SCHEDULE 3 - Additional Licensing Standards for Private Hospitals authorised to provide Specialised Services

Regulation 6(6) , (7) , (8) and (9)

PART 1 - Cardiac Catheterisation

1.    Interpretation

In this Part –

cardiac catheterisation means the procedure of passing a catheter (or other instrument) through a major blood vessel to the heart for a diagnostic or therapeutic purpose.

2.    Medical advisory committee

The medical advisory committee of a private hospital authorised to provide cardiac catheterisation services is to include a cardiologist trained in cardiac catheterisation techniques, and an anaesthetist experienced in cardiac procedures, while matters relating to cardiac catheterisation are being discussed.

3.    Conduct of cardiac catheterisation unit

(1) Coronary angioplasty may be performed only on –

(a) patients who would not be expected to require cardiac surgery regardless of the outcome of the angioplasty; or

(b) patients for whom there is a low risk of requiring urgent cardiac bypass surgery.

(2) Emergency coronary angioplasty may be performed in a private hospital only in a case of –

(a) cardiogenic shock; or

(b) acute myocardial infarction, where thrombolytic therapy is relatively contraindicated, or found to be ineffective; or

(c) acute myocardial infarction where the coronary artery anatomy is known and the lesion is suitable for angioplasty.

(3) A patient requiring emergency coronary angioplasty may not be transferred from another hospital to the private hospital and must be transferred to the nearest public hospital with a cardiac catheterisation unit that can undertake emergency procedures.

(4) Patients for whom there is a high or moderate risk of requiring urgent coronary artery bypass surgery, including patients who would require ambulance standby or cardiac surgery operating theatre standby, are to be transferred to the nearest public hospital with a cardiac catheterisation unit that can undertake emergency procedures.

(5) Angioplasty may be performed at a private hospital only by a cardiologist who has performed at least 75 angioplasty procedures in the previous 12 months.

(6) Morbidity records on a person having coronary angioplasty at the private hospital are to be provided to the Secretary in an approved form and the records are to be provided in respect of each year before 31 March in the following year or at any other time when requested by the Secretary.

(7) A private hospital authorised to provide cardiac catheterisation services –

(a) must have a written policy in respect of all of the following matters:

(i) the criteria for the admission of patients to cardiac catheterisation;

(ii) the program of care for patients following cardiac catheterisation;

(iii) the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift;

(iv) the qualifications of those practitioners and staff;

(v) the provision made for the transfer of patients to another hospital that provides a higher level of medical service; and

(b) must have a written policy giving full details of the quality assurance procedures established by the private hospital concerning cardiac catheterisation services; and

(c) must have a suitable number of appropriate staff, including a specialist director of cardiac catheterisation services, registered nursing staff with relevant experience and allied health staff; and

(d) must have an in-patient orientation and education program; and

(e) if the private hospital is not authorised to carry out open heart surgery, must have contingency arrangements with a nearby hospital capable of performing open heart surgery for the transfer of patients in an emergency.

4.    Retention of clinical records

The films or other archival media on which a cardiac catheterisation procedure is recorded must be kept for at least 3 years after the date when the procedure was carried out.

5.    Identification of patients

(1) An identification band must be fitted around a wrist or an ankle of a cardiac catheterisation patient.

(2) The patient’s name and date of birth and the attending medical practitioner’s name must be written indelibly and legibly on the band.

6.    Medical, surgical and nursing equipment

Each procedure room in a cardiac catheterisation unit must have its own resuscitation equipment including a defibrillator.

PART 2 - Emergency Services

1.    Interpretation

In this Part –

emergency service means a service for the care of persons injured in accidents, or for those suffering from medical or other emergencies, through the provision of reception, resuscitation, medical and surgical facilities and life support systems.

2.    Conduct of emergency service

A private hospital approved to provide an emergency service –

(a) must have a written policy relating to all of the following matters:

(i) the coordination of the service with other emergency services in the same district as the private hospital;

(ii) the integration of the emergency service with the clinical and educational activities of the private hospital;

(iii) the admission and discharge of patients and the review of the care provided to patients;

(iv) the provision of information and counselling to relatives and friends of patients; and

(b) must have an appropriately qualified and experienced medical practitioner appointed as director of the emergency service; and

(c) must have arrangements for appropriate specialists to be available on close call at all times; and

(d) must have sufficient appropriately trained and experienced staff on duty and immediately available at all times; and

(e) must have an effective system of triage which separates patients needing emergency services from patients needing primary health care; and

(f) must have arrangements for the provision of primary health care in appropriate cases; and

(g) must have contingency arrangements for the transfer of patients by retrieval teams to a hospital providing a higher level of care if needed.

