Medical Emergency Response Policy Clinical Escalation of

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Date of Last Review: November 2021 Page 1 of 32 Date Next Review: November 2026

Effective:

Clinical Escalation of Acute Physiological Deterioration including Medical Emergency Response Policy

1. Background

This policy addresses the requirements for early recognition of acute physiological deterioration and clinical escalation, including Medical Emergency Response (MER) for adult, maternity, newborn and paediatric patients, inclusive of mental health inpatients and aged care residents within WACHS healthcare facilities. Where a MER is required outside the health campus, ambulance assistance is to be sought by dialling 000 (WACHS staff may be first responders). Consistent with the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration, each WACHS healthcare facility must have a formal documented escalation procedure that is appropriate to the size, role and staffing mix of the hospital, which sets out actions required to respond to different levels of abnormal physiological observations. The processes should be documented using the relevant endorsed templates (See Appendices 1-4). Early intervention has been shown to reduce mortality and morbidity in the critically ill patient. The decision to initiate a MER call is made in response to established criteria on the observation and response charts and in consideration of the situation at the time e.g. staff available/staffing mix. This Policy does not include the processes to recognise and escalate mental state deterioration.

2. Policy Statement This policy is to be read in conjunction with the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration, and the WA Health Recognising and Responding to Acute Deterioration Policy and supporting information. 2.1 Observation and Response Charts The following observation and response charts are endorsed for use in WACHS: • MR140a Adult Observation and Response Chart (AORC) • MR140b Maternal Observation and Response Chart (M-ORC) • MR140d Newborn Observation and Response Chart (NORC). This chart is for use

in newborns <1 month in Special Care Nursery, and newborns on the postnatal ward if perinatal risk factors are identified (e.g. any resuscitation at birth, meconium stained liquor, risk of early onset sepsis, <37 weeks gestation, <2500g) and/or an observation is abnormal. Refer to WACHS Recognition and Response to Acute Deterioration (RRAD) in the Newborn.

• MR 140e Paediatric Observation and Response Charts (PORC under 3 months).

Effective: 15 November 2021

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WACHS Clinical Escalation of Acute Physiological Deterioration including Medical Emergency Response (MER) Policy



2.1.1 Modifications In keeping with the WA Health Recognising and Responding to Acute Deterioration Policy, modifications to the response criteria can only be made in exceptional circumstances and should only be made by consultants, or by the most senior doctor available in smaller sites. Modifications can only be made following a full review of the patient, and with sound clinical rationale and justification documented. Where a health service is covered utilising a senior doctor whom is remotely on call in a single location or Emergency Telehealth Service, the modification (i.e. written on the front of ORC) may be electronically transmitted via fax, email, or endorsed electronic system e.g. MMeX to the doctor’s location for signing and then faxed back for inclusion in the medical record in accordance with the WA Health Information Security Policy If electronic transmission occurs the hard copy document with the doctor’s original signature MUST be kept at the site from which the doctor authorised the modification.

2.2 Escalation and Medical Emergency Response Procedures

2.2.1 Escalation of Physiologically Deteriorating Patient Each site is to identify the internal and external contacts to assist with any adult, maternal or paediatric escalation and MER procedures. At some sites Medical Review and MER may be via telephone or videoconference e.g. Emergency Telehealth Service. Escalation and MER processes are to be completed for each WACHS clinical site, and each WACHS site providing an emergency service. The processes should be documented using the relevant endorsed templates (See Appendices 1-4).

If at any time, the escalation process is not progressing in a timely manner, the staff member may contact the Regional Director Nursing & Midwifery or Medical Director for advice or assistance.

Remote Area Nurses (RANs) are encouraged to maintain one point of contact and only contact the Medical Officer (MO), Director of Nursing (DON) or Hospital Service Manager (HSM) on call for the site. The MO is responsible for contacting the specialist/s for further advice. RANs and contact MO/DON/HSMs are to make use of conference phone calls where possible, and include specialists and transport service officers in discussions regarding patient management with a view to minimising the number of phone calls and relayed messages required to provide optimal care.

WACHS endorses the Australian and New Zealand Committee on Resuscitation (ANZCOR) guidelines and flowcharts for Basic and Advanced Life Support (Adult, Infants and Children). Refer to Appendices 5-7. WACHS endorses the Women and Newborn Health Service (WNHS) Resuscitation Algorithm for the Newborn. Refer to Appendix 8.





When applied, the information contained in these guidelines must take account of the context and scope of practice, level of service delivery and facility capacity. 2.2.2 Medical Emergency Response A Code Blue emergency call should be placed for all patients with MER criteria (purple zone observations, or red zone on PORC series), airway threat, respiratory or cardiac arrest, sudden fall in consciousness, oxygen saturations ≤ 84%, seizure, unattended medical review or you or a family member are concerned. It must be clear to all team members who the MER team leader is at the beginning of the medical emergency response and thereafter when the leadership role changes.

All MER calls are to be documented on either the – • MR 140 Medical Emergency Response (MER) / Code Blue Record • MR 75B Newborn Medical Emergency Response (MER) Record

The senior nurse is to ensure a MER record form is completed for every MER.

All MER events require a regional process for clinical review, and results should be tabled at appropriate regional committees.

The outcome and events preceding every MER are to be assessed by a senior nurse or medical officer to determine if a clinical incident has occurred. Where a clinical incident is considered to have occurred this is to be reported in the Datix Clinical Incident Management System (CIMS) and investigated in accordance with the WA Health Clinical Incident Policy. 2.2.3 Aishwarya’s CARE Call

Aishwarya’s CARE Call provides patients, their families and carers a way to receive or call for assistance when they feel that the healthcare team has not fully recognised the patient's changing health condition. Aishwarya’s CARE Call supports

established strategies to improve the recognition and response to physiological deterioration. Aishwarya’s CARE Call comprises three steps:

Step one- Reminds the patient, their family or carer to talk to the nurse, midwife or doctor caring for them if they have any concerns about their or their loved one’s health.

