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Canberra Health ServicesProcedure Alert Management Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Alert Management System.....................................................................................3

Section 2 – Administrative Alert Management.........................................................................8

Section 3 – Clinical Alert Management.....................................................................................9

Section 4 – Coordinated Care Alert Management..................................................................12

Section 5– Infectious Organism Alert Management...............................................................13

Section 6 – Legal Alert Management......................................................................................16

Section 7 – Respecting Choices Alert Management................................................................18

Section 8 – Behaviour and Safety Alert Management.............................................................20

Section 9 – Home Environment Alert Management...............................................................22

Section 10 – Special Needs and/or Preferences Alert Management.......................................23

Section 11 – Governance of Alerts..........................................................................................26

Evaluation............................................................................................................................... 26

Related Policies, Procedures, Guidelines and Legislation.......................................................27

Definition of Terms................................................................................................................. 28

Search Terms.......................................................................................................................... 29

Attachments............................................................................................................................30

Attachment 1: Alert information flow between systems....................................................31

Attachment 2: Patient Digital Journey Board Alert Icons....................................................32

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Purpose

The purpose of this procedure is to inform Canberra Health Services (CHS) staff of: the types of alerts available in the Alert Management System the process to add, edit and close alerts the roles and responsibilities for alert management.

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Alerts

Alerts modified and added to the patient’s profile in the Alert Management System within Clinical Portal will be forwarded to other clinical information systems such as the ACT Patient Administration System (ACTPAS), Mental Health, Alcohol, Justice Health Integrated Care Electronic Record (MAJICeR), Patient Digital Journey Boards (PDJB), Emergency Department Information System (EDIS), cbord (nutrition system), Clinical Patient Folder (CPF), Flow manager and Integrated Diagnostic Imaging Solution (IDIS).

CHS staff MUST also add any known allergies or adverse reactions into the following stand-alone clinical systems if they have access, including Electronic Medication Management (EMM) – MedChart, ARIA (oncology information system), CHARM (oncology information system), CardioBase (Cardiology information system), Clinical Vision V (CV5) and MetaVision (electronic clinical information system in Intensive Care Unit).

Food allergies must be entered into the Alert Management System as adverse reactions. For Inpatients on the Canberra Hospital campus with food allergies, staff are to ring Nutrition Department on extension 5124 2567 so they can update DietPAS and Mymeal systems with the food allergy.

See Attachment 1 for a diagram of the alert information flow between systems used at CHS.

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Scope

This procedure applies to alert management of all patients being treated through any CHS service, this includes the Canberra Hospital campus, University of Canberra Hospital (UCH), Community Health Centres and Home visits. For the purpose of this document the term patient refers to anyone accessing care at CHS including consumers, clients, people or persons.

This document applies to the following CHS staff working within their scope of practice: Medical Officers Nurses and Midwives Allied Health Professionals

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Work Health Safety staff Quality, Safety, Innovation and Improvement staff Administration officers Health Information Services staff Students under direct supervision.

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Section 1 – Alert Management System

The Alert Management System within Clinical Portal manages all patient alerts, allergies and adverse reactions. This is the primary Alert Management System at CHS. All alerts are to be entered into Clinical Portal. Alerts entered into Clinical Portal will be automatically transferred into the following systems: ACTPAS MAJICeR PDJB DietPAS at University of Canberra EDIS cbord CPF Flow Manger IDIS

Relevant alerts must also be entered into area specific systems that do not receive the alerts electronically from the Clinical Portal. The following systems DO NOT receive alerts automatically from Clinical Portal: DietPAS at Canberra Hospital campus. To add an alert to this system please contact

Nutrition Department on x42567. ARIA CHARM CardioBase CV5 EMM MetaVision

A flow chart demonstrating the flow of alert information between systems is at Attachment 1.

TrainingTo access the Alert Management System and Clinical Portal, staff must complete the required eLearning modules. Training requirements are based on staff roles. More

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information is available at: https://actgovernment.sharepoint.com/sites/intranet-ACTHealth/SitePages/Clinical-Portal.aspx?web=1 under the training section.

Accessing the Alert Management SystemTo access the alerts for a patient, click on the alerts and adverse reaction button in the patient’s profile in Clinical Portal. Please be aware, there are two sections to the Alert Management System in Clinical Portal: 1. The first section is general patient alerts.2. The second section is specific to allergies and adverse reactions.

A yellow alert and adverse reaction symbol (exclamation mark in a triangle) indicates there are alert and adverse reaction entries in the patient’s record. A grey symbol indicates the patient has no active alert or adverse reactions.

When entering information into the Alert Management System for a patient, please ensure that you complete both the general patient alerts and the adverse reactions sections. Alerts are divided into the following categories: Administrative: Alerts related to Administrative tasks Clinical: Alerts related to patient safety risks Coordinated Care: Alerts related to care under a coordinated care program Infectious Organism: Alerts to inform staff that a patient has an infection that requires

transmission-based precautions Legal: Alerts when a patient has a legal order/direction/agreement Advance Care Planning: Alert to inform staff when a patient has an Advance Care Plan Behaviour and Safety: Alerts related to risk to staff and safety of others Additional needs: Alerts to inform staff the patient has additional requirements that

need to be considered when delivering care.

All members of the patient care team should be aware of these alerts, their meaning and the steps required to update alerts in the Alert Management System. For any clinical areas not currently using the Alert Management System, staff will need to ensure they can access Alert Management System within Clinical Portal to update alerts. To access help sheets for the Alert Management System please go to Technology – How to get help – Alert Management on the Health hub, https://actgovernment.sharepoint.com/sites/intranet-ACTHealth/SitePages/Alerts-Management.aspx

Note: any field with a red asterisk is a compulsory field and must be completed.

Adding an Adverse Reaction AlertTo add a new adverse reaction alert to a patient profile:1. Log onto Clinical Portal2. Select patient 3. Click on the add Alert or Adverse Reaction button4. Select Adverse Reaction

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5. Select drug or non-drug6. Start typing the agent or substance name and select the item from the list 7. Add the reactions and severity8. Add where the information about the reaction came from, onset of reaction and if it is

suspected or confirmed.

Note: An adverse reaction or alert is confirmed if it has been witnessesed by the reporter; verified by a test result; or confirmed by two or more sources. An adverse reaction or alert is suspected if it is probable but has not been witnessed by the reporter; there is no test result to verify; and is not confirmed by two or more sources.

9. Click add Adverse ReactionSee How to add an Adverse Reaction information sheet for further information.

Adding an AlertTo add a new alert to a patient profile:1. Log onto Clinical Portal 2. Select patient 3. Click on the add Alert or Adverse Reaction button4. Select Alert5. Click on the button displaying … to view the categories

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6. Select the required Alert Category7. Complete the mandatory fields marked with a red asterisk.8. Enter an expiry date if appropriate9. Include an approximate date to review the alert in the comments field10. Click “Add”

See How to Add an Alert information sheets for further information.

Editing or Closing an AlertTo Edit or Close an existing alert from a patient profile:1. Log onto Clinical Portal. 2. Select patient 3. Click on the alert to be edited4. Click “Edit” and select ‘Update’ or ‘Close’5. Make the relevant changes6. Click update

See How to edit an Alert or Adverse Reaction information sheet for further information. Reopening a closed AlertTo reopen a closed alert in the patient profile:1. Log onto Clinical Portal2. Select patient 3. Click on alert and adverse reaction icon to show list of alerts4. Click on “show” next to closed in the alerts heading.5. Click on the closed alert6. Select the edit button and then select reopen item.7. Amend any details required and enter the reason into Reason for Reopen text field

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8. Select Reopen to make the alert active. The alert will now be listed as active in the Alerts summary list.

