venous Access Device (CVAD) during the neonatal period ie to 28 days of age and/or being cared for in NICU/CICU and PICU only
Detail the procedures involved in the insertion and management of central venous access devices.
To outline postoperative care for patients undergoing cerebral angiogram. To guide frequency of observations, what to look for when checking of cerebral angiogram site and potential complications.
Instructions on how to care for a patient with a (suspected) spine policy
To provide guidance to PICU and Spinal team clinical staff about cervical spine immobilisation and clearance in intubated PICU patients. Not for use outside of PICU
To provide guidance to clinical staff on the emetogenic potential of chemotherapeutic agents and appropriate prophylaxis and treatment of chemotherapy-induced nausea and vomiting
Chest Drain Management
Manage chicken pox and herpes zoster contacts and prevent transmission within SCHN
This document has been developed to prevent or reduce child morbidity following needle stick incidents or exposure to blood or potentially blood contaminated secretions.
Guide clinicians in the appropriate use of play therapy during procedural interventions.
Clear management of child presenting to Emergency Department where sexual assault is suspected
To help Emergency Department Staff to manage suspected physical abuse and neglect in children in the Emergency Department
Provide information about the roles of the Child Protection Units at Randwick and Westmead and referral pathways to the CPUs
Overview of Child Safe Standards, from the Office of the Children's Guardian. The Royal Commission into Institutional Responses to Child Sexual Abuse recommended 10 child safe standards, drawing on its findings, research and consultation about what makes organisations child safe. this document will out line the 10 child safe standards and provide information for staff on how SCHN meet these standards with links to other documents and webpages. A child safe culture is a set of values and practices that guide the attitudes and behavior of all staff.
• The Child and Family Health Clinical Nurse Consultant (CFH CNC) provides expert clinical services, advice and advocacy for clients, parents/carers and health care professionals within the specialty of Child and Family Health. • Patients are referred to the Child and Family Health Clinical Nurse Consultant when an inpatient with the hospital. • This document gives guidance to medical and nursing staff involved in referring a patient for Child and Family Health Nurse Consultation and specifies the procedures involved.
Standardisation of chylothorax diagnosis and management for children admitted to CHW. This mostly applies to children following cardiac surgery and may be admitted to NICU, PICU and Edgar Stephen Ward. It also includes congenital chylothorax in neonates.
Educate and reinforce skills learnt to be used in the home setting or equivalent.
To enhance prior learning and reference guide to children and their carers I the process of Intermittent catheterisation in all aspects of society.
To reinforce the child's and parents skills, understanding and confidence in attending to the catheterisation by newly formed channel.
This guideline is replacing the previous clinical pathways which were designed to standardise care and guide clinical practise. This guideline serves as a management guide to staff caring for patients undergoing this procedure.
This document has been developed to provide current and up to date guidelines on the pre-operative and post-operative care of the child undergoing cleft lip and/or palate repair.
The document is to describe the requirements for children attending the Outpatient Cleft Palate Clinic with acute ear infections.
This document was created to replace the previously used 'clinical pathways'. It is a standardised way to care for all patients admitted for this procedure and serves as a guide to nursing and medical staff on the management and cares for the children undergoing this procedure.
Provide safe handover procedures from NETS to receiving units.
To establish protocols on the collection, use, disclosure, storage and security of clinical images at The Sydney Children’s Hospitals Network (“SCHN”).
Explains the policy expectations related to clinical incident management and responsibilities of local managers, Clinical Program Directors and CGU. Where to find additional information to clinical incident management as stated by NSW Health policy.
To provide guidance in relation to the Clinical Manual Handling Program and provide responsibilities and practical assistance to staff, i.e. Mentors, Managers etc
The purpose of this procedure is to describe the process by which access to the electronic medical record for the purposes of inspection for clinical research is managed at SCHN.
The purpose of this procedure is to ensure that bio specimens for clinical research are collected in compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Bio specimens for clinical research are collected and processed in a safe and compliant manner by appropriately qualified and trained personnel to whom the Investigator has delegated responsibility; * The integrity of bio specimens for clinical research is preserved by ensuring that the bio specimens are maintained under suitable conditions during collection and processing; and * Appropriate records detailing the chain of custody for the bio specimens are maintained in compliance with the SCHN Procedure - Record Keeping [DRAFT]
The purpose is to outline the procedure for accessing user support, notification of planned and unplanned downtime and obtaining access to electronic documents stored in the SCHN Clinical Trial Management System (CTMS) in the event of unplanned downtime.