Note: there are both paediatric and adult versions of the Aishwarya’s CARE Call materials with tailored wording of Step one.


http://wachs.hdwa.health.wa.gov.au/index.php?id=14808





Step two - Encourages the patient, family member or carer to ask to speak to the shift coordinator, nurse or midwife in charge if they still have concerns and feel that these have not been addressed by their primary carer.

Step three - Provides the ability for the patient, family or carer to make an Aishwarya’s CARE call and speak to a senior staff member if they still have concerns that they do not feel have been adequately addressed. When an Aishwarya’s CARE call is made, a senior staff member should listen to the concerns of the person who made the call and make a full assessment of the patient’s situation, liaising with the treating medical team and other health care providers as required. A decision support flowchart is available to assist staff in managing Aishwarya's CARE Calls they receive. This includes the use of the MR141 WACHS CARE Call Clinical Review Record and a regional log of Aishwarya’s CARE Calls.

Aishwarya’s CARE Call is not intended as a system for consumers to provide general feedback or lodge complaints. Existing consumer feedback systems including consumer feedback leaflets, Care Opinion and complaints processes remain in place and should be actively promoted by WACHS sites, services and regions.

Region-specific promotional materials for Aishwarya’s CARE Call (including both paediatric and adult versions) are available from the WACHS Safety and Quality Recognising and Responding to Acute Deterioration: Aishwarya’s CARE Call Resources intranet page.

2.3 Clinical Area Specific Information/Special Considerations

2.3.1 Maternity and Newborns Maternity and newborn care is a specialised area and is often already staffed by the most appropriate responders to physiological deterioration. Specialist staff are to be contacted immediately in the event of suspected physiological deterioration e.g. on call midwife, on-call obstetric medical officer, paediatric medical officer. For obstetric or newborn emergencies, immediate advice regarding the most appropriate management plan including stabilisation and transfer is available by:

• Contacting the regional obstetrician and/or paediatrician on call • King Edward Memorial Hospital on-call consultant (08) 6458 2222. • Neonatal Emergency Transport Service (NETSWA) 1300 638 792.

WACHS has endorsed the clinical guidelines produced by WNHS including Resuscitation Algorithm for the Newborn, (Appendix 8).


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2.3.2 Paediatric Special considerations for paediatric patients are addressed in the various age appropriate paediatric observation and response charts. The paediatric escalation and MER procedure templates (Appendix 2 and Appendix 4) are aligned with the ‘actions required’ described on the escalation zone criteria section in paediatric charts. WACHS has endorsed the ANZCOR2 guidelines and Advanced Life Support for Infants and Children Flowchart for basic and advanced life support (see Appendices 5 and Appendix 7) to guide practice. 2.3.3 Emergency Department All patients that present to WACHS facilities that provide emergency care will have observations recorded on the WACHS observation and response charts at the time of primary assessment, and no patient should be discharged or transferred from ED with abnormal vital signs without a medical review and a comprehensive management plan which may include modifications and follow up if required. Sites are required to document their escalation and MER processes on the Emergency Department - Adult and Maternity, or Paediatric Observation and Response Escalation and MER templates (Appendix 3 and Appendix 4). Note: The observation and response charts, and escalation and MER process templates are not for use when triaging patients. Refer to WACHS Assessment and Management in the Emergency Department - Clinical Practice Standard. 2.3.4 Mental Health There is overwhelming evidence indicating poor physical health outcomes for people with mental illness.12 It is important to minimise delays in recognising and escalating the patient’s physiological deterioration. This Policy applies to all WACHS mental health patients. Standards for clinical care of mental health patients – inclusive of physical care are outlined in the WA Chief Psychiatrist’s Standards for Clinical Care 2015 (and also covered within the Charter of Mental Health Care Principles). If the patient’s mental health condition is hindering the escalation of their physiological deterioration, consider the following: • use or review of PRN and routine medications • contact:

− the patients treating psychiatrist or − the local mental health team or − RuralLink (Free call 1800 552 002 – [TTY] 1800 720 101).

Certain circumstances concerning deterioration may require incidents to be reported via CIMS Datix or to the Chief Psychiatrist – refer to the Policy for Reporting of Notifiable Incidents to the Chief Psychiatrist - Public Mental Health Services 2018.


https://www.chiefpsychiatrist.wa.gov.au/standards-guidelines/

https://www.chiefpsychiatrist.wa.gov.au/wp-content/uploads/2015/11/OMH-Charter_of_Mental_Health_Brochure.pdf

https://www.chiefpsychiatrist.wa.gov.au/wp-content/uploads/2019/12/Policy-Mandatory-Reporting-Notifiable-Incidents-to-the-Chief-Psychiatrist-Public-Mental-Health-Services-031219.pdf

https://www.chiefpsychiatrist.wa.gov.au/wp-content/uploads/2019/12/Policy-Mandatory-Reporting-Notifiable-Incidents-to-the-Chief-Psychiatrist-Public-Mental-Health-Services-031219.pdf




2.3.5 Theatre, Recovery, Intensive Care Units and High Dependency Units These are specialised areas in which the most appropriate respondents to clinical deterioration are often present, thus it may not always be appropriate to call the MER team. Local escalation plans for the area are to be followed. 2.3.6 Older Person An atypical disease presentation is the most common illness presentation in the elderly. Vague and nonspecific complaints are not to be dismissed as they may be signs of a medical emergency. An acute deterioration of mental state is an early marker of a serious condition. Early recognition and escalation can improve the older person’s health outcomes and reduce rates of co morbidities for treatable geriatric syndromes. If an atypical presentation of illness in an older person, or changes in vital signs are identified, or if staff are concerned about the person, a senior nurse must undertake full assessment and a medical officer must review the person (see Appendix 9).

2.4 Facility Equipment and Systems

2.4.1 Code Blue Alarm System Testing It is a requirement for each region to ensure they have a process for testing of code blue alarm systems at all their facilities on a minimum annual basis, with scheduling of the testing and maintenance to be documented within the Agility Maintenance Database coordinated by Facilities Management.

2.4.2 Refrigerated Medications Resuscitation medications that require refrigeration are to be stored in an appropriate area that is easily accessible in the event of a MER. The team leader is to ensure that these medications accompany the MER team to the patient.