9. The Reopen Reason will be listed in the activity section of the alert.

Removing an AlertAn alert should only be removed if it has been added to the wrong patient profile or is a duplicate alert for the patient.To remove an alert from a patient profile:1. Log onto Clinical Portal2. Select patient 3. Click on alert and adverse reaction icon to show list of alerts4. Click on the alert you wish to remove5. Select the edit menu and select remove6. Select Reason for Removal form the drop-down list7. Enter relevant notes in the Comment text field8. Select Remove button. The alert will no longer be displayed and will not be visible as a

closed alert.

Display of alerts on the Patient Digital Journey The Alert Management System informs the alert displayed in the Patient Digital Journey.

In CHS areas that have patient digital journey boards (PDJB), the journey board displays up to four alert icons next to the patient’s name on the 55-inch display and on the desktop view. If the patient has more than four alerts a plus symbol will be displayed. If there is a plus symbol displayed for a patient, clinicians can use the desktop view to access a list of the patient’s current alerts. See Patient Digital Journey Board User Guide for more information.

The patient room boards in CHS areas that have them installed will display up to ten alerts on the room boards.

The alert icons are displayed in the following order:1. Safety and Behaviour related alerts2. Adverse reaction alerts3. Dying process alert4. Legal related alerts5. Any remaining alerts are displayed in alphabetical order.

Infectious Organism alerts have their own column so are displayed independent of other alerts.

The icons displayed on the PDJB are at Attachment 2.

Reviewing patient alerts in the Alert Management SystemIt is important that the alerts on the patient profile in the Alert Management System are up to date and regularly reviewed to ensure the alerts reflect the patient’s current needs and

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care requirements. Alerts that are out of date but left active on the patient’s profile can affect the care delivered to the patient, to reduce the risk of this occurring the alerts on a patient profile should be reviewed as outlined below.

When a patient commences an episode of care with a CHS service including: admission as an inpatient day only admission, e.g. for day surgery or Mental Health day services attending an outpatient clinic presenting to the Emergency Department or Walk in Centre having a home visit attending a community setting appointment

The admitting treating team member or clinician seeing the patient is to: review any existing alerts for currency, updating information as appropriate. If existing

alerts are no longer current, they should be closed by the appropriate staff member, please see the management of alerts section (grouped by type of alert).

assess if any new alerts should be added to the patient’s profile in the Alert Management System. When adding an alert that is relevant for one admission or a specified time period you can enter an expiry date for the alert, once this date is reached the alert will automatically close.

When a patient completes their episode of care with CHS including: discharge from inpatient services or day surgery discharge from Emergency Department or Walk in Centre discharge from a program completion of a series of appointments the member of the treating team completing the discharge summary/report/final clinical record entry is to review the alerts on the patient’s profile in the Alert Management System and update or close them as appropriate.

Alerts that are closed or expired can be accessed in the patient’s profile in Clinical Portal and CPF.

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Section 2 – Administrative Alert Management

Administration Alerts inform staff on considerations for managing the administration tasks related to their work and the patient.

These alerts are managed by Administrative staff including, but not limited to, Ward Clerks, Clerical staff, Community Health Centre staff, Health Information Services (HIS) and Outpatient clinic staff.

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Double Appointment Required – the patient requires a double appointment for Breast Screening appointments. Breast screen staff manage the double appointment alert.

Extended Record Retention Period - An element or section of the patient's clinical record is subject to an extended retention period, in compliance with the approved Records Disposal Schedule for Health Treatment and Care records.

Merged During Migration - The patient’s record was merged during migration. If there are any indications that the merge is incorrect, please contact: HIS - 5124 2124 (weekdays 9:00-17:00) Email: CHS.HIS.Registry@act.gov.au. Please include further information in the alert Details section.

Potential Duplicate Record - The patients record may be a duplicate record. For further information please contact: HIS - 5124 2124 (weekdays 9:00-17:00) Email: CHS.HIS.Registry@act.gov.au Please add further information into the Details section.

Same Name or Similar Name – The patient has the same name or similar name as another patient at the healthcare service. This is NOT a duplicate record. For further information, please contact HIS - 5124 2124 (weekdays 9:00-17:00) Email: CHS.HIS.Registry@act.gov.au Please add further information into the Details section.

Other Administrative - The patient has an administrative alert that is not defined elsewhere. For further information, please contact HIS - 5124 2124 (weekdays 9:00-17:00) Email: CHS.HIS@act.gov.au Please add information about the alert in the Details section.

Management of Administrative AlertsDuring an episode of care at CHS when the administrative officer is admitting a patient to the hospital or for an appointment, they review any existing administration alerts in ACTPAS and ensure they still apply. If the administrative officer identifies that an administrative alert needs to be placed on the patient’s profile or an existing alert needs to be edited, they are to email the required change to HIS. HIS staff will add or edit the administrative alert to the patient’s profile in the Alert Management System.

When patients are discharged, the discharging staff member reviews the administrative alerts for the patient to see if they are still required or require editing. If the alert is not required or requires editing, the staff member emails the required change to HIS for actioning in the Alert Management System.

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Section 3 – Clinical Alert Management

Clinical Alerts inform clinicians of patient safety risks and things for consideration when delivering care and/or treatment to the patient.

These alerts are managed by all members of the patient’s treating team. The minimum requirement for reviewing of Clinical Alerts is on admission/initiation of episode of care, with any change in the patient’s condition, and at discharge/completion of episode of care.

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Clinical Alerts in the Alert Management System are: Adverse Reaction – the patient has experienced an adverse reaction from a medicine,

drug or food. Please include as much information as possible in the alert, e.g. type of reaction, severity, and time to resolution. Medicine allergy alerts should not be removed from the Alert Management system. If it has been proved that a patient can tolerate a medicine that has been documented as an adverse reaction alert, then the alert should be updated to closed and documentation of allergy test or rechallenge attached. Please see Medication Handling Policy for further information.

Chemotherapy – the patient is currently receiving chemotherapy treatment. This alert is to be closed when the chemotherapy treatment has been completed. For further information, please contact: Chemotherapy Clinical Development Nurse, call Canberra Hospital switch (dial 4000 at Canberra Hospital or 6244 2244 for other sites) and leave a message for pager 50269 (weekdays 8:30-17:00)

Clinical Trial – the patient is taking part in a clinical trial. The clinical trial co-ordinator should be listed as a contact in the alert so clinicians can contact them for further information about the trial. The patient may have a specific health condition which may benefit from receiving otherwise unavailable treatment/s. The clinical trial may impact on patient's ability to participate in other treatment. This alert needs to be closed when the clinical trial has ended.

Comfort Care – the goal of the patient’s care is their ongoing comfort. All provided interventions are directed towards this goal. Actions to achieve comfort are expressed in a comfort care plan, which is available in the patient’s clinical record. This alert should be added to the patient’s profile when the plan/pathway is activated.

Device in Situ – the patient has a medical device in situ. The patient has an implanted or external device that may affect procedures, or other treatment/s required. Details of the device and its location and a contact person for the device (if applicable) should be included in the alert.

Difficult Intubation – The patient may be difficult to intubate. A difficult intubation trolley should be made available if the patient requires an endotracheal intubation.

