Policies and procedures





					Policies and Procedures Infection Control Policy We have an appointed Infection Control Officer. The Infection Control Officer is provided with sufficient resources and opportunities to further develop their knowledge and skills to improve the standards of practice in infection control. In accordance with the Gastroenterological Nurses College of Australia infection control guidelines, the Infection Control Officer has developed written guidelines for asepsis, disinfection, housekeeping techniques, and the safe disposal of sharps and monitoring of endoscopy procedures. The Infection Control Officer is a member of the Quality Assurance committee. All infection control procedures comply with the guidelines set down by National Health and Medical Research Council, the Gastroenterology Society of Australia, Gastroenterological Nurses College of Australia and Australian Bureau of Standards. Instrument reprocessing procedure Particular attention is paid to the effective cleaning and disinfection of the endoscopes and re-usable accessories used in our procedures. The instruments are thoroughly cleaned by fully trained Registered Nurses who follow a strict protocol. All endoscopes are then subjected to high-level disinfection using glutaraldehyde that is controlled for concentration, temperature and time. This disinfection usually takes place in an automated disinfection device (Medivator), but can also be performed manually in a fume cupboard. All re-usable accessories are autoclave sterilised with appropriate monitoring. Emergency Policy Written agreement has been obtained from nearby hospitals to transfer patients in an emergency situation. A fully equipped emergency trolley, including instrumentation for cardiac monitoring and resuscitation and appropriate drugs is maintained at each facility and routinely checked by a registered nurse. Documentation of checking is kept as part of the quality assurance program. All medical and nursing staff receive regular ongoing training in resuscitation to maintain their skills. Emergency flip charts are displayed at all key telephones and/or areas that are appropriate for easy access. A copy of the Emergency Procedure policy is available in Reception and Word Processing, while a copy of the Medical Emergency Procedure policy is in the Nursing Practice Manual. All staff are made aware of these policies during orientation and are encouraged to familiarise themselves with them regularly. Fire drills are carried out twice yearly and all staff must attend at least one session a year. Consent for Procedure Policy Consent obtained for procedures performed comply with the guidelines as issued from time to time by the National Health and Medical Research Council. It is the responsibility of the endoscopist to obtain the patient's written consent before the patient receives sedation. In obtaining the consent from the patient, the nature and purpose of the procedure and any generally foreseeable consequences that might flow from the procedure must be explained to the patient. If a patient requires a narcotic analgesia as a consequence of specific problems encountered, a formal consent is not required. When a patient is unable to sign a "Consent for Procedure" form the consent of a legal guardian or ACT Community Advocate is required. Emergency consent may be obtained by telephone with the responsible medical practitioner and a registered nurse witnessing the telephone consent Sedation Policy There is a specialist anaesthetist appointed as Director of Anaesthesia to maintain standards in the provision of conscious sedation within each Centre. The Director also organises a program to develop and maintain skills and resuscitation techniques for anaesthetists or sedationists, endoscopists and nursing staff of the Centre. Procedures regarding the use of drugs, patient observations and procedure documentation is determined by the Board and the Director of Anaesthetics, and are based on the guidelines of the Gastroenterological Society of Australia, the Australian & New Zealand College of Anaesthetists and the Royal Australasian College of Surgeons. All anaesthetists or sedationists are required to be knowledgeable of, and comply with, the by-laws that apply to them. All patients who have received any sedative drug are clearly advised in writing that they are not to drive a motor vehicle or operate machinery till the day after the procedure. Sedation Technique The vast majority of Australian patients prefer to have endoscopies performed under sedation although it is possible to complete both gastroscopy and colonoscopy without any sedation. Gastroscopy does however provoke powerful and unpleasant gag reflexes in many patients and colonoscopy can commonly cause significant pain. We therefore recommend that our patients receive our standard sedation, although we are prepared to perform endoscopy with minimal or no sedation for patients who prefer that option. The endoscopist and/or anaesthetist or sedationist assesses all patients undergoing procedures and have their vital signs checked prior to the procedure. Patients considered to be at very high risk are usually selected to have their