2.4.3 Resuscitation Equipment WACHS Resuscitation Trolley Standardisation lists (Appendix 10) provide the recommended minimum content for MER at all sites. The standardised lists ensure provision in all clinical areas for access to resuscitation equipment and drugs consistent with the ANZCOR Standards for Resuscitation: Clinical Practice and Education 2014, recommendations and suggested equipment.3

• All clinical staff are to be familiar with the location and appropriate use of

resuscitation equipment including competency requirements. This information is to be provided to staff during orientation.

• Portable oxygen and suction must be available, and in good working order • Resuscitation equipment including defibrillator is to be checked by the

nurse/midwife who has the delegated clinical responsibility for the area. Frequency of checking: – As a minimum of daily or after use (except Nursing Posts where checking is to be

once per week). – Every shift where an area/bay is designated for emergency services or critical care,

and staff are rostered on a shift by shift basis in the area.





– Checking of all defibrillators is to occur as per the manufacturer’s guidelines. • Where a problem is identified, the problem and the actions taken are to be

documented. 2.5 Communication and Documentation Ensure accurate documentation in patient notes and use of iSoBAR for all communication including transfer of care to another facility, clinical care coordination team, or with transport providers (e.g. ambulance personnel, RFDS) occurs in accordance with the - • MP0095 Clinical Handover Policy • WACHS Assessment and Management of Interhospital Patient Transfers Policy and

MR184 WACHS Inter-hospital Clinical Handover Form

All MER calls are to be documented on either the: • MR140 WACHS Medical Emergency Response (MER) / Code Blue Record • MR75B WACHS Newborn Medical Emergency Response (MER) Record

Refer to 2.2.2 Medical Emergency Response

3. Definitions

ALS Advanced Life Support Clinical Incident A clinical incident is an event or circumstance resulting from

health care which could have, or did lead to unintended and/or unnecessary harm to a patient/consumer8.

Medical Review The patients admitting doctor, medical team or Emergency Telehealth Service or RFDS reviews the patient, or adequately assesses the patient by phone or videoconference within 30 minutes. The most senior nurse/midwife available must be aware the medical review has been requested.

Code Blue The call code made for a Medical Emergency Response (MER) within the WACHS Emergency (Disaster) Management Policy7 consistent with the Australian Standard AS4083-2010 Planning for emergencies – health care facilities.

Medical Emergency Any event in which trained personnel are required to respond to a medical crisis1. Includes Acute Myocardial Infarction, Sepsis and Stroke

Medical Emergency Response (MER)

The system for providing emergency assistance to patients whose condition is deteriorating. On the Adult Maternal & Newborn Observation and Response Chart (AORC/MORC/NORC) this is represented by the purple section, and on the Paediatric Observation and Response Charts (PORC) this is represented by the red section

Medical Emergency Response Team (MER Team)

The defined team/personnel required to respond to a medical emergency response as defined on the site escalation procedure.





Medical Officer Includes all types of medical officers including District Medical officer (DMO), Health Service Medical Practitioner (HSMP), Senior Medical Practitioner (SMO), Resident Medical Officer (RMO), Registrar, Consultant, Visiting Medical Officer/Practitioner (VMO or VMP), Fellow of the Australasian College of Emergency Medicine (FACEM) or General Practitioner (GP).

Newborn An infant from birth to aged less than 28 completed days. ORC Observation and Response Chart Senior Nurse/Midwife

Depending on the size of the service, this includes the senior nurse / midwife on duty, e.g. shift coordinator; after hours Nurse Manager; Clinical Nurse Manager (CNM); after hours CNM; DON/HSM.

Senior Nurse/Midwife Review

The most senior nurse/midwife available (after hours nurse manager or clinical nurse manager) is to review the patient and, if required contact the medical officer to determine if a clinical review is required.

4. Roles and Responsibilities

Staff Member Responsibilities

Ward Nurse (Enrolled Nurse, Registered Nurse, Registered Midwife)

• Escalate response as per ORC or if concerned. • Escalate response if family and or carer indicate concern. • Communicate effectively with Shift Coordinator • Document observations and escalation of care

appropriately. • Ensure resuscitation trolley nearby if deterioration

identified. • Ensure patient notes and Observation and Response

Charts are available at bedside. • Follow instruction by MER leader and deliver appropriate

care within their scope of practice • Check and re-stock MER equipment daily (weekly for

Nursing Posts) and immediately following use. • Report equipment issues to nursing manager.

Shift Coordinator (may be senior nurse, Remote Area Nurse, nurse practitioner or senior midwife)

• Assess patient. • Communicate to medical officer if medical review is

required. • Initiate MER if need identified and if other staff have not

already done so. • Contact other medical staff as requested by MER leader

(e.g. second MO, obstetrician, anaesthetist, surgeon). • Contact radiology, pathology and theatre team on call as

required/available. • Initiate BLS and ALS (where competent) until MER Team

arrives.





Staff Member Responsibilities

• Communicate patient’s condition, history and progress to MER Team.

• Complete and submit MR140 or MR75B (Newborn) Medical Emergency Response Record

Medical Officers • Provide appropriate medical intervention as required. • Communicate effectively with the other members of the

team. • Ensure adequate post MER follow up or appropriate

escalation of care. MER Team Leader This role is to be performed by the most experienced clinical expert available.

• Ensure that it is clear to all team members who the MER team leader is at the beginning of the medical emergency response and thereafter when this leadership role changes

• Be ALS (adult/paediatric/neonatal as required for the situation) competent and experienced staff member.

• Communicate effectively with all team members. • Identify the tasks or roles required specific to the

emergency. • Identify and notify all available human resources including

ensuring sufficient and suitable medical, nursing and support personnel are called.

• Coordinate and delegate roles in accordance with priority of need and in consideration of skill levels/competency/scope of practice of team members.

• Delegate the retrieval of additional equipment/ medications to an appropriate nursing or other staff member.

• Ensure situational awareness of immediate and surrounding environments including the delegation of care of all other patients to appropriate personnel.

• Maintain a safe working environment Note: If there are perceived issues around the decision to activate a MER, then

these are best discussed during debriefing in a safe environment.