The purpose of this procedure is to ensure that close-out and archiving is performed in accordance with NSW Health, SCHN and regulatory and protocol requirements.
To provide clear guidance on what is required when obtaining consent to participate in human research conducted across SCHN.
The purpose is to outline the procedure for the creation of certified copies of original records for clinical research, in compliance with NSW Health, SCHN and regulatory requirements.
The purpose of this procedure is to ensure that deliveries of equipment and/or supplies (excluding IMP) for clinical research are received, processed, evaluated and stored in compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Investigators or Delegates receiving deliveries promptly identify that the delivery contains equipment/supplies for clinical research purposes; * Deliveries of equipment and/or supplies are promptly processed, evaluated and stored by the Investigator or Delegate.
The purpose of this procedure is to ensure that equipment/supplies for clinical research are appropriately maintained and calibrated (if applicable) in accordance with NSW Health, SCHN, regulatory, Protocol requirements and manufacturers guidelines. It is acknowledged that there may be some variations in the procedure for the maintenance and calibration of equipment/supplies depending upon the protocol-specific arrangements dictated by the Sponsor or Delegate. Adherence to this procedure will ensure that: * Responsibilities for the maintenance, calibration (if applicable) and inventory management are clearly defined and enacted; and * Equipment and supplies for clinical research are in good working order and available for use by Investigators or Delegates for their intended purpose;
The purpose of this procedure is to ensure the appropriate financial management of clinical research, in compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Financial and operational risk to SCHN is reduced by ensuring that resources and funds are adequate to conduct the clinical research to a high standard of quality and safety and the Supporting Departments involved in the delivery of the research are reimbursed for costs incurred; * There is appropriate stewardship of public and other resources whereby funding is used ‘for purpose’ and the receipt, investment and expenditure of funds complies with NSW Accounts and Audit Determinations for Public Health Organisations; and * A high quality, efficient, sustainable and competitive service, delivered by experienced clinical and research personnel, is available to Investigators and Sponsors or Delegates, now and in the future.
The purpose of this procedure is to ensure consistency in the performance of accountability tasks for IMP for clinical research, in compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Detailed records for IMP for clinical research are maintained providing details of all occasions of receipt, dispensing, transit/transfer, quarantine, return and/or destruction; and * IMP for clinical research is managed in accordance with the protocol-specific instructions of the Sponsor or Delegate and only used in accordance with, and for the purposes of the approved clinical research for which it has been provided.
The purpose of this procedure is to ensure that unused or unfit IMP that are authorised for disposal by the Sponsor or Delegate are processed in accordance with NSW Health, SCHN and regulatory and Protocol requirements.
The purpose of this procedure is to ensure that IMP for clinical research is prepared and dispensed in accordance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * IMP is accurately and safely prepared, dispensed (including packaged and labelled) and released to clinical research participants in a timely manner as per the protocol; and * Records are maintained in compliance with the SCHN Procedure - Record Keeping [DRAFT].
The purpose of this procedure is to ensure that prescriptions for IMP used in clinical research are created, approved, completed and authorised, as applicable, in incompliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Personnel preparing, authorising, receiving and processing the prescription promptly identify that the prescription relates to clinical research; * IMP is prescribed and dispensed in compliance with the current Protocol; * Prescriptions for IMP are completed and authorised by appropriately qualified personnel to whom the Investigator has appropriately delegated responsibility, as documented by the Signature and Delegation Log; and * Records are maintained in compliance with the SCHN Procedure - Record Keeping [DRAFT].
The purpose of this procedure is to ensure that unused or unfit IMP identified by the manufacturer, Investigator, Sponsor or Delegate(s), as requiring quarantine is managed in compliance with NSW Health, SCHN, regulatory and Protocol requirements.
The purpose of this procedure is to ensure that deliveries of IMP for clinical research are appropriately received, processed and stored in compliance with NSW Health, SCHN, regulatory and Protocol requirements. It is acknowledged that there may be some variations in the procedure for the receipt and storage of IMP depending upon the protocol-specific requirements dictated by the Sponsor or Delegate, and in accordance with risk-assessments made by Pharmacy, as applicable. Adherence to this procedure will ensure that: * Pharmacy personnel receiving deliveries promptly identify that the delivery contains IMP for clinical research; * IMP deliveries are promptly acknowledged, processed and appropriately stored by the Senior Clinical Trials Pharmacist or Delegate.
