Clinical Skills Assessment Manual

International SOS
MEDICAL SERVICES
L4 MS CORP Clinical Skills Assessment

Manual
Linked to:
L2 MS Standards for Medical Facilities
L2 MS Standards for Medical Service Centres
L3 Medical Escalation Protocols for Doctors Nurses &
Paramedics
L3 MS CORP Clinical Governance in Medical Services
Version 1.01
Document Owner: Medical Services

Document Manager: Group Assistant General Manager Quality & Compliance
Effective: August 2020
© 2018 All copyright in these materials are reserved to AEA International Holdings Pte. Ltd.
No text contained in these materials may be reproduced, duplicated or copied by any means
or in any form, in whole or in part, without the prior written permission of AEA International
Holdings Pte. Ltd.
The only controlled copy of this document is maintained electronically. If this document is
printed, the printed version is an uncontrolled copy.
L4 MS Clinical Skills Assessment Manual
Version 1.01
August 2020
TABLE OF CONTENTS
1. INTRODUCTION........................................................................................................................... 6
1.1. Purpose ............................................................................................................................... 6
1.2. Objectives ............................................................................................................................ 6
1.3. Scope ................................................................................................................................... 6
2. CLINICAL SKILL LEVELS ............................................................................................................ 7
3. GUIDELINES FOR USE ............................................................................................................. 11
4. SECTION 1 – PATIENT ASSESSMENT .................................................................................... 12
4.1. Hand Hygiene .................................................................................................................... 13
4.2. Systematic Approach ......................................................................................................... 14
4.3. Vital Sign Assessment (VSS) ............................................................................................ 15
4.4. Glucometry ........................................................................................................................ 16
4.5. Temperature Assessment ................................................................................................. 17
4.6. Pulse Oximetry .................................................................................................................. 18
4.7. Urinalysis (Dipstick) ........................................................................................................... 19
5. SECTION 2 – MOVING A PATIENT ........................................................................................... 20
5.1. Scoop Stretcher ................................................................................................................. 21
5.2. Spine Board ....................................................................................................................... 22
5.3. Kendrick Extrication Device (KED) .................................................................................... 23
5.4. Vacuum Mattress ............................................................................................................... 25
5.5. Stair Chair .......................................................................................................................... 26
5.6. Standard Ambulance Stretcher ......................................................................................... 27
5.7. Ambulance Stretcher Drop Wheel ..................................................................................... 28
5.8. Removal of a Helmet ......................................................................................................... 29
6. SECTION 3 – AIRWAY MANAGEMENT .................................................................................... 30
6.1. Oropharyngeal Airway ....................................................................................................... 31
6.2. Nasopharyngeal Airway ..................................................................................................... 33
6.3. Laryngeal Mask Airway (LMA) ........................................................................................... 34
6.4. Laryngoscopy & Magill Forceps ........................................................................................ 36
6.5. Endotracheal Intubation ..................................................................................................... 38
7. SECTION 4 – OXYGEN THERAPY ............................................................................................ 41
7.1. Nasal Cannula ................................................................................................................... 42
7.2. Nebulising Mask / Nebulisation ......................................................................................... 43
7.3. Simple Face Mask ............................................................................................................. 45
7.4. Non – Rebreather Mask .................................................................................................... 46
7.5. Intermittent Positive Pressure Breathing (IPPB) ............................................................... 48
7.6. Intermittent Positive Pressure Ventilations (IPPV) ............................................................ 50
7.7. Oxylog 1000 Ventilator ...................................................................................................... 51
7.8. Oxylog 2000 Ventilator ...................................................................................................... 53
7.9. Oro-Naso Pharynx Suctioning ........................................................................................... 55
7.10. ETT Suctioning .................................................................................................................. 57
7.11. Capnography ..................................................................................................................... 59
8. SECTION 5 – CARDIO PULMONARY RESUSCITATION ......................................................... 60
8.1. Adult CPR / AED................................................................................................................ 61
8.2. Child CPR / AED................................................................................................................ 63
8.3. Infant CPR ......................................................................................................................... 65
9. SECTION 6 – DEFIBRILLATION / CARDIAC MONITORING .................................................... 67
For Intl.SOS Internal Use Only

Page 2 of 134
Version 1.01
August 2020
9.1. Cardiac Monitoring 3 Lead / 12 Lead ................................................................................ 68