5. Compliance Failure to comply with this policy may constitute a breach of the WA Health Code of Conduct (Code). The Code is part of the Integrity Policy Framework issued pursuant to section 26 of the Health Services Act 2016 (WA) and is binding on all WACHS staff which for this purpose includes trainees, students, volunteers, researchers, contractors for service (including all visiting health professionals and agency staff) and persons delivering training or education within WACHS. WACHS staff are reminded that compliance with all policies is mandatory.

6. Records Management All WACHS records must be stored in the approved Electronic Documents and Records Management System.


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https://www.legislation.wa.gov.au/legislation/statutes.nsf/main_mrtitle_13761_homepage.html




Records Management Policy Health Record Management Policy

7. Evaluation

Governance and evaluation of recognition and response systems, including MER, involves data collection and interpretation at a site, regional and area level. This is to include:

• Audit using the agreed WACHS audit tools available on the WACHS Clinical Audit intranet page to assess the: - documentation of recorded observations, as specified in the patient’s care plan - appropriate recognition and escalation when observations fall into one of the

shaded zones on the observation and response charts

• To evaluate the use of the recognition and response systems, and any failures in these systems, the following investigations are to occur: - All MERs and cardiac arrests for patients without an advance care directive or

an agreed treatment-limiting order (such as Not for Resuscitation) require a full clinical review

- All missed MERs identified through audit require a full clinical review - All missed Medical Reviews identified through audit are to be followed up by

local investigation

• Review of the collated analysis of data from MER record forms every quarter at multidisciplinary meetings, with a summary of findings presented to Regional Safety and Quality Governance Groups

• Senior nurse is responsible for ensuring by audit, that compliance with checking of resuscitation equipment has been met.

8. Standards

National Safety and Quality Health Service Standards Standard 8 - Recognising and Responding to Acute Deterioration Standard National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration WA Chief Psychiatrist’s Standards for Clinical Care 2015

9. Legislation Access via: Western Australian Legislation or Commonwealth legislation. Health Services Act 2016 Carers Recognition Act 2004 Disability Services Act 1993






https://www.safetyandquality.gov.au/wp-content/uploads/2017/11/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

https://www.safetyandquality.gov.au/our-work/recognising-and-responding-deterioration/recognising-and-responding-physiological-deterioration/national-consensus-statement-essential-elements-recognising-and-responding-acute-physiological-deterioration

https://www.safetyandquality.gov.au/our-work/recognising-and-responding-deterioration/recognising-and-responding-physiological-deterioration/national-consensus-statement-essential-elements-recognising-and-responding-acute-physiological-deterioration

https://www.chiefpsychiatrist.wa.gov.au/standards-guidelines/

https://www.legislation.wa.gov.au/

https://www.comlaw.gov.au/Commonwealth




Guardianship and Administration Act 1990 Health Practitioner Regulation National Law (WA) Act 2010 Mental Health Act 2014 Poisons Act 1964 Poisons Regulations 1965 State Records Act 2000

10. References 1. Australian Standard AS4083-2010 Planning for emergencies – health care

facilities 2. Australian and New Zealand Committee on Resuscitation Flowcharts

[Accessed: 13 March 2020] 3. Women and Newborn Health Service (WNHS) Resuscitation Algorithm for the

Newborn [Accessed: 13 March 2020] 4. Australian and New Zealand Committee on Resuscitation (2014) Standards for

Resuscitation: Clinical Practice and Education [Accessed: 13 March 2020] 5. Australian Commission on Safety and Quality in Health Care. National

consensus statement: Essential elements for recognising and responding to acute physiological deterioration (second edition) Canberra Australia. January 2017 [Accessed: 13 March 2020]

6. Australian Commission on Safety and Quality in Health Care. Recognising and Responding to Acute Physiological Deterioration Standard [Accessed: 13 March 2020]

7. WACHS Emergency (Disaster) Management Arrangements Policy 8. WA Health MP0122/19 Clinical Incident Management Policy 2019 9. WA Health MP0095 Clinical Handover Policy 10. WACHS Resuscitation, Education and Competency Assessment Policy 11. WA Health MP0086/18 Recognising and Responding to Acute Deterioration

Policy 12. Stanley, S. & Laugharne, J. (2010). Clinical guidelines for the physical care of

mental health Consumers. Community, Culture and Mental Health Unit, School of Psychiatry and Clinical Neurosciences, The University of Western Australia. Perth: The University of Western Australia. Available from: https://www.chiefpsychiatrist.wa.gov.au/wp-content/uploads/2015/11/Clinical_Guidelines_Physical_Care_MH_Consumers_UWA.pdf [Accessed 18 May 2020].

11. Related Forms

MR140 WACHS Medical Emergency Response / Code Blue Record MR140A Adult Observation & Response Chart AORC MR140B Maternal Observation and Response Chart (M-ORC) MR140D Newborn Observation & Response Chart (N-ORC) MR140E Paediatric Observation and Response Chart (P-ORC - Under 3 Months) MR140F Paediatric Observation and Response Chart (P-ORC - 3 - 12 Months) MR140G Paediatric Observation and Response Chart (P-ORC - 1 - 4 Years)


https://resus.org.au/guidelines/flowcharts-3/



https://www.acccn.com.au/documents/item/165

https://www.acccn.com.au/documents/item/165

https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-consensus-statement-essential-elements-recognising-and-responding-acute-physiological-deterioration-second-edition



https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard

https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard


https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Governance-Safety-and-Quality/Mandatory-requirements/Clinical-Incident-Management-Policy

https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Governance-Safety-and-Quality/Mandatory-requirements/Clinical-Handover-Policy


https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Governance-Safety-and-Quality/Mandatory-requirements/Recognising-and-Responding-to-Acute-Deterioration-Policy


https://www.chiefpsychiatrist.wa.gov.au/wp-content/uploads/2015/11/Clinical_Guidelines_Physical_Care_MH_Consumers_UWA.pdf













MR140H Paediatric Observation and Response Chart (P-ORC - 5 - 11 Years) MR140I Paediatric Observation and Response Chart (P-ORC - 12+ Years) MR141 WACHS CARE Call Clinical Review Record MR149 WACHS Neurovascular Observation Chart MR184 WACHS Inter-hospital Clinical Handover Form MR 75B WACHS Newborn Medical Emergency Response (MER) Record

