Download Introduction

File 6 introduction
Introduction
The Primary Clinical Care Manual 6th edition has been developed and reviewed according
to the principles set out by the National Health and Medical Research Council [1]. The
clinical care guidelines and Health Management Protocols (HMP) contained in the 6th
edition are based on the current evidence as applied to rural and remote practice settings.
While the Primary Clinical Care Manual is aimed at rural and isolated practice setting
facilities there needs to be an awareness of the patients’ condition, the capacity of the
facility to provide the required care and the level of clinical skills required to meet the
patients’ needs. Medical Officers must be aware of the Clinical Services Capability of the
facilities in which they work / cover. Refer to Clinical Services Capability Framework
http://qheps.health.qld.gov.au/pcb/cscfv2_home.htm and Credentialing and Defining the
Scope of Clinical practice for Medical Officers in Queensland www.health.qld.gov.au.
The Primary Clinical Care Manual 6th edition complies with the Health (Drugs and
Poisons) Regulation 1996 for registered nurses, Aboriginal and Torres Strait Island health
workers, midwives, paramedics and nurse practitioners who work in rural hospitals and
isolated practice areas as set out in Appendix 5, 8a and 9 of the Health (Drugs and
Poisons) Regulation 1996 and sexual and reproductive health endorsed registered nurses
and health workers and immunisation program registered nurses and health workers.
How to use the Primary Clinical Care Manual
The Primary Clinical Care Manual 6th edition has 6 sections
1. Patient assessment and transport
2. Emergency care
3. General care
4. Mental Health and substance use
5. Sexual and Reproductive Health
6. Paediatrics care
 Health
This symbol is used to identify HMP (which contain Drug Therapy
Management
Protocols [DTP]). It designates HMP in the title and index and
Protocol (HMP)
distinguishes a HMP from Clinical Care Guideline.
HMP’s set out the approved conditions and restrictions applying to
the administration and supply of drugs listed in each DTP.
Non DTP drug boxes are shaded to separate them from DTP
Clinical Care
Follow the same format as HMP’s. They may contain
Guidelines (CCG)
recommended medication but do not contain DTP
Recommend
Identifies recommendations or reminders on the care of the
patient for that condition
Background
Incudes relevant definitions / terminology / epidemiology
information
Related topics:
Identifies other HMP’s / CCG relevant to the condition the patient
is presenting with for consideration
HMP / CCG are set out according to the requirements of the Health (Drugs and Poisons)
Regulation 1996. Numbering has been introduced in the 6th edition
1. May present with
Some of the presenting signs and symptoms that the patient may
experience
2. Immediate
Urgent, life saving measures that may be required
management
3. Clinical
The details are outlined in the patient assessment and physical
assessment
examination (adult and child) at the beginning of this manual.
For each patient presentation clinicians are required to

Take a patient history
File 6 introduction


4. Management
5. Follow-up
6. Referral /
Consultation
Perform standard clinical observations
Perform physical examination
Outlines measures in collaboration with colleagues (who may be
consulted by telephone) to meet the needs of the patient and their
presenting condition
Care at the primary level requires follow-up / monitoring to ensure
clinical improvement and not deterioration is occurring
Patients may require evacuation / hospitalisation in a regional
facility to meet their care needs, or referral to visiting Specialists
1. Health (Drugs & Poisons) Regulation 1996
Authorisation to administer and / or supply in designated practice area

Registered nurses (not endorsed)
 may administer an S2 or S3 poison to a patient without a doctors instruction
 must have a doctor or nurse practitioner instruction to administer an S8 or S4
drug
 registered nurses working in Isolated Practice Areas who do not have the
endorsement required to use a DTP must have a doctor or nurse practitioner
instruction to supply an S8, S4 and / or S 2 and S3 drugs
 the director of nursing of a rural hospital, or a registered nurse nominated by the
director of nursing, may supply an S8 or S4 drug or S2 or S3 poison, on the
instruction of a doctor. However, supply of these scheduled medications can
only occur in instances where the rural hospital does not employ a pharmacist
or, if the rural hospital employs a pharmacist, the pharmacist is absent from the
hospital at the time the medication(s) is/are supplied

Endorsed registered nurses i.e. the registered nurse has successfully completed
an accredited course and has been endorsed by the Queensland Nursing Council
(QNC). They must follow the situations and conditions outlined in the DTP for
administration and supply of medication
 rural and isolated practice nurse (RIN), practicing in an isolated practice area
or rural hospital as defined in the Health (Drugs and Poisons) Regulation 1996,
may as part of the persons nursing duties, administer or supply the S8, S4 listed
under the DTP conditions contained in the protocol
 sexual and reproductive health registered nurse (SRH), employed in a
sexual or reproductive health program may as part of the person’s duties, supply
or administer the S4 and supply the S2 and S3 poisons listed under the DTP
conditions
 immunisation program nurse (IPN), practicing in an approved immunisation
program may, as part of the person’s duties, administer the S4 drugs listed in the
DTP under the conditions contained in the protocol