Dysphagia – The patient has been assessed as having swallowing difficulties with food, fluids or medications by an appropriately trained clinician. Any information about the strategies or texture modification for the patient should be included in the alert. If the dysphagia is not ongoing the assessing clinician should close the alert when the patient is discharged/episode of care completed. The alert is to be given a default 3-month end date unless otherwise clinically indicated. Please see Dysphagia – Management in Adults and Children (Speech Pathology) Guideline or Acute Screening of Swallow in Stroke, Transient Ischaemic Attacks (ASSIST) for Adults procedure

Note: you MUST add dysphagia alerts to the EMM - MedChart alerts as well as the Clinical Portal Alerts so prescribing clinicians are aware that the patient has swallowing difficulties.

Malnutrition – the patient has been diagnosed with malnutrition. The assessing Dietitian adds the alert to the patient’s file, the alert is to be given a default 3-month end date.

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The alert will be closed by a Dietitian after review has confirmed the patient is no longer malnourished.

Management Plan - The patient has a management plan that details how the patient is to be managed when they present at a specified service/s. A management plan is developed when adverse events have occurred and are likely to occur in the future care and management of the patient. An adverse event may be related to the patient’s clinical care or the safety and security of those treating the patient. The management plan may relate to the service/s to be provided or not provided, how the service is to be provided, the treatment regime to be followed, and the safety and security precautions to be implemented. The Management Plan is to be uploaded to CPF. Please document further information in the alert Details section.

Neck Breather – The patient has a tracheostomy in situ or has had a laryngectomy. A neck breather breathes only through a tracheal stoma - that is air only enters the lungs via the stoma opening at the neck, NOT via mouth or nose. These patients no longer have a connection between the mouth/throat and lung. The patient may be a total or partial neck breather. No occlusive dressings to be placed over neck stoma at any time. For further information please refer to Tracheostomy Management Adult Patients Procedure or Tracheostomy Care and Management – Infants, Children and Adolescents Guideline for further information. This alert will be permanent for patients with a laryngectomy and will be closed for patients with a tracheostomy following decannulation.

Non-Adherence to Medication Regimen - The patient currently has an intentional non-adherence to medication regimen. The patient may intentionally omit or cease to take a medication, or their non-adherence may be the result of a disability, health condition, or a mental illness which leads them to simply forget to take their medication. Please add additional information to the alert Details section.

Pressure Injury – the patient has one or more current pressure injuries in any anatomical position. A pressure injury is a localised injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure (including pressure associated with shear), device, or another object related. This alert is to be closed when the pressure injury has completely healed. Please see Pressure Injury Prevention and Management Procedure for more information.

Radioactive – the patient is receiving radioactive treatment. The patient currently contains an isotope that emits alpha, beta or gamma rays as radiation energy. Details of where the radioactive therapy is located on the patient and any safety information should be included in the alert. This alert is to be closed when the radioactive treatment is completed. For further information refer to Inpatient Radioactive Iodine – 131 Therapy Adult Procedure or contact Nuclear Medicine Department (weekdays 08:00 – 17:00) 5124 2439 or Radiation Safety Officer via switchboard.

Renal Dialysis – The patient is receiving renal dialysis therapy. Please include any specific information other clinicians may need to know about the patient’s dialysis therapy in the alert. This alert is to be closed when the patient no longer requires renal dialysis therapy. Please see Haemodialysis for Adults Procedure, Intermittent Haemodialysis Operational Guideline or Peritoneal Dialysis Procedure for more information.

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Seizures –The patient currently suffers from seizures. Please add information about the seizures and treatment in the alert Details section. For further information about management of seizures related to alcohol withdrawal please refer to Medical Management of Alcohol Withdrawal Guideline or for seizures in paediatric patients refer to Paediatrics – Acute Management of Seizures

Transplant – the patient has received a transplant. The patient may be immunocompromised and should be isolated from people who are infectious. Please include any information other clinicians may need to know about the treatment of the patient in the alert Details section.

Other Clinical – the patient has a clinical alert not defined elsewhere. Please add information to the alert Details section.

Management of Clinical AlertsDuring an episode of care at CHS if the patient receives any treatment or change in care the clinical alerts should be added or closed as appropriate to ensure the patient’s profile in the Alert Management System is reflective of the current care/treatment for the patient.

When the patient completes their episode of care with CHS the member of the treating team completing the discharge summary/report/final clinical record entry is to review the clinical alerts on the patient’s profile in the Alert Management System and update or close them as appropriate.

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Section 4 – Coordinated Care Alert Management

Coordinated Care Alerts inform clinicians that the patient is under the care of a coordinated care program/centre.

Coordinated Care Alerts are managed by the coordinated care program/centre clinicians.

Coordinated Care Alerts in the Alert Management System are: Haemophilia Treatment Centre – the patient has haemophilia A, B, C or von Willebrands

disease and is under the care of the Haemophilia Treatment Centre. If a patient with this alert presents to hospital with any trauma/bleed or for surgical intervention the Haemophilia Treatment Centre, 5124 2188 or 5124 5544, should be notified. If after hours the on-call haematologist MUST be called via switchboard. There are Medication Standing Orders for these patients attending Emergency Department for Biostate, Recombinant Factor VIII and Recombinant Factor IX on the policy register. for further information refer to Coagulation Factor Replacement Products Continuous Infusion Adults, Paediatrics including Adolescents and Infants NOT Neonates Procedure.

IMPACT Program – the patient is part of the IMPACT program, co-ordinating service for pregnant women, their partners and their young children who are clients of MHJHADS and/or receiving opioid replacement therapy and require assistance to manage their involvement with multiple services. Please contact IMPACT on 1800 211 274 when the patient presents.

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Pregnancy/Parent Enhancement Program (PEP) - The patient is currently part of the PEP. PEP is a service that offers additional support to vulnerable woman who are pregnant and/or have a family with a child less than 12 months of age. The clinician adding the alert is to record the stage of the program the patient is accessing in the alert Details section. Please contact PEP if the patient presents, Pregnancy Enhancement Program: Antenatal CMC - 6174 7368 (weekdays 9:00-17:00) Email: TCHPEPS@act.gov.au or Parenting Enhancement Program: Maternal and Child Health CNC North, ACT Health - 6205 1815 (weekdays 8:30-17:00) Email: HDMACHLiaisonClient@act.gov.au or Maternal and Child Health CNC South, ACT Health - 6205 2753 (weekdays 8:30-17:00) Email: HDMACHLiaisonClient@act.gov.au

All of these alerts are placed on the patient’s profile in the Alert Management System when they join the program or care co-ordination by the clinician who processes the patient’s referral.

These alerts are to be closed in the patient’s profile in the Alert Management System when the patient is discharged from the program or care co-ordination by the discharging clinician.

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Section 5– Infectious Organism Alert Management

Infectious Organism Alerts inform clinicians that the patient has an infection that requires transmission-based precautions.

Only Infection Prevention and Control Unit (IPCU) staff of CHS and Calvary Public Hospital Bruce can add, amend or close infectious organism alerts. IPCU staff manage these alerts during business hours Monday to Friday. Infectious organism alerts are not added/closed out of hours. Out of business hours staff are to implement the required transmission-based precautions for the patient when notified by pathology of the positive result.

Infectious Organism Alerts in the Alert Management System are: CDIFF – Clostridium Difficile - CDIFF causes severe diarrhoea and other intestinal

diseases when antibiotics suppress the healthy bacteria which allow the CDIFF organism to multiply and produce toxins. The patient requires placement in a single room with standard and contact isolation precautions.