12. Related Policy Documents

WACHS Assessment and Management of Interhospital Patient Transfers Policy WACHS Assessment and Management in the Emergency Department - Clinical Practice Standard WACHS Adult Airway Management Clinical Practice Standard WACHS Chest Pain and Acute Coronary Syndrome Clinical Practice Standard WACHS Clinical Observations and Assessments Clinical Practice Standard (physiological (vital signs), neurovascular, neurological and fluid balance) WACHS Maternal and Newborn Care Capability Framework Policy WACHS Oxygen Therapy and Respiratory Devices - Adults Clinical Practice Standard WACHS Resuscitation, Education and Competency Assessment Policy WACHS Recognition and Response to Acute Deterioration (RRAD) in the Newborn

13. Related WA Health System Policies

MP0095 Clinical Handover Policy MP0122/19 Clinical Incident Management Policy 2019 MP0086/18 Recognising and Responding to Acute Deterioration Policy MP0067/17 Information Security Policy

14. Policy Framework

Clinical Governance, Safety and Quality

15. Appendices

Appendix 1: Adult and Maternity Observation and Response Escalation and MER

Template Appendix 2: Paediatric Observation and Response Escalation and MER Template Appendix 3: Emergency Department - Adult and Maternity Observation and

Response Escalation and MER Template Appendix 4: Emergency Department - Paediatric Observation and Response

Escalation and MER Template Appendix 5: Basic Life Support Flowchart2 Appendix 6: Advanced Life Support for Adults Flowchart2 Appendix 7: Advanced Life Support for Infants and Children Flowchart2 Appendix 8: Resuscitation Algorithm for the Newborn3

Appendix 9: Clinical Deterioration and Early Response in the Older Person Appendix 10: Resuscitation Trolley Lists




















https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Governance-Safety-and-Quality/Mandatory-requirements/Clinical-Handover-Policy

https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Governance-Safety-and-Quality/Mandatory-requirements/Clinical-Incident-Management-Policy


https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Information-and-Communications-Technology/Mandatory-requirements/Information-Security-Policy

https://ww2.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Governance-Safety-and-Quality




This document can be made available in alternative formats on request for a person with a disability

Contact: Program Manager – Clinical Quality and Performance Directorate: Safety & Quality EDRMS Record # ED-CO-13-52403

Version: 6.00 Date Published: 15 November 2021 Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.





Appendix 1: Adult and Maternity Observation and Response Escalation and MER Template





Appendix 2: Paediatric Observation and Response Escalation and MER Template





Appendix 3: Emergency Department - Adult and Maternity Observation and Response Escalation and MER Template





Appendix 4: Emergency Department - Paediatric Observation and Response Escalation and MER Template





Appendix 5: Basic Life Support Flowchart

Source: https://resus.org.au/guidelines/flowcharts-3/




.



Appendix 6: Advanced Life Support for Adults Flowchart






Appendix 7: Advanced Life Support for Infants and Children





Date of Last Review: October 2021 Page 21 of 32 Date Next Review: October 2026

Effective: XXX Appendix 8: Resuscitation Algorithm for the Newborn

Source: Women and Newborn Health Service Resuscitation Algorithm for the Newborn

Please read in conjunction with WA Addendum



https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/NMAHS/WNHS/Forms%20and%20Templates/NRP%20WA%20Addendum2015.pdf

WACHS Clinical Escalation of Acute Physiological Deterioration including Medical Emergency Response (MER) Policy _____________________________________________________________________________________________________________



Appendix 9: Clinical Deterioration and Early Response in the Older Person

Adult Observation and Response Chart





Appendix 10: Resuscitation Trolley Lists

Recommended Minimum Equipment – Newborns

Refer to the WACHS Maternal and Newborn Care Capability Framework Policy and the relevant Appendices:

• Appendix 5: Emergency Birth Box for non-maternity sites • Appendix 7: Maternal and Newborn Equipment and Medication List (CSF Level

2 +) • Appendix 8: Newborn resus cot checklist (Maternity units only)

Recommended Minimum Equipment lists on the following pages in this appendix:

• Adult MER Trolley • Paediatric and Adult Trolley • Paediatric MER Trolley • Nursing Post/Small Centre MER Pack






Recommended Minimum Equipment – Adult MER Trolley

Top of Trolley: Quantity Defibrillator 1

• ECG Leads attached 1 Set • Defibrillation pads attached 1 Set

IV Pole 1 Sharps Container Small 1 Bag-Valve Mask - Adult 1 Pressure Bag 1000ml 1 Goggles 2 Glucometer 1 Non Sterile Gloves box Small, Medium, Large 1 Each Calculator 1 Stethoscope 1 Right Side of Trolley: Quantity C-Size oxygen cylinder with oxygen nipple attached 1 Twin-o-vac suction unit with suction tubing & Yankauer sucker attached 1 Hudson mask Adult 1 Each Nasal Prongs Adult 1 Oxygen tubing 1 Nebuliser mask Adult 1 Left side of Trolley Quantity MR 140 Medical Emergency Response (MER)/Code Blue Record 2 Resus Trolley check list (Clip board) 1 ANZCOR Advanced Life Support for Adults Flowchart laminated 1 Draw 1: Drugs Quantity Adrenaline 1:1000/1ml 10 Adrenaline 1:10 000/10ml 5 Amiodarone 150mg/3ml 3 Atropine 600mcg/ 1ml 5 Adenosine 6mg/ 2ml 6 Aspirin 300mg 2 Calcium Gluconate 10ml 1 Glucose 25g in 50ml (50%) 1 Bottle Glucose 5% in 100ml 1 Bottle Glycerine Trinitrate S/L 1 Bottle Ipratropium 500mcg/2.5ml Nebules 2 Midazolam 5mg/5ml 2 Magnesium Sulphate 10mmol/5ml 2 Naloxone 400mcg/1ml 2 Normal Saline 10ml 10 Salbutamol Nebules 5mg/2.5ml 2 Water for Injection 10ml 4 Sodium Bicarbonate 8.4g/100ml 1 Bottle Alcohol swabs 10 Chlorhexidine swabs 2 ABG Syringe 2 Syringe 2, 5, 10, 20ml 5 each Syringe 50ml Luer Lock 1 Blunt Drawing up needle 18G 5