The purpose of this procedure is to ensure that the quality and integrity of IMP is maintained in compliance with NSW Health, SCHN, regulatory and Protocol requirements through the monitoring of temperature in locations used for the storage IMP for clinical research. Adherence to this procedure will ensure that: * A valid, continuous record of temperature is available for all locations used for the storage of IMP for clinical research; and * Temperature deviations are promptly identified, escalated and acted upon, as appropriate, in consultation with the Sponsor or Delegate.
The purpose is to outline the procedure for the reimbursement of out of pocket or other expenses incurred by clinical research participants during their involvement in clinical research.
The purpose of this procedure is to ensure that the qualifications and training of clinical research personnel are documented and maintained to ensure compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Accurate records are maintained of the qualifications and training of clinical research personnel delegated to perform duties or tasks by the Investigator, under their supervision.
The purpose of this procedure is to ensure that a consistent approach is taken by SCHN Investigators with regards to the appropriate delegation of tasks and duties for clinical research, in compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure that: * Investigators or Delegates appropriately assign duties or tasks to qualified and trained clinical research personnel operating under their supervision; * The delegation of duties or tasks by the Investigator is appropriately documented through completion and maintenance of a Signature and Delegation Log.
The purpose is to outline the procedure for the creation and management of records used as part of clinical research.
The purpose of this procedure is to ensure that all medical tests conducted for clinical research purposes are reviewed by the Investigator to ensure the safety of clinical research participants, adherence with the protocol and compliance with applicable NSW Health, SCHN and regulatory regulations. This procedure applies to all clinical research conducted within SCHN where the Investigator is responsible for reviewing medical test results to ensure clinical research participant safety and care, as per the protocol. This procedure applies regardless of whether such tests are performed at SCHN or by external agencies, such as central laboratories. Adherence to this procedure will ensure that: * Investigators promptly receive and review medical test results for clinical research participants under their care; * Investigators promptly act to review, escalate, respond and document any decisions made or actions taken, as a result of the review of medical tests to ensure the safety of clinical research participant under their care (as appropriate); and * Investigators respond in compliance with the requirements of the protocol (as applicable) and regulatory approvals, except when necessary to eliminate immediate hazards to the participant as per ICH GCP Section 3.3.7.
The purpose is to outline is to ensure that statistical analysis for clinical research sponsored by SCHN are developed, performed and reported, as applicable, in compliance with NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this procedure will ensure the accuracy, validity and integrity of results drawn from the analysis of data for clinical research through use of appropriate statistical methodology and practices.
The purpose of this procedure is to outline requirements for the safe storage of chemicals, including flammable and/or corrosive agents for clinical research. It is acknowledged that there may be some variations in the procedure depending upon the recommendations and/or specifications for handling a specific chemical agent, with consideration of requirements as stated in its SDS, and in accordance with risk-assessments made by the responsible laboratory facility Head or Delegate.
The purpose is to outline the procedure for the maintenance of essential documents as part of the TMF for clinical research, in compliance with NSW Health, SCHN and regulatory requirements
The purpose of this procedure is to ensure the standardised and safe use of BSCs by clinical research personnel.
The purpose of this procedure is to ensure the standardised and safe use centrifuges by clinical research personnel.
The purpose of this procedure is to ensure the safe use of dry ice by clinical research personnel.
The purpose is to outline the procedure for the use of electronic signatures on records for clinical research, in compliance with NSW Health, SCHN and regulatory requirements. Adherence to this procedure will ensure: * Quality control systems and procedures are enacted to ensure the appropriate use of electronic signatures; * Improved consistency and efficiencies in workflow processes for clinical research personnel; and * Appropriate records detailing the chain of custody for original documents involving electronic signatures are maintained at all times;
The purpose of this procedure is to ensure the standardised and safe use of fridges and freezers by clinical research personnel.
The purpose of this procedure is to ensure the standardised and safe use of Fume Hoods by clinical research personnel.
The purpose of this procedure is to enable equitable access to, and effective communication with, people who require the use of interpreter services in order to consider and/or participate in clinical research. Adherence to this procedure will ensure that: * An inclusive and equitable approach to the opportunity for involvement in clinical research is taken; * Effective communication and/or support is provided to individuals prior to, and during, participation in clinical research; and * Appropriate records of the use of interpreter services are maintained in compliance with the SCHN Procedure - Record Keeping
The purpose of this policy is to ensure that laboratory facilities for clinical research are used in compliance with best practice guidelines as well as NSW Health, SCHN, regulatory and Protocol requirements. Adherence to this policy will ensure that: * Investigators or Delegates use laboratory facilities that are fit for purpose with consideration of protocol-specific requirements dictated by the Sponsor or Delegate, and in accordance with risk-assessments; * Laboratory facilities and equipment are used in a safe, equitable and compliant manner; and * Any data garnered from the performance of laboratory tasks is reliable and credible for analysis.