3.    Clinical records

The private hospital’s clinical record for each emergency patient must include –

(a) the date and time of arrival and separation; and

(b) a description of significant clinical, laboratory and radiological findings; and

(c) accurate details of any treatment provided; and

(d) the identity and signature of the attending medical officer.

4.    Medical and nursing equipment

An emergency service must be equipped with –

(a) suitable monitors and ventilators; and

(b) resuscitation and diagnostic equipment and drugs, adequate for the planned maximum numbers of child and adult patients who may be undergoing examination or treatment by the service at any one time.

PART 3 - Intensive Care

1.    Interpretation

In this Part –

intensive care means the observation, care and treatment of patients with life-threatening or potentially life-threatening illnesses, injuries or complications, from which recovery is possible, in a separate intensive care unit that is specially staffed and equipped for that purpose.

2.    Medical advisory committee

When matters relating to intensive care are being considered, the medical advisory committee of a private hospital authorised to provide intensive care must include a medical practitioner with experience in intensive care.

3.    Conduct of an intensive care unit

Intensive care services must comply with the Minimum Standards for Intensive Care Units as published by the Joint Faculty of Intensive Care Medicine.

4.    Identification of patients

(1) An identification band must be fitted around a wrist or an ankle of each patient admitted to the intensive care unit.

(2) The patient’s name and date of birth and the attending medical practitioner’s name must be written indelibly and legibly on the band.

5.    Medical, surgical and nursing equipment

An intensive care unit must have the following:

(a) ventilators;

(b) hand ventilating assemblies;

(c) suction apparatus;

(d) airway access equipment, including bronchoscopic equipment;

(e) vascular access equipment;

(f) monitoring equipment, both non-invasive and invasive;

(g) defibrillation and pacing equipment;

(h) equipment to control patients’ temperatures;

(i) chest drainage equipment;

(j) infusion and specialised pumps;

(k) transport monitoring equipment;

(l) specialised intensive care beds.

PART 4 - Neonatal Intensive Care

1.    Interpretation

In this Part –

neonatal intensive care means life support, monitoring and care for newly born children suffering from life-threatening prematurity, illness or disability at birth or post-birth complications.

2.    Medical advisory committee

When matters relating to neonatal intensive care are being considered, the medical advisory committee of a private hospital authorised to provide neonatal intensive care must include a specialist paediatrician with neonatal experience.

3.    Conduct of a neonatal intensive care unit

A private hospital authorised to provide neonatal intensive care –

(a) must have a written policy in respect of all of the following matters:

(i) the private hospital’s criteria for admission to the neonatal intensive care unit;

(ii) the care of children admitted for neonatal intensive care;

(iii) the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift;

(iv) the quality assurance programs established by the private hospital;

(v) provision made by the private hospital for the transfer of patients to another hospital providing a higher level of service; and

(b) must have a specialist paediatrician or paediatric registrar on close call at all times, or a resident medical officer on duty at all times and a specialist paediatrician or paediatric registrar on call at all times; and

(c) must have a sufficient number of registered nurses, a majority of whom are specially trained and permanently attached to the unit, on duty in the neonatal intensive care unit at all times; and

(d) must have contingency arrangements for the transfer of patients to a hospital providing a higher level of neonatal intensive care in an emergency.

4.    Identification of patients

(1) An identification band must be fitted around a wrist and an ankle of each neonatal intensive care patient.

(2) The patient’s name and date of birth and the attending practitioner’s name must be written indelibly and legibly on the band.

5.    Medical, surgical and nursing equipment

A neonatal intensive care unit –

(a) must have at least one-half of the approved number of cots fitted as humidicribs; and

(b) must have cardio-respiratory monitoring equipment for each cot; and

(c) must have sufficient intravenous fluid therapy equipment; and

(d) must have sufficient tube feeding equipment; and

(e) must have sufficient phototherapy equipment; and

(f) must have a resuscitation trolley containing a complete set of paediatric resuscitation and monitoring equipment.