Draw 2: Simple Airway/ IV Quantity Non Rebreather Mask 1 Hudson Mask 1 Elastic bandage 1 Blood sample bottles Green, Purple, Blue 1 Each Blood Culture Bottles 1 Blood transfusion set 1 IVC 14, 16, 18,20G 3 Each IVC Dressing pack 1 IV Dressing Adult 5 IV Fluids administration/giving set 1 IV 3 Way taps 2 Micropore tape 1 Needle free bungs 3 Needles 21, 23 & 25G 5 Each Primary Pump (hand pump) IV infusion set 1 Pulse oximeter 1 Tourniquet 1 Yankauer Sucker 1 Draw 3: Advanced Airway/ Intubation Quantity Laryngoscope handle 1 Laryngoscope blade Mackintosh (Standard & Long) size 3 & 4 1 Each Batteries AA 6 Batteries C 2 Bougie 10Fr 1 Cobbs connector 1 CO2 Filter 1 CO2 Detector 1 Cotton ETT Tape 20 ETT Cuffed size 6, 6.5, 7.0, 7.5, 8, 8.5 & 9 1 Each Face masks for Bag-Valve Mask Size 4 & 5 1 Each LMA size 3, 4, & 5 1 Each Lubricant Sachet 5 Magill’s forceps 1 Nasogastric Tube10 & 12Fr 1 Each NPA Size 32 & 34G 1 Each OPA Size 3, 4 & 5 1 Each Stylet 10 & 14Fr 1 Each Suction Catheters 12 & 14Fr 1 Each Pen Torch 1 Draw 4: IV Fluids/ Intraosseous Quantity Normal Saline 0.9% 1000ml bag 1 Compound Sodium Lactate 1000ml bag 1 Glucose 5% 100ml bag 1 IIntraosseous Tray Intraosseous insertion device 1 Intraosseous needles 25mm, 45mm 2 each Chlorhexidine swab 5 IVC dressing pack 1 IV Extension tubing 25cm 2 Syringe 50ml Luer Lock 1 Needle free bung 1 Draw 5: Miscellaneous Quantity ECG Monitoring Dots 1 Packet Defibrillator printing paper 1 Refill Defibrillator Pads 1 Set Drug/Plain Labels 1 Roll





Recommended Minimum Equipment –Paediatric and Adult Trolley Top of Trolley: Quantity Defibrillator 1

• ECG Leads attached 1 • Defibrillation pads attached - Adult • Defibrillation pads >15kg • Defibrillation pads <15kg

1 set Each

IV Pole 1 Trauma Scissors 1 Sharps Container Small 1 Bag Valve Mask with size 4 Facemask attached 1 Bag Valve Mask- Paed 500ml with size 2 Facemask attached 1 Bag Valve Mask - Neonate 250ml with size 1 Facemask attached 1 Pressure Bag 500ml 1 Goggles 1 Glucometer 1 Non Sterile Gloves box - Small, Medium, Large 1 Calculator 1 Stethoscope 1 Right Side of Trolley: Quantity C-Size oxygen cylinder with oxygen nipple attached with Adult Hudson Mask attached 1 Twin-o-vac suction unit with suction tubing & Yankauer sucker Adult attached 1 Nasal Prongs Adult & Paediatric 1 Oxygen tubing 1 Nebuliser mask Adult & Paediatric 1 Left side of Trolley Quantity MR 140 Medical Emergency Response (MER)/Code Blue Record 2 Resus Trolley check list (Clip board) 1 ANZCOR Advanced Life Support for Adults & Advanced Life Support for Infants and Children Flowcharts laminated

1 Each

Paediatric Drug dose reference i.e. Broselow tape, Monash Drug book, Kidshealthwa Guidelines

1

Draw 1: Drugs Quantity Adrenaline 1:1000 10 Adrenaline 1:10 000 5 Amiodarone 150mg/3ml 3 Atropine 600mcg 5 Adenosine 6mg/2ml 6 Aspirin 300mg 2 Calcium Gluconate 10ml 1 Glucose 25g in 50ml (50%) 1 Bottle Glucose 10g in 100ml (10%) 1 Glucose 5% in 100ml 1 Bottle Magnesium Sulphate 10mmol/5ml 2 Naloxone 400mcg 2 Normal Saline 10ml 10 Sodium Bicarbonate 8.4g/100ml (8.4%) 1 Bottle Alcohol swabs 10 Chlorhexidine swabs 2 ABG Syringe 2 Syringe 2, 5, 10, 20ml 5 each Syringe 50ml Luer Lock 1 Blunt Drawing up needle 18G 5





Draw 2: Simple Airway/ IV Quantity Elastic bandage 1 Blood sample bottles Green, Purple, Blue - Adult & Paediatric 1 Each Blood Culture Bottles Adult & Paediatric 1 Blood transfusion set 1 IVC 14, 16 18, 20G, 22, 24G 3 each IVC Dressing pack 1 IV Dressing Adult & Paediatric 5 IV Fluids administration set 1 IV 3 Way tapes 2 Micropore tape 1 Needles 19, 21, 23, 25G 5 Each Needle free bungs 3 Primary Pump IV infusion set 1 IV Burette Paediatric 1 Pulse oximeter 1 Tourniquet 1 Draw 3: Advanced Airway/ Intubation Quantity Laryngoscope handle 1 Laryngoscope blade Macintosh- Standard & Long size 3 &4 1 each Batteries AA 6 Batteries C 2 Bougies 5 & 10Fr 1 Each Cobbs connector 1 CO2 Filter 1 CO2 Detector Easy Cap Adult & Paediatric 1 Each Face masks for Bag Valve mask 00,1,2, 3 & 5 1 Each Lubricant Sachet 5 Magills forceps Paediatric & Adult size 1 Nasogastric Tubes Size 6, 8, 10, & 12Fr 1 Each Suction Catheters 6, 8, 10, 12 & 14Fr 1 Each Pen Torch 1 Draw 4: IV Fluids/ Intraosseous/Miscellaneous Quantity Glucose 10% 500ml 1 Glucose 5% 100ml bag 1 Normal Saline 0.9% 500mls 1 Compound Sodium Lactate 1000ml bag 1 I/O Tray Quantity Intraosseous insertion device (drill) 1 Intraosseous needle 15mm, 25mm, 45mm, 2 each Chlorhexidine Swab 2 IVC Dressing pack 1 IV Extension tubing 25cm 1 Syringe 50ml Luer Lock 1 Needle free bung 1 Miscellaneous Quantity ECG Monitoring Dots - Adult & Paediatric 1 Packet Defibrillator printing paper 1 Refill Defibrillator Pads- spare Adult, <15kg, >15kg 1 Set Drug/Plain Labels 1 Roll