sedation delivered by a specialist anaesthetist rather than a GP sedationist. All patients have automated monitoring of pulse, blood pressure and oxygen saturation and receive supplemental oxygen during the procedure. Nearly all endoscopy patients are given a combination of midazolam (Hynovel), fentanyl (Sublimaze) and propofol (Dipravan) intravenously as the sedating agents. We have found that this gives excellent sedation, with nearly all patients having minimal recall of the procedure and recovering without any nausea or prolonged drowsiness. The doses of the drugs can be easily adjusted to ensure every patient is completely comfortable during the procedure. After the procedure the patients are moved to the recovery area where they continue to be monitored by our experienced nursing staff till fully awake. The safety of this technique has been confirmed by a recent review of 28,000 procedures performed in our endoscopy centres over a five-year period. The staff in the endoscopy or recovery areas successfully managed the few problems that were encountered. Quality Assurance (QA) Policy The Practice has received full accreditation by the Australian Council of Healthcare Standards and adheres to all their guidelines. There is an appointed QA Manager who is responsible for the organisation-wide Quality Assurance Program The QA Committee has developed manuals of policy, which have been approved by the Board. These manuals are regularly updated and checked at least every two years. The QA Manager and Medical Director prepare a written report twice yearly (February and August) for presentation to the Board. The performance audit is collated monthly and reported at the QA Meeting. The required six-monthly clinical indicator performance audit is sent to ACHS as part of the QA program (EQuIP). The organisation carries out second yearly 'Patient Satisfaction Surveys' and audits the performance of the Clinic Nurses. Other surveys are carried out as required. The organisation is involved in many scientific research activities and has presented these results at national and international gastroenterology conferences and in peer-reviewed journals. All medical staff comply with the Maintenance of Professional Standards programs required by their learned Colleges. Confidentiality Policy All patient Medical Records are secured in a purpose designed storage area which is locked outside the working hours of the practice. Only those healthcare workers responsible for that patients care have access to the Medical Record and clerical staff are discouraged from informing themselves of the contents of a Medical Record, apart from that knowledge that is necessary for the performance of their duties. The Medical Record remains the property of the practice and shall not be removed from the facility, other than in accordance with a court order, subpoena or statute, without the approval of the Medical Records Supervisor. Subpoenaed Medical Records shall be sent by safe hand in a sealed envelope, clearly marked "Confidential Medical Record" and a copy of the subpoena shall be attached to the envelope. Information contained in the Medical record shall be treated as 'strictly confidential' and shall not be released to any unauthorized person. The Medical Practitioner and patient shall both be notified that the Medical Records have been subpoenaed. Copies of Medical Records shall be made available in accordance with a patient's written authority and with the permission of the patient's medical practitioner. Communications that contain clinical information and that are to be faxed must be transmitted with a "Confidentiality Note" cover sheet. Patient access to their Medical Records Patients are entitled to access their Medical Records as provided for in the Freedom of Information and Privacy Acts and our practice has always facilitated patients who seek such access. Patients wishing to view their Medical Records should speak to the Word-processing Supervisor, Cate Maloney to obtain access to their records. Booking Policy A schedule for each practitioner has been setup, with the number of patients and types of procedures mutually agreed to by the Medical Director, Nurse Supervisor and individual practitioner. The list of patients booked for either consultation or procedures is prepared at least 48 hours before the respective list. The Admitting Practitioners must ensure that all patients booked into the Mugga Wara Endoscopy Centre have a clear understanding of the billing policy and out of pocket expenses. Clinical Privileges Policy Consultants, including anaesthetists/sedationists must apply to the Board for clinical privileges. It is a condition of maintaining clinical privileges that all practitioners participate in the quality assurance program. All newly appointed practitioners will undertake an orientation program prior to starting work. An orientation checklist has been developed and approved by the Board. The Board may terminate clinical privileges by notice in writing. A decision to terminate the privileges requires a meeting of the Board with a minimum of four Board members present. Appeal against a decision relating to clinical privileges is allowed for.