COVID-19 – The patient has tested positive for COVID-19. The patient requires to be cared for using droplet and contact precautions. If the patient requires and aerosolising generating procedure, the patient must be nursed in a negative pressure room with airborne precautions.

CRAB – Carbapenem Resistant Acinetobacter Baumannii - Acinetobacter baumannii is an opportunistic pathogen found in soil and water. The patient requires placement in a single room with standard and contact isolation precautions.

CRE - Carbapenem Resistant Enterobacteriaceae- Infections with these germs are very difficult to treat and can be deadly. Some CRE bacteria have become resistant to most

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available antibiotics. The patient requires placement in a single room with ensuite or dedicated bathroom with standard and contact isolation precautions.

ESBL – Extended Spectrum Beta-Lactamase - ESBL is an enzyme (chemical) produced by some bacteria, that can break down many common antibiotics, making antibiotics ineffective. The patient requires placement in a single room with standard and contact isolation precautions.

MRAB – Multi Resistant Acinetobacter Baumannii - Acinetobacter is a species of pathogenic bacteria which is resistant to most antibiotics. The illness can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body. The patient requires placement in a single room with standard and contact isolation precautions.

MRO – Multi Resistant Organism - MRO includes multi resistant organisms not categorised elsewhere, such as Pseudomonas and E.coli. Multi resistant bacteria are a group of bacteria are resistant to some antibiotics. Please see the alert Details for further information. The patient requires placement in a single room with standard and contact isolation precautions.

MRSA – Methicillin Resistant Staphylococcus Aureus - MRSA includes Multi Resistance MRSA (MR MRSA), UK 15 MRSA and UK 16 MRSA. These bacteria are resistant to some antibiotics. Please see the alert Details for further information. The patient requires placement in a single room with standard and contact isolation precautions.

MRTB – Multi Drug Resistant (Pulmonary) Tuberculosis - Pulmonary TB transmission (a Notifiable Disease) is usually by airborne droplets, expelled from the respiratory tract of a person with smear-positive pulmonary or laryngeal TB. The patient requires placement in a negative pressure room with standard and airborne isolation precautions. N95/P2 masks must be worn when in contact with a person with TB. Patient must wear a N95/P2 mask when being transported.

Multiple Drug-Resistant Escherichia Coli Multi resistant bacteria are a group of bacteria that do not respond to some of the antibiotics. The patient requires placement in a single room with standard and contact isolation precautions.

NMMRSA – Non-Multi Methicillin Resistant Staphylococcus Aureus - Non Multi Methicillin Resistant Staphylococcus Aureus (NMMRSA) was formerly known as Community MRSA. These bacteria are resistant to some antibiotics. Please see the alert Details for further information. The patient requires placement in a single room with standard and contact isolation precautions.

Suspected COVID-19 – The patient is suspected to have COVID-19 and should be treated as being positive until a negative result is confirmed. The patient requires to be cared for using droplet and contact precautions. If the patient requires and aerosolising generating procedure, the patient must be nursed in a negative pressure room with airborne precautions.

TB – Tuberculosis (Notifiable Disease) - Pulmonary TB transmission is usually by airborne droplets, expelled from the respiratory tract of an infected person. Extrapulmonary TB occurs as a result of bacilli migrating from the lungs to other parts of the body. Airborne Precautions are not required for extra pulmonary disease, unless there is exposure to body fluids e.g. changing a drain. Extrapulmonary TB is not normally transmissible but can occur with direct contact/inoculation of tuberculosis material, e.g. wound drainage.

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The patient requires placement in a negative pressure room with standard and airborne isolation precautions. N95/P2 masks must be worn when in contact with a person with TB. Patient must wear a N95/P2 mask when being transported.

VRE – Vancomycin Resistant Enterococcus - VRE are frequent causes of urinary tract infections, intra-abdominal infections, bacteraemia and endocarditis. These bacteria are resistant to some antibiotics. Please see the alert Details for further information. The patient requires placement in a single room with standard and contact isolation precautions.

Vancomycin Resistant Enterococcus VAN A Strain – a sub group of VRE, as above. Vancomycin Resistant Enterococcus VAN B Strain – a sub group of VRE as above. Other Infectious Organism (this covers respiratory illnesses) - The patient has an

infectious organism alert that is not defined elsewhere. Please see the alert Details for further information. The patient requires precautions as advised by Infection Prevention and Control Unit. It is important to understand the method of transmission of the microorganism as this will determine the isolation precautions required.

For more information please refer to Infection Prevention and Control - Healthcare Associated Infection Procedure or contact: Infection Prevention and Control 5124 3695 (weekdays 8:00-17:00).

Procedure for management of infectious organism alerts.1. If clinicians are testing a patient for an infectious organism and they strongly suspect,

there will be a positive result they are to contact IPCU and discuss the possibility of placing a suspected alert on the patient’s profile in the Alert Management System.

2. Microbiology or the molecular unit in Pathology will notify the IPCU staff when a test for an infectious microorganism is suspected to be positive or confirmed. After Hours suspected or confirmed results are notified to the clinical area staff by microbiology or molecular units.

3. Wards/units, if patients are an inpatient, are notified of the suspected positive or confirmed result. If the patient is an outpatient, then it is the responsibility of the person ordering the test to notify the patient of a positive result.

4. The Alert is added to the patient’s profile in the Alert Management System as suspected or if confirmed as positive by an IPCU staff member.

5. If the test is suspected positive within 24 hours the microbiology/molecular unit will confirm with IPCU that the test is finalised and what the outcome is. Wards are again notified, and the alert is updated to reflect the finding by IPCU staff.

6. IPCU visit the ward if this is a new finding. The patient is seen by IPCU staff (patients who are having repeat testing would most likely have been seen previously). A sticker is placed in the patient notes to inform staff of the result. Patients are given information regarding the specific micro-organism.

7. For Other infectious Organism alerts – when the patient is identified as having influenza an end date will be added to the alert.

8. The infectious organism alerts are updated by IPCU staff as new information is supplied by pathology or the ward.

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9. IPCU staff close an infectious organism alert after consultation with the patient’s treating team or pathology.

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Section 6 – Legal Alert Management

Legal Alerts inform clinicians when there is a legal order/direction/agreement for the patient that may need to be considered when delivering care and treatment to the patient.

Legal Alerts are managed by the treating team and Tribunal Liaison team.

Legal Alerts in the Alert Management System are: Advance Agreement – a document stating a person’s preferences regarding future

mental health treatment, care or support when they have reduced decision-making capacity (also known as impaired decision-making capacity). The agreement also states who staff can contact and share information with when the patient is unwell. The treating team member who receives the Advance Agreement document is responsible for entering the alert in the Alert Management System and uploading the document into MAJICeR. For more information about Advance Agreement please refer to Advance Agreements, Advance Consent Directions and Nominated Persons under the Mental Health Act 2015 procedure.

Advance Consent Direction – is a legal document that contains major decisions about mental health treatment that a person consents to receiving when they have reduced decision-making capacity (also known as impaired decision-making capacity). The treating team member who receives the Advance Consent Direction document is responsible for entering the alert in the Alert Management System and uploading the document into MAJICeR. For more information about Advance Consent Direction please refer to Advance Agreements, Advance Consent Directions and Nominated Persons under the Mental Health Act 2015 procedure.