Draw 5: Paediatric Equipment Quantity Hudson mask Paediatric 1 each Nebuliser mask Paediatric 1 Nasal Prongs Paediatrics 1 Non Rebreather Mask Paediatric 1 Yankauer Sucker Paediatric 1 Laryngoscope short handle 1 Elastoplast tape 2.5cm 1 CO2 Detector Pedi Cap 1 each Tongue depressors 5 Blood Culture Bottles Paediatrics 1 IVC 18, 20, 22, 24 G 3 each IV Butterflies 21, 23, 25G 2 Each IV Dressing Paediatric 5 IV Arm board Neonate/Paediatric 1 Each IV Burette Paediatric 1 Stethoscope Paediatric 1 3-5kg Quantity Oropharyngeal Airway (OPA) Size 000, 00, 0 1 Each Nasopharyngeal Airway (NPA) 14Fr 1 Laryngeal Mask Airway (LMA) size 1 1 Stylet 5Fr 1 Endotracheal Tube (ETT) uncuffed 2.5 & 3 1 Each Miller Laryngoscope blade size 0 & 1 1 Each 6-11kg Quantity OPA Size 0, 1 1 Each NPA 14, 18Fr 1 Each LMA Size 1.5, 2 1 Each Stylet 5Fr 1 ETT uncuffed Size 3.5 & cuffed size 3, 3.5, 4 1 Each Miller Laryngoscope blade size 1 1 12-23kg Quantity OPA Size 1, 2 1 Each NPA 20, 22Fr 1 Each LMA Size 2, 2.5 1 Each Stylet 10Fr 1 ETT Cuffed size 4, 4.5, 5, 5.5 1 Each Mackintosh Laryngoscope Blade size 1 & 2 1 Each 24-42kg Quantity OPA Size 3 1 NPA 22, 24Fr 1 LMA Size 2.5, 3 1 Stylet 10Fr 1 ETT Cuffed size 5, 5.5, 6, 6.5, 7 1 Each Mackintosh Laryngoscope Blade size 2 & 3 1 Each





Recommended Minimum Equipment – Paediatric MER Trolley Top of Trolley: Quantity Defibrillator 1

• ECG Leads attached 1 set • Defibrillation pads attached >15kg 1 Set • Defibrillation pads <15kg 1 Set

Trauma Scissors 1 IV Pole 1 Sharps Container Small 1 Bag- Valve Mask- Adult- size 4 face mask attached 1 Bag- Valve Mask- Paed 500ml- size 2 face mask attached 1 Bag- Valve Mask- Neonate 250ml- size 1 face mask 1 Pressure Bag 500ml 1 Goggles 1 Glucometer 1 Non Sterile Gloves box Small, Medium, Large 1 Each Calculator 1 Stethoscope 1 Right Side of Trolley: Quantity C-Size oxygen cylinder with oxygen nipple attached 1 Twin-o-vac suction unit with suction tubing & yankauer sucker attached 1 Hudson mask Paediatric 1 Nasal Prongs Paediatric 1 Oxygen tubing 1 Nebuliser Mask Paediatric- 3 sizes 1Each Left side of Trolley Quantity MR 140 Medical Emergency Response (MER)/Code Blue Record 2 Resus Trolley check list (Clip board) 1 ANZCOR Advanced Life Support for Infants and Children Flowcharts laminated 1 Paediatric Drug dose reference i.e. Broselow tape, Monash Paediatric Emergency Book or kidshealthwa (PMH) Resuscitation Guideline

1

Draw 1: Drugs Quantity Adrenaline 1:1000/1ml 10 Adrenaline 1:10 000/10ml 5 Amiodarone 150mg/3ml 3 Atropine 600mcg/1ml 5 Adenosine 6mg/2ml 6 Calcium Gluconate 1g/10ml 1 Glucose 10g in 100ml (10%) 1 Glucose 25g in 50ml (50%) 1 Bottle Glucose 5% in 100ml 1 Bottle Ipratropium Bromide 500mcg/2.5ml Nebules 2 Midazolam 5mg/5ml- leave on to align with other trolleys 2 Magnesium Sulphate 10mmol/5ml 2 Naloxone 400mcg/1ml 2 Normal Saline 10ml 10 Sodium Bicarbonate 8.4g/100ml (8.4%) 1 Bottle Salbutamol Nebules 2.5mg/2.5mls & 5mg/2.5mls trolleys 2 Each Alcohol swabs 10 Chlorhexidine swabs 2 ABG Syringe 2 Syringe 2, 5, 10, 20ml 5 each Syringe 50ml Luer Lock 1 Blunt Drawing up needle 18G 5