9.2. Cardiac Monitoring Recording 12 Lead ECG ................................................................... 69
9.3. Defibrillation ....................................................................................................................... 72
9.4. Synchronised Cardioversion .............................................................................................. 75
9.5. Transcutaneous Cardiac Pacing (TCP) ............................................................................. 77
10. SECTION 7 – DRUG/FLUID ADMINISTRATION ....................................................................... 79
10.1. Oral Medication Administration .......................................................................................... 80
10.2. Vaccination ........................................................................................................................ 82
10.3. Subcutaneous Injections ................................................................................................... 84
10.4. Intramuscular Injections ..................................................................................................... 85
10.5. Intravenous Injections ........................................................................................................ 86
10.6. Intraosseous Cannulation .................................................................................................. 88
10.7. Extra Jugular Venous Cannulation .................................................................................... 89
10.8. Fluid Replacement ............................................................................................................. 90
10.9. Syringe Driver .................................................................................................................... 92
11. SECTION 8 – PROCEDURES .................................................................................................... 93
11.1. Phlebotomy ........................................................................................................................ 94
11.2. Urinary Catheter Insertion – Female Patient ..................................................................... 96
11.3. Urinary Catheter Insertion – Male Patient ......................................................................... 99
11.4. Nasogastric Tube Insertion .............................................................................................. 102
11.5. Suturing ........................................................................................................................... 105
11.6. Vision Testing .................................................................................................................. 108
11.7. Eye Examination / Eye Irrigation / Removal of Foreign Object ....................................... 110
12. SECTION 9 – FRACTURE MANAGEMENT............................................................................. 114
12.1. Vacuum Splints ................................................................................................................ 115
12.2. Sager Bilateral S304 / TRAC 3 (HARE) Traction Splints ................................................ 116
12.3. Cervical Collar ................................................................................................................. 117
13. SECTION 10 – DRESSINGS & BANDAGES ........................................................................... 118
13.1. Aseptic Dressings ............................................................................................................ 119
13.2. Apply a Sling .................................................................................................................... 121
13.3. Burns Dressing ................................................................................................................ 123
13.4. Haemorrhage Control ...................................................................................................... 124
13.5. Envenomation .................................................................................................................. 126
14. SECTION 11 – OTHER EMERGENCY PROCEDURES .......................................................... 127
14.1. Emergency Chest Decompression .................................................................................. 128
14.2. Chest Drain Insertion ....................................................................................................... 130
14.3. Cephalic Delivery ............................................................................................................. 132
14.4. Breech Delivery ............................................................................................................... 133
15. ENFORCEMENT AND REPORTING BREACHES .................................................................. 134

Page 3 of 134
Version 1.01
August 2020
Medical Services International SOS Templates

LINK TO STANDARD: L2 MS Standards for Medical Facilities DOCUMENT OWNER: Medical Services
L2 MS Standards Medical Service Centres
L3 Medical Escalation Protocols for Doctors, Nurses & Paramedics
L3 MS Clinical Governance Medical Services Platform
EFFECTIVE DATE: April 2020 DOCUMENT MANAGER: Group Assistant General
Manager Quality & Compliance
Revision History
Revision Rev. Date Description Prepared by Reviewed by Date Approved by Date
Paul Brinkworth, Paul Brinkworth, Karen
1.00 Sept 2018 Original Document Karen Foster, Joey Foster, Joey Botha, Nov 2018 Myles Neri Dec 2018
Botha Chris Van Straten
Updated to align with the Medical
Escalation Protocols for Doctors, Chris van Straten,
Martin Botha, Paul
1.01 Feb 2020 Nurses and Paramedics & changes Martin Botha, Paul June 2020 Myles Neri August 2020
Brinkworth
in current best clinical practice Brinkworth
guidelines.
Responsibilities
Abbreviations and Definitions

AVPU Alert Verbal Pain Unconscious
BSL Blood Sugar Level
BVM Bag Valve Mask
CM Centimeter

Page 4 of 134
Version 1.01
August 2020
COPD Chronic Obstructive Airway Disease

CPAP Continuous Positive Airway Pressure
ETT Endrotrachael Tube
ETI Endotrachael Intubation
GCS Glascow Coma Score
HCP Health Care Professional
IO Intraosseous
IV Intraveneous
KED Kendrick Extrrication Device
LOC Level of Consciousness
LMA Laryngeal Mask Airway
Lpm Litres per Minute
OP Opropharyngeal
OPA Oropharangeal Airway
SGD Supraglottic Devices
TB Tubuerculosis
VSS Vital Sign Survey
References and Attachments
© 2018 All copyright in these materials is reserved to AEA International Holdings Pte. Ltd. No text contained in these materials may be reproduced, duplicated or
copied by any means or in any form, in whole or in part, without the prior written permission of AEA International Holdings Pte. Ltd.

Page 5 of 134
Version 1.01
August 2020
1. INTRODUCTION
1.1. Purpose
To provide a standardised tool for the Health Care Professionals operating at
Intl.SOS medical facilities, assessing and ensuring skills competency regarding
skills required within the scope of practice and clinical operations of the facility.
1.2. Objectives
To provide a standardised tool to be used by line managers, senior health care
professionals (peers) to assess and review clinical skills related to the job
description and role to ensure clinical skills competency as part of induction to
the role and annual competency measurement.
1.3. Scope
This document applies to all Health Care Professionals operating at
International SOS medical facilities.