Care and Protection Order – The child/young person is subject to a Care and Protection Order (CPO). Any member of the treating team who becomes aware that a child/young person is subject to a CPO, is required to confirm the details of the order by contacting Child Youth and Protection Service (CYPS) to obtain a copy and is responsible for placing a Care and Protection Order alert on the Alert Management system. This action is to be documented and a hard copy of the CPO placed in the front of the patient medical notes. The CPO is to be scanned and emailed to HIS at CHS.HIS@act.gov.au as soon as practicable, to be uploaded to CPF. The email is to have as the subject title, the consumers URN: and marked ‘Care and Protection Order’. HIS will scan the CPO as soon as practicable to CPF (at minimum within 2 business days). It is the responsibility of all members of the treating team to review the details and timeframe of the CPO, confirm the alert is still current and close the alert if the order has ceased at each episode of care. At minimum a CPO alert should be reviewed at the commencement of an episode of care and the treating team member confirm the currency of the CPO.

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Note: a child/adolescent under a CPO may also have a Specific Parental Authority (SPA), a legislative instrument that provides a kinship or foster carer with legal authority to have certain aspects of parental responsibility, this does not include the authority to provide consent for general anaesthetic but may include consent for minor medical/dental procedures and immunisations. Please check if the carer has SPA for the child/adolescent and the details of this.

Guardianship Order and/or Management Order –A guardian and/or manager may be appointed by the ACT Civil and Administrative Tribunal for a person who is found to have a decision-making impairment. When an order is received by a clinician or administration officer, they are responsible for adding the alert to the Alert Management system and sending a copy of the order to HIS for upload to CPF for the treating team to access.

Mental Health Order – an order which authorises treatment, care and support for a person with a mental illness or disorder. The Mental Health Order may be: Psychiatric Treatment Order (PTO) - A legal order from the ACT Civil & Administrative

Tribunal which authorises the involuntary psychiatric treatment of a person with a mental illness with impaired decision-making capacity.

Community Care Order (CCO) - A legal order from the ACT Civil & Administrative Tribunal which authorises the involuntary psychiatric treatment of a person with a mental disorder with impaired decision-making capacity.

Emergency Detention Order (ED3/7) – an order approved by a Doctor which authorises detention of a person with a mental illness or disorder, who has refused treatment, support or care, for immediate treatment, care or support necessary for the person’s wellbeing or to protect another person or the public.

Forensic Mental Health Order – A legal order from the Act Civil and Administrative Tribunal which authorises the involuntary psychiatric treatment of a person who presents a risk of serious endangerment to the community.

When a Mental Health Order is put in place the Tribunal Liaison team enter an alert in the Alert Management System. The Mental Health Order will be uploaded to MAJICeR or CPF (if patient is not a mental health patient) for staff to access. For more information about Mental Health Order please refer to Care of Persons Subject to Forensic Mental Health Orders (FMHOs) procedure or Care of Persons subject to Psychiatric Treatment Orders (PTOs) with or without a Restriction Order (RO) procedure.

Nominated Person – a person nominated by the consumer (patient) to support and help make decisions, express the views of the person and receive information about their treatment, care and support. This may be a friend, carer, family member or other person chosen by the consumer. Nominated persons may support the consumer’s decision making, advocate the consumer’s decisions and rights, be consulted in decisions (for example if an application is made for a mental health order) and receive relevant information about the consumer. Please document who the nominated person is in the details section.

Other Legal – The patient has a legal document that is not defined elsewhere, such as Workplace Protection Order, Specific Parental Authority or Section 309 of the Crimes Act. The legal document is to be sent to HIS for upload to the CPF for the treating team to access. Please document information about the document in the alert Details section.

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My Rights, My Decisions When patients with a mental illness or disorder have reduced decision-making capacity (also known as impaired decision-making capacity) they may have an Advance Agreement, Advance Consent Direction or a Nominated Person in place to assist with decision making. These decision-making supports are put in place using the My Rights, My Decisions (MRMD) form kit. MRMD supports patients to express their views and preferences about their mental health treatment, care and support. More information can be found at https://www.actmhcn.org.au/mrmd/

Hospital Safety PlanFor patients with a Care and Protection Order the treating team should consider requesting a Hospital Safety Plan for the child or young person (available on the Clinical Forms register) from CYPS. This document is completed by CYPS staff and can then emailed to CHS, with a hard copy placed in the patient’s medical record and a copy uploaded to CPF. The Hospital Safety Plan outlines the current nature of care arrangements for the child/young person including who has parental responsibility, who may have contact, known risks to the child/parent/carer/staff, what services are involved in the child/young person’s care, contact details of case manager, and enables optimal care planning for the child/young person. For further information refer to Child Protection Policy, Child Protection and child and prenatal concern reporting guideline.

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Section 7 – Respecting Choices Alert Management

Respecting Choices Alerts inform clinicians when a patient has an Advance Care Planning (ACP) document. Clinicians should review the ACP before delivering care or treating the patient. The ACP document will be available in the patient’s clinical record and on CPF. For more information on ACP documents please refer to the Advance Care Plan Guideline. The patient may also upload their My Health Record System.

These alerts are added to the Alert Management by the clinician/HIS/Community-based Clinical Records Unit (CRU) who receives the Advance Care Plan. If the clinician receives the Advance Care Plan a copy of the document must be sent to HIS or CRU to be uploaded to the patient’s CPF record. For more information about Advance Care Plans refer to Advance Care Planning Procedure.

Respecting Choices Alerts in the Alert Management System are: Advance Care Plan - outlines a person’s values and wishes for treatment preferences to

guide families and treating teams, recognised in common law as the person’s voice and respected accordingly. Advance Care Plan Statement of Choices is the document currently used within the ACT. There are two versions, competent (15305) and no legal capacity (15306). Many Registered Aged Care Facilities and primary care have their own version, hand crafted documents also acceptable versions

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Enduring Power of Attorney (EPA) – is a legal document that enables the patient to appoint another person/s to act on their behalf in the instance of impaired decision-making capacity. NSW patients may have an Enduring Guardian who makes decisions for health and personal care. In NSW an Enduring Power of Attorney limits decision making to finance and property decisions. To be legally valid these documents must be completed when the person has the capacity to do so and witnessed by a lawyer or clerk of the court.

Goals of Care – the patient has a Goals of Care and/or Resuscitation Plan which documents the patient’s goals for their medical treatment and end of life care, as agreed between the patient, family, carers and healthcare team. The treating team member who records the Goals of Care and/or Resuscitation Plan in the patient’s clinical record should place the alert in the patient’s profile in Alert Management System. For more information refer to Goals of Care and Resuscitation Plan Guideline

Health Direction – is a legal document that enables the patient to document their refusal of certain medical treatment (except palliative care). A Health Direction becomes invalid if it is inconsistent with a later dated EPA. The latest dated document either Health Direction or EPA will be the one referred to.

Power of Attorney - is a legal document authorising an attorney/decision maker to act on behalf of a person in relation to finance. It does not allow the attorney to make personal or healthcare decisions, including consenting to medical treatment for the patient. A Power of Attorney is only valid while the patient has legal capacity and has an end date.

Other Advance Care Plan - the patient has a current ACP that is not defined elsewhere. Please list the documents in the alert details section.

Management of Respecting Choices AlertsWhen the Advance Care Planning team assist the patient to develop and complete the document/s or when documents are submitted to the program for lodgement the team member will add the alert to the patient’s profile in the Alert Management System and send a copy of the document/s to HIS for upload to the patient’s CPF record.

When a patient provides a copy of their ACP document/s to Clinical Records (HIS) directly, the ACP document will be passed to one of the HIS supervisors or managers to add the alert to the patient’s profile in the Alert Management System and upload the document/s to the patient’s CPF record.