Draw 2: Simple Airway/ IV Quantity Oxygen masks size 4 & 5 1 Non Rebreather Mask Paed 1 Elastic bandage 1 Blood sample bottles Green, Purple, Blue- Paediatric 1 Each Blood Culture Bottles Paediatrics 1 Blood transfusion set 1 set IVC 18,20, 22, 24 G 3 each IV Butterflies 21, 23, 25G 2 Each IVC Dressing pack 1 IV Dressing Paediatric 5 IV Arm board Neonate & Paediatric 1 Each IV Fluids administration set 1 IV Burette Paediatrics 1 IV 3 Way taps 2 Micropore tape 1 Needles 19, 25G 5 Each Needle free bungs 3 Pulse oximeter 1 Tourniquet 1 Yankauer Sucker - Paediatric & Adult size 1 Draw 3: Advanced Airway/ Intubation Quantity Laryngoscope short handle 1 Batteries AA 6 Batteries C 2 Bougies 5 & 10Fr 1 Each Cobbs connector 1 CO2 Filter 1 CO2 Detector Pedicap & Easy Cap 1 each Elastoplast tape 2.5cm 1 Face masks for Bag Valve Mask Size 00, 1, 2, 3, & 4 1Each Lubricant Sachet 5 Magill’s forceps- neonatal, paediatric & adult 1 Nasogastric Tubes Size 6, 8, 10, & 12Fr 1 Each Suction Catheters 6, 8, 10, 12 & 14Fr 1 Each Tongue depressors 5 Pen Torch 1





Recommended Minimum Equipment – Nursing Post/Small Centre MER Pack

Equipment (Top of Trolley or external to Pack) Quantity Automated External Defibrillator 1

• Defibrillation adult pads - attached 1 Set • Defibrillation paediatric pads (easily accessible next to it) 1 Set

IV Pole 1 Trauma Scissors 1 Sharps Container Small 1 Bag- Valve Mask Adult with size 4 Face Mask attached 1 Bag- Valve Mask Paediatric 500ml with Size 2 Face Mask attached 1 Bag- Valve Mask-Neonate 250ml with Size 1 Face Mask attached 1 Pressure Bag 500ml 1 Goggles 1 Glucometer 1 Non- Sterile Gloves box- Small, Medium, Large 1 Each Calculator 1 Stethoscope 1 (Right Side of Trolley or external to pack): Quantity Portable suction/ C-Size oxygen cylinder with oxygen nipple attached 1 Twin-o-vac suction unit with suction tubing & Yankauer Sucker attached 1 Hudson mask Adult & Paediatric with Oxygen tubing attached 1 Each Nasal Prongs Adult & Paediatric 1 Each Nebulizer Masks Adult & Paediatric 1 Each (Left side of Trolley or within pack) Quantity MR 140 Medical Emergency Response (MER)/Code Blue Record 2 Resus Trolley check list (Clip board) 1 ANZCOR Advanced Life Support for Adults & Advanced Life Support for Infants and Children Flowcharts laminated

1 Each

Paediatric Drug dose reference i.e. Broselow tape, Monash Paediatric Emergency Book or kidshealthwa (PMH) Resuscitation Guideline

1

(Draw 1: Drugs or in Drugs box in pack) Quantity Adrenaline 1:1000/1ml 10 Adrenaline 1:10 000/10ml 5 Amiodarone 150mg/3ml 3 Adenosine 6mg/2ml 6 Aspirin 300mg 2 Atropine 600mcg/1ml 5 Calcium Gluconate 10ml 1 Glucose 10g in 100ml (10%) 1 Glucose 25g in 50ml (50%) 1 Glycerine Trinitrate S/L 1 Bottle Ipratropium Nebules 500mcg/2.5ml 2 Magnesium Sulphate 10mmol/5ml 2 Naloxone 400mcg/ 1ml 2 Water for injection 10ml 4 Normal Saline 10ml 10 Sodium Bicarbonate 8.4g/100ml (8.4%) 1 Bottle Salbutamol Nebules 5mg/2.5ml 2 Alcohol swabs 10 Syringe 2, 5, 10, 20 5 Each Syringe 50ml Luer Lock 1 Blunt Drawing up needle 18G 5





(Draw 2: Simple Airway/ IV or within pack) Quantity Non Rebreather Mask Adult &Paediatric 1 Each Hudson Mask Adult & Paediatric 1 Each Elastic bandage 1 Blood sample bottles Green, Purple, Blue adult & paediatric 1 Each Blood Culture Bottles adult & paediatric 1 set Blood transfusion set 1 IVC 14, 16, 18,20, 22 & 24G 3 Each IVC Dressing pack 1 IV Dressing Adult/Paediatric 5 Each IV Fluids administration set 1 IV 3 Way tap 1 Micropore tape 1 Needle free bungs 3 Needles 19, 21, 23 & 25G 5 Each Primary Pump IV infusion set 1 IV Burette paediatric 1 Tourniquet 1 Yankauer Sucker Adult & Paediatric 1 Each (Draw 3: Advanced Airway/ Intubation or within Pack) Quantity Laryngoscope handle 1 Laryngoscope blade Mackintosh size 0, 1, 2, 3 & 4 1 Each Bougie 5, 10Fr 1 Each Cobbs connector 1 CO2 Detector, Adult & Pedicap 1 Each Cotton ETT Tape 20cm 1 ETT Uncuffed size 2.5, 3, 3.5 Cuffed 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7.0, 7.5, 8, 8.5 & 9 1 Each Face masks for BVM Size 00,1, 2, 3 & 5 1 Each LMA size 1.5, 2, 2.5, 3, 4, & 5 1 Each Lubricant Sachet 2 Magill’s forceps Adult & Paeds 1Each Nasogastric Tube 6, 8, 10 & 12Fr 1 Each NPA Size 14, 18, 20, 22, 24, 32 & 34G 1 Each OPA Size 000, 00, 0, 1, 2, 3, 4 & 5 1 Each Stylet 10 & 14Fr 1 Each Suction Catheters 6, 8, 10, 12 & 14Fr 1 Each Pen Torch 1 Draw 4: IV Fluids/ Intraosseous/Miscellaneous Quantity Normal Saline 0.9% 1000ml bag 1 Compound Sodium Lactate 1000ml 1 Glucose 5% 100ml bag 1 I/O Tray Intraosseous Insertion device (drill) 1 I/O Needle 15mm, 25mm & 45mm 2 Each Chlorhexidine Swab 2 IVC Dressing Pack 1 IV Extension tubing 25cm 2 Needle free bung 1 Syringe 50ml Luer Lock 1 Draw 5: Miscellaneous ECG monitoring dots 1 Packet Defibrillator printing paper 1 Refill Drug/Plain Labels 1 set Defibrillator Adult and Paediatric Pads - Spares 1 set

each