Nurse practitioner (NP), may prescribe, give a written or oral instruction, supply and
administer the S8 and S4 drug(s) contained within the Queensland List of Approved
Medicines (LAM), under the conditions contained in the DTP

Midwife, endorsed midwife (MID), may as part of the person’s midwifery duties,
supply or administer the S4, S8 listed under the DTP conditions

Ambulance Officer, for authorisation under the DTP, Isolated Practice Area
Paramedics (IPAP) must successfully complete an approved course and have
approval by Queensland Ambulance Service. An IPAP working in an isolated
practice area as defined in the Health (Drugs and Poisons) Regulation 1996 may, as
part of the person’s ambulance duties administer or supply the S4, S8 and S2 and S3
poisons listed on a Medical Officer’s instruction, unless otherwise stated
 Isolated Practice Area Paramedics (IPAP)
File 6 introduction

Health Worker, authorised Aboriginal and Torres Strait Islander Health Workers
practising in an Aboriginal and Torres Strait Islander community in an Isolated
Practice Area in a specified health service district, as part of the Aboriginal and
Torres Strait Islander Health Workers duties may administer S8, administer or supply
S4, S2, S3 listed in Appendices 1, 2,3 and 4, under the conditions of the DTP
 Aboriginal and Torres Strait Islander (Indigenous) Health Worker Isolated
Practice Area (IHW)
Health (Drugs & Poisons) Regulation 1996 - requires a drug therapy protocol (DTP)
2. Drug Therapy Protocol (DTP)

Is certified by the chief executive and governed by the DTP committee
(Environmental Health branch Queensland Health)

It applies to – individual health professionals who have endorsement / authorisation
under the Health (Drugs & Poisons) Regulation 1996

It contains a list of drugs that have been approved for use and states the
circumstances (conditions and restrictions) under which the drugs can be used
Conditions of the Drug Therapy Protocol

Authority to practice

Requirement for a Health Management Protocol (HMP)

Development of HMP

Content of HMP

Endorsement and renewal of HMP – 2 years

Responsibility of professionals with DTP endorsement

Appendix listing all approved drugs with the respective conditions / restrictions
Endorsed / authorised health professional’s (licensed or unlicensed) practicing
under a DTP is required to possess:

A copy of their DTP

Health Management Protocol (HMP) relevant to their DTP (for nurse
practitioners “and the nurse practitioners area of practice”). The Primary
Clinical Care Manual fulfils this criterion.

A current Australian Prescription Product guide and / or current MIMS
Annual

A copy of the Health (Drugs and Poisons) Regulation 1996

A current edition of the NHMRC Australian Immunisation Handbook
3. Health Management Protocol (HMP)

Is a clinical protocol that supports and details the clinical use of the drug for the
patient condition

The content of the HMP’s contained in the Primary Clinical Care Manual is governed
by the editorial review committee (RFDS and QH)

Involves peer review and best practice review of each clinical condition and indication
for medication use

Must be endorsed by District CEO as per DTP
Drug Therapy Protocols and Health Management Protocols are inextricably linked and are
required under the Queensland Health (Drugs and Poisons) Regulation 1996
DTP + HMP = drug management legislation + patient condition management
File 6 introduction
DTP (Drug Therapy Protocol), IHW (Indigenous Health Worker),
IPAP (Isolated Practice Area Paramedic, RIN (Rural & Isolated
Practice Endorsed RN), SRH (Sexual & Reproductive Health
Endorsed RN), NP (Nurse Practitioner)
Chloramphenicol
DTP IHW/RIN/NP/IPAP
(eye drops and ointment)
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must
consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Recommended
Form
Strength
Route of Administration
Duration
Dosage
Ointment
1%/4 g
Topical to eye
Nocte
5 days
1-2 drops every 2-4
Drops
0.5%/10 mL
As above
As above
hrs
Provide Consumer Medicine Information if available: Advise the patient to store the drops in
the fridge
Management of Associated Emergency: Consult MO
Schedule
4
4. Professional bodies

Define the scope of practice

Accreditation of education provider and courses in accordance with the Nurses Act
1992, Medical Practitioners Registration Act 2001, etc

Professional statement – responsibility and accountability in expanded role
5. Collaborative practice framework

Different authorisations (eg IHW vs Paramedics)

Clearly sets out the boundaries / scope of practice for individual health care providers
(dependent on endorsement / authorisation) and when to escalate / refer to Medical
Officer. Medical Officer to refer to more experienced practitioner
Process for approval of HMP at the Health Service District level
Distribution of Controlled A4 PCCM to designated Rural Hospitals and Isolated
Practice Areas as set out in Health (Drugs and Poisons) Regulation 1996