The purpose of this procedure is to ensure the safe handling of liquid nitrogen by clinical research personnel.
Governance of nursing clinical skill standards of assessment throughout SCHN
The purpose of this procedure is to ensure that Investigator’s Brochures (IB) developed or used by SCHN Investigators for clinical trials comply with NSW Health, SCHN and regulatory requirements.
The purpose of this procedure is to ensure that protocols being developed by SCHN Investigators comply with NSW Health, SCHN and regulatory as well as best practice recommendations.
This policy outlines the application and review process for SCHN staff who wish to have SCHN take on Clinical Trial Sponsorship responsibilities.
Provides safety reporting process for all staff conducting research at SCHN.
Minimising the transmission of toxogenic clostridium difficile in children with diarrhoea
To educate the best evidence based practice for all clinical staff in Grace Centre for Newborn Care.
This outlines the activation, response and management of a Code Black (personal threat) that may arise from a patient or individual confronting staff, patients and/or visitors in a violent or threatening manner.
This document formalises the ED response to critically ill children. It encompasses a code crimson trauma response in addition to outlining a response for critical airway, breathing, circulation and neurological emergencies requiring rapid escalation of care.
To provide a guideline for hospital staff wishing to access data involving neonatal patients in Grace Centre for Newborn Care
This document provides background information regarding the processes required to develop a new Committee (and any associated working or project groups). The document clarifies the approval processes for the development of new committees and information on the administration of all committees within the Network. The document provides staff with templates to be used for all committee proposals, terms of reference, agenda and minutes.
Policy and procedures for visiting Company Representatives at CHW
The purpose of this policy is to provide staff guidance on the use of CAM within hospital. The guidance applies to therapeutic products which are supplied from outside the hospital and are not listed on the hospital formulary and also to unconventional therapies or treatments
The Sydney Children’s Hospitals Network (the Network) compliance management framework ensures the Network’s operations are conducted in accordance with legislative requirements and NSW Health Policy Directives.
To put in place a procedure for repairs to natural compressed air lines for plant & equipment for the maintenance department.
To promote promote personal health and well being by minimising the risk associated with alcohol consumption during events and functions and to provide information to staff on their responsibilities regarding the service of alcohol and related procedures.
To guide the management of the newborn with CDH
To provide clinical staff information on how to arrange a Gynaecology consult.
This document outlines the process for consumer feedback (complaints, compliments, suggestions or observation) management at SCHN. The procedure specifically provides strategies for dealing with complaints at the first point of contact, assessing the severity of complaints, investigating complaints and resolving complaints. The procedure also outlines the process for management of compliments, suggestions and observations.
To guide clinicians to obtain a single ECG trace or display a continuous ECG reading so that cardiac arrhythmias can be identified and analysed.
This protocol covers the procedure for patients admitted to wards for the initiation of CPAP or Bilevel support under care of the Sleep Medicine Service.
To provide a clinical guideline for practice to staff caring for patients receiving regional block infusions or prescribing regional block infusions.
Guidelines for setting up and running haemodiafiltration in PICU including PrisMax machine.
Guideline for the correct application of a CAM boot
The purpose of the Corporate Records Management policy is to ensure that full and accurate records of appropriate activities and decisions of the Sydney Children's Hospitals Network are created, managed and disposed of in accordance with the State Records Act 1998.
Clinical guidance for post-operative cares following craniofacial procedures.
• Maintain the safety and quality of care that patients receive from Health Practitioners and employees. • Support best practice, ensure compliance with professional standards and meet accreditation requirements. • Sustain the confidence of the public and the professions. • Ensure the qualifications, experience, skills and other relevant attributes to fulfil the Scope of Practice are accurately described in the selection criteria of position descriptions. • Ensure credentialing and defining the Scope of Practice occurs at the point of consideration for employment and on an ongoing basis via the appraisal/performance review process or as required.
Clinical Care guideline for Emergency Staff
To provide a comprehensive multidisciplinary document for the management of CF patients.
Management of children with Cystic Fibrosis and Non-CF Bronchiectasis who require antibiotic therapy and physiotherapy in the home.
Define the management including infection control measures for Cystic Fibrosis patients at SCH