When a patient provides their ACP document/s directly to a member of their treating team at any time during their episode of care, the team member who receives the documents should add the alert to the patient’s profile in the Alert Management System and send a copy of the document/s to HIS for upload to the patient’s CPF record. Administrative Officers can assist the clinician to send a copy of the document/s to HIS.

ACP documents are valid until a new document is written to supersede the previous document, so ACP alerts do not require expiry dates. However, the treating team should

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check with the patient and/or their carer/family at each episode of care that the document we have on record is the most current one.

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Section 8 – Behaviour and Safety Alert Management

Behaviour and Safety Alerts inform clinicians when there is a risk to staff and/or risk to the safety of other patients.

Behaviour and Safety Alerts in the Alert Management System are: Absconding – the patient is at risk of absconding or wandering. Absconding is when a

patient leaves the ward or hospital without permission. Wandering may be the result of a mental health issue, cognitive impairment or another disorder. If the wandering behaviour of the patient is of concern, a management plan should be developed and implemented for the patient. Please provide details of the behaviour and management plan in the details section. Please see Absconding or Missing Patient Procedure for more information.

Aggressive/Violent Behaviour – there is a risk of aggression and/or violence towards others. Aggressive and/or violent behaviour may include: any form of physical attack, attempts to perform a physical attack, physical intimidation, verbal intimidation, and written communication with threats. Please specify in the details section who the aggression/violence may come from, for example: the patient, the child’s parent, the consumer’s carer. Please also document any recommendations for managing the aggression/violence. Please refer to Occupational Violence Policy, Occupational Violence Procedure, Identification, Mitigation and Management of Aggression and Violence for MHJHADS and Searching of a Consumer’s Person or Property Policy.

Carries weapons - The patient is known to carry weapons. The patient may conceal their weapon on their person or in a bag. Weapons may include knives, syringes, guns, and baseball bats. An assessment of the risk associated with providing services to a patient who carries a weapon should be undertaken, and processes put in place to ensure the safety of staff and other patients. Security staff may need to be present for appointments with a patient who is known to carry weapons. Please add information about the management plan in the alert Details section. If considering searching the patient, please refer to Searching of a Consumer’s Person or Property Policy.

Excluded Visitor – the patient has requested that a person/people be excluded from visiting them while they are an inpatient. This may be due to personal safety reasons or other personal reasons. Staff should not provide any information about the patient to the excluded visitor or allow the excluded visitor access to patient. Security should be called if the excluded visitor presents and staff, the patient or other patients/visitors feel threatened. If there is a safety concern, a safety plan should be documented in the details section. Please provide information about the person/people excluded from seeing the patient in the details section.

Falls Risk – a falls risk assessment has been completed with a patient and they have been identified as at risk of having a fall. Please refer to Falls Prevention and Management Procedure for further information

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Family Violence – the patient is experiencing family violence. Note: All staff should proceed with caution to ensure that the patient/consumer’s confidentiality is always maintained, including ensuring that the patient’s paperwork that displays this alert is held in a secure location (preferably placed immediately in a clinical folder). This also includes noting anonymous status or where there is a concurring excluded visitor or other safety alert.

It is the responsibility of all Tier 2 SHRFV trained specialist family violence clinicians, as a component of conducting Family Violence Risk Assessment and Safety Planning, to consider the placement of an alert on clinical portal. A Family violence (FV) alert should only be activated with the consent of the patient/consumer and with due consideration given to any additional risk/benefit of placing an alert on clinical portal. Where relevant, the specialist family violence clinician is responsible for obtaining a copy of a Family Violence Order (FVO) and emailing this document as soon as practicable to HIS to be uploaded to CPF. The email is to have as the subject title, the patient/consumers URN: and marked ‘Family Violence Order’. HIS will scan the CPO as soon as practicable to CPF (at minimum within 2 business days). Upon subsequent inpatient episodes, it is the responsibility of any member of the treating team to re-activate a referral to a Tier 2 trained social worker for review. Where the patient/consumer has ongoing contact with a trained specialist family violence clinician, it is the responsibility of this clinician, as a component of ongoing risk assessment and safety planning to review at regular intervals the FV alert and any associated FVO. At minimum a FV alert should be reviewed at the commencement of an episode of care. For more information please see Family Violence Adults and Children Guideline.

Inappropriate Sexual Behaviour - The patient has recently displayed inappropriate sexual behaviour leading to discomfort of CHS staff or others. Inappropriate sexual behaviour can include talking about sex, lewd jokes, flirtatiousness, hugging and/or kissing, fondling and/or masturbation, urination, disrobing, obscene or explicit language, or touching people when they don't want to be touched. If the inappropriate sexual behaviour of the patient is of concern, a Management Plan should be developed and implemented. Please document information about the behaviour and management of the behaviour in the alert Details section. Please refer to Occupational Violence Policy and Occupational Violence Procedure.

Pre-birth alert – indicates that there are risks which have been identified during pregnancy for the safety of the child once it is born. The ward clerk in delivery suite receives the Pre-Birth Alert document from Child and Youth Protection Services and places a copy in the patient’s clinical record. A copy of the document is sent to HIS for uploading into CPF. A member of the treating team places the alert on the mother’s profile in Alert Management System. The alert is closed by a treating team member once the child is born. Once the child is born Child and Youth Protection Services will undertake a risk assessment/appraisal/emergency action as required. For further information refer to Child Protection Policy and Child and Prenatal Concern Reporting Guideline.

Self-harm – the patient has displayed non-fatal self- inflicted harm behaviour recently (within 4 weeks, or longer if consider clinically relevant). This behaviour may be due to mental illness, disability or head injury. If the self-harm behaviour of the patient is of

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concern, a management plan should be developed and implemented for the patient. Please provide details of the behaviour and management plan in the details section. Please see the following related procedures for further management information Initial Management, Assessment and Intervention for People Vulnerable to Suicide Procedure, Ligature Risk Management for Mental Health, Justice Health and Alcohol and Drug Services Inpatient Mental Health Units, Ligature use in Inpatient Mental Health Units Response and Management Procedure, or Adolescent Mental Health Assessment and Referral School Youth Health Nurse Procedure.

Thoughts of Arson – the patient is experiencing thoughts of arson. Arson is a criminal act where a person wilfully and maliciously sets fire to or aids in setting fire to a structure, dwelling or property of another. This behaviour may include voicing wanting to start fires or watch something burn. If the thoughts of arson by the patient is of concern, a Management Plan should be developed and implemented. Please document information about the behaviour and management of the behaviour in the alert Details section.

Other Behaviour and Safety - The patient is expressing behaviour that is not defined elsewhere. If the behaviour is of concern, a Management Plan may need to be developed and implemented. Please add information about the behaviour and management of the behaviour in the alert Details section.

Management of Behaviour and Safety AlertsThese alerts, except for family violence and pre-birth alert, are managed by all members of the patient’s treating team. The minimum requirement for reviewing of Behaviour and Safety Alerts is on admission/initiation of episode of care, with any change in the safety and security of staff and other patients (such as completion of a staff or clinical incident form relating to safety and security), with any change to a patient’s behaviour or management of the behaviour and at discharge/completion of episode of care.

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Section 9 – Home Environment Alert Management

Home Environment Alerts inform clinicians when there is a risk to staff or information staff need to be aware of when visiting a patient’s home.