The use of the HMP must be supported at the District level by a interdisciplinary
health team (eg. District Executive) consisting of at least Medical Practitioner,
Registered Nurse and Pharmacist who must recommend use of the PCCM in the
Health Service District

The Health Service District Executive Officer must endorse the use of all HMP’s and
amendments in the District

Once endorsed the PCCM applies to all Rural Hospitals and Isolated Practice Areas
within the Health Service District
File 6 introduction
What’s new in the 6th edition?
Penicillin Benzathine (Pan Benzathine) drug boxes have been removed as stocks of
Penicillin Benzathine (LA Penicillin) restored to Australia
Paracetamol and Paracetamol / Codeine drug boxes on back cover to allow for ease of
reference
Metoclopramide – not for use in patients with Parkinson’s disease or children and caution
in use in women less than 20 years of age
Normal clinical observation ranges adult and child
 Pain management for inter-facility transfer (adult only)
New HMP
Emergency section
Intranasal Fentanyl for pain relief in children
 Anaphylaxis and severe allergic
Mild and moderate allergic reaction has been
reaction
included in the General section
 Fits/ convulsions / seizures
Midazolam now medication of choice – use
intranasal, buccal, IMI or IVI
Epistaxis
Sucking ice has been removed from the
management as there is no evidence to support
this
 Acute hypertensive crisis
Sublingual Glyceryl Trinitrate (GTN) added
Nifedipine removed
Subarachnoid haemorrhage
New clinical care guideline
Drowning
“Near drowning” term no longer used
Chest pain (Acute coronary
Modified in line with Addendum to the NHF
syndrome, unstable angina,
“Guidelines for the management of acute coronary
myocardial infarct)*
syndrome” 2007
Acute pulmonary oedema
Name changed from Acute left ventricular failure /
heart failure for ease of recognition
 Compartment syndrome
New HMP
 Renal colic
New HMP
Bites and stings
Alternative procedure for removal of ticks
 Box jellyfish antivenom
IMI route removed as recent evidence does not
support this route
 Irukandji syndrome
New HMP
Poisons and drug emergencies
Overdose of Valproic acid (sodium valproate) has
been added
General section
 Mild and moderate allergic
New HMP
reaction
 Acute and chronic headache
New HMP moved from mental health section
Trauma to teeth
Clindamycin recommended if allergic to Penicillin
Eye problems
Routine padding of the eye not recommended
 Flash burn to eye
Oxybuprocaine eye drops added
 Chemical burn to eye
Oxybuprocaine eye drops added
Conjunctivitis
New management - use a separate box of tissues
for cleaning the eye and then give box of tissues
to patient to take home in order to decrease risk of
cross infection
 Chronic asthma (adult and child)*
New HMP
Mental health section
This section has been reformatted
Delirium
New clinical care guideline
File 6 introduction
Dementia
Alcohol
Smoking
Sexual and reproductive health
Management of women with type 1,
type 2 and gestational diabetes
Protocol for commencing insulin in
pregnancy
Normal labour and birth*
 Pregnancy induced hypertension
(PIH)
 Group B streptococcal
Prophylaxis*
Preterm pre-labour rupture of
membranes*
 Suppression of preterm labour
 Rh D Immunoglobulin
Contraception
Paediatric section
Alerts on when to consult MO
 Acute Rheumatic Fever and
Rheumatic Heart Disease
Ear problems
Acute gastroenteritis and
dehydration*
 Bone or joint infections
New clinical care guideline
NHMRC recommendations 2009
AUDIT questionnaire removed
Identified need for caution in patient who is taking
clozapine and suddenly ceases smoking
New flowcharts
New protocol
Partogram showing normal and slow progress of
labour
Previously named  Pre-eclampsia
New HMP
Previously named Prelabour rupture of membranes
Nifedipine fist line management + increase in
Nifedipine dose from 10mg to 20mg
GTN patches added
New HMP
WHO medical eligibility criteria for contraceptive
use categories added
New recommendations added
Use erythromycin for people with documented
allergy to penicillin
Ciprofloxcin ear drops available for use in
Aboriginal and Torres Strait Islander patients
Cholesteatoma added
Procedure for insertion of naso-gastric tube added
Previously named Osteomyelitis and septic arthritis
*Root cause analysis recommendation
Use of standing orders in areas designated as rural and isolated practice settings per the
Health (Drugs and Poisons) Regulation 1996 should not conflict with the HMP / DTP
contained in the Primary Clinical Care Manual.
Referencing occurs throughout the text and is designated by numbers in brackets [ ].
References
1.
National Health and Medical Research Council, A guide to the development,
implementation and evaluation of clinical practice guidelines. 1999, Commonwealth of
Australia: Canberra.