Home Environment Alerts in the Alert Management System are: Access Issues - The patient’s home currently has access issues for staff. Access issues

may inhibit a staff member's ability to access to the patient to provide care. Access issues include remote residences, difficulty accessing the property the residence resides on, the need to utilise stairs to access the residence, and behaviours that may inhibit access, including hoarding and booby traps. Please add information about the access issues in the alert Details section. See Home Visiting Procedure for more information.

Access to weapons – the patient has access to weapons. Please include in the details section if the patient is known to carry the weapon, if a risk assessment for treating the patient has been completed and required processes to ensure the safety of staff and other patients. If considering searching the patient, please refer to Searching of a

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Consumer’s Person or Property Policy. If the patient is having home visits, please confirm if a home visiting risk assessment has been completed and the outcome. See Home Visiting Procedure for more information.

Animal in the Home - The patient currently has an animal/s in the home. The animal/s may be an indoor or outdoor pet. The animal/s may not be dangerous or aggressive; but may impact on the staff member providing care or impede care being provided. Staff may request the animal/s be housed in their cage or outside during a home visit. Please add information about the animal and management (if required) in the alert Details section. See Home Visiting Procedure for more information.

Phone Reception - The patient currently has limited mobile coverage in transit to or at the home. Staff members should appropriately assess the impact to safety the limited mobile coverage may have. Emergency calls are still available to staff on a mobile phone with no mobile coverage if required. Please add information about the reception issued in the alert Details section. See Home Visiting Procedure for more information.

Two Workers Recommended - The patient currently has a recommendation that two workers attend home visits. Two workers may be recommended for a variety of reasons. These reasons may not be apparent when undertaking an Off Campus Visit Risk Assessment Form or Home Visit Pre-Assessment form, the issue may have been found by a staff member/s who has undertaken a home visit in the past. Suitable precautions should be taken when home visiting the patient. Please add information about the issue and how to manage the issue in the alert Details section. See Home Visiting Procedure for more information.

Other Home Environment – The patient or their home environment place a risk to staff visiting the patient’s home that is not covered by the other Home Environment Alerts. Please add information about risk and any management processes in place in the alert Details section.

Management of Home Environment AlertsThese alerts are managed by all members of the patient’s treating team. The minimum requirement for reviewing of Home Environment Alerts is on admission/initiation of episode of care, with any change in the safety and security of staff (such as completion of a staff or clinical incident form relating to safety and security), and at discharge/completion of episode of care

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Section 10 – Special Needs and/or Preferences Alert Management

Special Needs and/or Preferences Alerts are to inform clinicians when a patient has additional requirements that need to be considered when delivering care and treatment to the patient.

Special Needs and/or Preferences alerts are managed by all members of the patient’s treating team. The minimum requirement for reviewing of Special Needs and/or Preferences Alerts is on admission/initiation of episode of care, with any change in the patient’s condition, and at discharge/completion of episode of care.

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Special Needs and/or Preferences Alerts in the Alert Management System are: Bariatric - The patient currently has bariatric requirements. Overweight and obesity is

measured for adults using the Body Mass Index (BMI), which is calculated by dividing weight in kilograms by height in metres squared. According to the World Health Organisation, an adult is considered overweight if they have a BMI of 25.00 or above. Overweight: >= 25.00 Pre-obese: 25.00 - 29.99 Obese class 1: 30.00 - 34.99 Obese class 2: 35.00 - 39.99 Obese class 3: >= 40.00 Please consider manual handling issues and utilise specialised bariatric equipment when caring for the patient. For further information on manual handling and access to bariatric equipment, please refer to Active Management of Larger (Bariatric) Adult Patients Procedure or Obesity – Pregnancy Labour Birth and Postnatal Care Guideline. Please add information about the patient’s requirements in the alert Details section.

Carer Required - The patient requires a carer to accompany them to treatment. A patient may require a carer due to a disability, a chronic health condition or mental illness, or because they are recovering from an illness or accident. Please add information about the carer and the support they offer the patient in the alert Details section.

Cognitive Impairment – the patient has been assessed as having impaired cognition (Abbreviated Mental Test 10 score less than or equal to 7). Nursing staff who complete the assessment on the patient place the alert on the Alert Management System. Please see Cognitive Impairment (CI) Procedure for more information.

Dietary Requirement - The patient has a dietary requirement. A patient's dietary requirement may be due to safety or personal reasons. Safety reasons may include the need for a texture modified diet or thickened fluid diet. Personal reasons may be due to the patient's religious, cultural or personal beliefs; and may include such diets as halal, kosher, vegetarian, or vegan. If the patient has a dietary allergy and/or intolerance they should be recorded as an Adverse Reaction, please see Section 2. Please document information about the dietary requirement in the alert Details section.

Family Bereavement – the patient has experienced the death of a child or loss of a pregnancy or the patient has died, and their family are wanting to visit the patient to say goodbye/conduct religious ceremonies. Please document information about the requirements of the patient/their family in the alert Details section. For more information refer to Neonatal Death, Bereavement, Palliative Care and Borderline of Viability Guideline, Termination of Pregnancy, Miscarriage or Fetal Death Guideline, or Death and Dying Procedure.

Hearing Impaired - The patient has difficulty hearing. The patient may have trouble communicating and have a preferred method of communication. Possible methods may include lip reading, Auslan (Australian Sign Language), written instructions, or a combination of methods. Special contact requirements, e.g. National Relay Service (NRS), should be recorded under the Special Contact Method Required alert. The use of an Auslan interpreter should be recorded under the Interpreter Required alert. Please document information about the patient’s hearing impairment and management in the alert Details section.

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Interpreter Required - The patient requires an interpreter. An interpreter is required where there is a likelihood of misunderstanding due to language differences. Family members should not be used as an interpreter. The Translating and Interpreting Service (TIS) provides interpreting services in over 170 languages and are available on-site or via telephone 24 hours a day. For further information on interpreter services, please refer to Language Services Interpreters Policy and Procedure. Please document details of the patient’s requirements, including language required and if the interpreter should be male or female, in the alert Details section.

Physical Disability - The patient has a physical disability. The patient's physical disability may limit or restrict their mobility, impacting on their ability to access services and participate in treatment. The disability may also limit or restrict their ability to care for themselves, communicate, and complete paperwork. Please document information about the patient’s physical disability and management in the alert Details section.

Special Contact Method Required - The patient requires a special contact method requirement due to an impairment or illness, including a mental health illness. The patient may not respond to other forms of contact or may respond poorly to other contact methods. A special contact method may be a text message, email, Australia Post, or telephone. Please document the patient’s requirement for contact in the alert Details section.

Speech Difficulty - The patient has difficulty communicating verbally. The patient's speech difficulty may limit their ability to express themselves through verbal or written communication or understand verbal or written communication. This may impact on their ability to access services and participate in treatment. Their speech difficulty may also limit or restrict their ability to care for themselves and complete paperwork. Special contact requirements, e.g. National Relay Service (NRS), should be recorded under the Special Contact Method Required alert. Please document the patient’s speech difficulty and management in the alert Details section. The alert is to be given a default 3-month end date unless otherwise clinically indicated.

Vision Impaired - The patient is vision impaired. The patient may have trouble navigating their way to access services. The patient may use a white cane, guide dog, and/or a GPS navigating device to help them with their mobility. Please document the patient’s vision impairment and management in the alert Details section.

Other Special Needs and/or Preferences – The patient has a current additional requirement and/or preference that is not defined elsewhere, for example multiple chemical sensitivity/idiopathic environmental intolerances. Please add information about the requirement and/or preference in the Alerts details section. This alert is to be used to identify transgender patients who want to be known as a different name or gender but have not changed these details on the Births, Death and Marriage register.

Transgender patientsWhen a transgender patient who wants to be known by a name and/or gender different to their legal name and/or gender (the name and gender on their Medicare card) is admitted, they can request to be identified by their preferred name and/or gender. See Patient Identification and Procedure Matching Procedure for more information. The treating team staff member completing the admission of the patient can add an alert under other

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additional requirements and/or preferences. Rename the alert name to Gender and document the patient’s preferred name and gender in the alert details section. The preferred name and gender should also be documented in ACTPAS under the ALIAS section. Once the patient has legally changed their name and/or gender the staff member completing their admission or check in can use their new Medicare card to update their ACTPAS record and the alert can be closed in their Clinical Portal record.

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Section 11 – Governance of Alerts

Adding a new alert or alert category or editing an existing alert or categoryIf a clinician wants to add a new alert or alert category to the Alert Management System or change an existing alert or alert category, please send the details of the change and reason for the change to the Enterprise Systems Governance Committee for approval. Once the change is approved Digital Services Division at ACT Health Department will update the Alert Management System. The process of making a change in Alert Management System may take up to 12 weeks.

Enterprise Systems Governance CommitteeThis committee governs changes to information technology systems. All requests for changes to the Alerts Management System are to be submitted to ACTHealthCIO@act.gov.au . The terms of reference and meeting papers of the committee are available on the Digital Services Division Governance and Strategy SharePoint page https://actgovernment.sharepoint.com/sites/intranet-ACTHealth/SitePages/Governance-and-Strategy.aspx

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EvaluationOutcomePatient Alerts will be managed as documented in this procedure.

Measurement Consumer feedback complaints related alerts are reviewed annually. Incident reports (both Clinical and Work Health and Safety) related to alerts are reviewed

annually.Back to Table of Contents

Related Policies, Procedures, Guidelines and Legislation

Policies Nursing and Midwifery Continuing Competence Consent and Treatment

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Patient Identification and Procedure Matching Clinical Records Management Language Services Medication Handling Child Protection Occupational Violence Family Violence

Procedures Absconding or Missing patient Death and Dying Active Management of Larger (Bariatric) Adult Patients Infection Prevention and Control - Healthcare Associated Infections Patient Identification and Procedure Matching Clinical Records Management Community Based Clinical Records Discharge Summary Completion Falls Prevention and Management Pressure Injury Prevention and Management Clinical Handover Clinical Handover – MHJHADS Language Services Interpreters Initial Management, Assessment and Intervention for People Vulnerable to Suicide Ligature Risk Management for Mental Health, Justice Health and Alcohol and Drug

Services Inpatient Mental Health Units Adolescent Mental Health Assessment and Referral School Youth Health Nurse Care of Persons Subject to Forensic Mental Health Orders (FMHOs) Care of Persons subject to Psychiatric Treatment Orders (PTOs) with or without a

Restriction Order (RO) Advance Agreements, Advance Consent Directions and Nominated Persons under the

Mental Health Act 2015 Ligature use in Inpatient Mental Health Units Response and Management Paediatrics – Acute Management of Seizures Coagulation Factor Replacement Products Continuous Infusion Adults, Paediatrics

including Adolescents and Infants NOT Neonates Home Visiting Tracheostomy Management Adults Haemodialysis for Adults Peritoneal Dialysis Advance Care Planning Cognitive Impairment Occupational Violence Identification, Mitigation and Management of Aggression and Violence for MHJHADS Acute Screening of Swallow in Stroke, Transient Ischaemic Attacks (ASSIST) for Adults Multiple Chemical Sensitivity/Idiopathic Environmental Intolerance

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Guidelines Child Protection and Child and Prenatal Concern Reporting Fasting Guidelines – Elective and Emergency Surgery Family Violence Adults and Children Medical Management of Alcohol Withdrawal Obesity – Pregnancy Labour Birth and Postnatal Care Neonatal Death, Bereavement, Palliative Care and Borderline of Viability Guideline,

Termination of Pregnancy, Miscarriage or Fetal Death Goals of Care and Resuscitation Plan Tracheostomy Care and Management – Infants, Children and Adolescents Dysphagia – Management in Adults and Children (Speech Pathology) Intermittent Haemodialysis

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Mental Health Act 2015 Personal Violence Act 2016 Work Health and Safety Act 2011 Family Violence Act 2016 Guardianship and Management of Property Act 1991

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Definition of Terms

ACT Patient Administration System (ACTPAS) is a computerised Patient Management System.

ARIA – oncology information management system used by Radiation Oncology CardioBase - Cardiology electronic medical record system used by cardiology services Cbord - nutrition information management system CHARM – oncology information management system and is an outpatient scheduler for

consultations, treatment pathways and ad-hoc treatments for Haematology, Immunology and Medical Oncology

Clinical Patient Folder (CPF) is an electronic document storage and retrieval system, it provides online access to scanned clinical records for authorised users.

Clinical Vision V (CV5) electronic medical, nursing, allied health and administrative information and data for renal patients in the ACT and Southern NSW Local Area Health Network. Used by renal and haemodialysis services.

DietPAS - computerised system that manages specific patient requirements through diet selection.

Electronic Medication Management (EMM) – MedChart is a clinical information system that supports the management of medication for patients from admission to discharge.

Emergency Department Information System (EDIS) – electronic medical record for Emergency Department patients.

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Flow manager system allows consumers to check in for their outpatient appointment via a self-service kiosk. Administration and clinical staff use the Flow Manager dashboard to manage patient arrivals and to communicate follow up appointment information.

Integrated Diagnostic Imaging Solution (IDIS)is an integrated technology solution for Medical Imaging services at public hospitals in the ACT.

Mental Health, Alcohol, Justice Health Integrated Care Electronic Record (MAJICeR) is the single source of integrated electronic clinical information for Mental Health, Justice Health, Drug and Alcohol Services.

MetaVision - electronic clinical information system used in Intensive Care Unit Patient Digital Journey Boards (PDJB) - provide increased visibility and distribution of

real-time information regarding the patient’s demographic information, location, alerts and transport needs. They are a communication tool designed to increase awareness of a patient’s status at any given time and assist care planning and the discharge process for every patient based on the shared information available to everyone

Protected Person – The person subjected to a guardianship order is known as a protected person.

SHRFV – Strengthening Health Responses to Family Violence Treating Team – Clinicians at CHS who are involved in the care and treatment of the

patient. This includes Medical, Nursing, Midwifery and Allied Health Staff Tier 2 SHRFV specialist family violence clinician – CHS clinician who has completed the

CHS Family Violence Risk assessment and safety planning training to consider whether a FV alert is included as a component of a family violence safety plan.

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Search Terms

Alerts, Management, Clinical Portal, Patient Digital Journey Board, ACTPAS, MAJICeR, DietPAS, EDIS, CPF, IDIS, patient, flow, CBORD, system, allergy, adverse reaction, food, violence, medication, legal, advance care plan, safety, security, additional, requirements, care, coordinated, infectious, aggression, physical, home visit, disability, OV, plan, behaviour

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Attachments

Attachment 1: Alert Information flow between systemsAttachment 2: Patient Digital Journey Board Alert Icons

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 17/06/2020 New Document Liz Chatham, ED QSII CHS Policy Committee

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This document supersedes the following: Document Number Document Name

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Attachment 1: Alert information flow between systems

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Attachment 2: Patient Digital Journey Board Alert Icons

The icons displayed have all been linked to alerts within the Alert Management System.

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Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register