Page 6 of 134
Version 1.01
August 2020
2. CLINICAL SKILL LEVELS
Clinical skill levels may vary in different locations and between various HCP’s based on
qualifications, additional courses, facility activities / scope of work / services and country
legislation. The Regional Medical Director will approve the required clinical skills for the
different facilities. Below is an example of the skills requirements according to
qualification.
Procedure / Skill Ambulance Basic Life Intermediate Advanced

Driver Support Life Support Life Support
(BLS) (ILS) (ALS)
PATIENT ASSESSMENT
Hand Hygiene
Systematic Approach
Vital Sign Survey Basic Only
Glucometry
Temperature Assessment
Pulse Oximetry
Urinalysis
Ophthalmic Examination
Aural Examination
Helmet Removal
MOVING A PATIENT
Scoop Stretcher
Spine Board
Kendrick Extrication Device
Vacuum Mattress
Stair Chair
Standard Ambulance Stretcher
Ambulance Stretcher RC-A1
Semi-Automatic
AIRWAY MANAGEMENT
Oropharyngeal Airway
Nasopharyngeal Airway
Laryngeal Mask Airway
Laryngoscopy & Magill’s Forceps
Endotracheal Intubation

Page 7 of 134
Version 1.01
August 2020

Attendant Support Life Support Life
(ATO) (BLS) (ILS) Support
(ALS)
OXYGEN THERAPY
Nasal Cannula
Nebuliser Mask
Simple face mask
Non-Rebreather Mask
Intermittent Positive Pressure
Breathing
Intermittent Positive Pressure CPR Only
Ventilation
Oxylog 1000 Ventilator
Oxylog 2000 Ventilator
Suctioning
ETT Suctioning
Capnography
CARDIO-PULMONARY
RESUSCITATION
Adult CPR
Child CPR
Infant CPR
DEFIBRILLATION / CARDIAC
MONITORING
Automatic External Defibrillation
Phillips MRX Defibrillator / Monitor
Cardiac Monitoring 3 Lead
Cardiac Monitoring 12 Lead Consult
Only
Synchronised Cardioversion
Transcutaneous Cardiac Pacing

Page 8 of 134
Version 1.01
August 2020

Attendant Support Life Support Life Support
(ATO) (BLS) (ILS) (ALS)
DRUG / FLUID
ADMINISTRATION
Oral Medication Administration Basic Only
Vaccination
Subcutaneous Injections
Intramuscular Injections
Intravenous Injections
Intraosseous Cannulation
Extra Jugular Venous Cannulation
Fluid Replacement
Syringe Driver
PROCEDURES
Inserting a Urinary Catheter -
Female
Inserting a Urinary Catheter -
Male
Nasogastric Tube Insertion
Irrigating & Removing Nasogastric
Tube
Suturing
Removal of Interrupted Sutures
Eye Irrigation & Dressing
FRACTURE MANAGEMENT
Vacuum Splints
Traction Splints
Cervical Collar

Page 9 of 134
Version 1.01
August 2020

Attendant Support Life Support Life
(ATO) (BLS) (ILS) Support
(ALS)
DRESSINGS & BANDAGES

Aseptic Dressings
Apply Bandages & Slings
Burns Dressings
Haemorrhage Control Basic Only Basic Only
Envenomation
OTHER EMERGENCY
PROCEDURES
Chest Decompression Consult
Only
Cephalic Delivery
Breech Delivery Consult
Only

Page 10 of 134
Version 1.01
August 2020
3. GUIDELINES FOR USE

The Clinical Skills Assessment Manual has been developed to be implemented as a
tool to assist in measuring a HCPs’ theoretical understanding and practical
competency in clinical procedures and equipment utilisation.
Theoretical Principles:
Clinicians must be able to verbalise all the theoretical principles being tested.
Goal of treatment: What am I trying to achieve?
Indications: When can I perform this procedure?
Contra-Indications / Precautions: When don’t I apply this procedure / What do I

need to be aware of?
Other Clinical Judgement Issues: What are the other clinically relevant issues
to be considered?
Practical Skills Assessment:
 Indicates the mandatory clinical standard required to be achieved.

Indicates the clinical options that will enhance patient care.
Validating Clinician:
HCPs can be assessed and validated by a line manager and / or peer or senior of the
same or higher clinical level with acquired competency of the skill.
Skill Assessment Completion:
At the completion of each skills assessment, the following must be completed at the
base of each page:
• Name of the HCP being assessed & assessment date.

• Name of the validating HCP & the assessment date.
• Comments.

Page 11 of 134
Version 1.01
August 2020
4. SECTION 1 – PATIENT ASSESSMENT

SECTION 1
PATIENT ASSESSMENT
1. Hand Hygiene 12
2. Systematic Approach 13
3. Vital Sign Assessment (VSS) 14
4. Glucometry 15
5. Temperature Assessment 16
6. Pulse Oximetry 17
7. Urinalysis (Dipstick) 18
HCPs ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR

APPROVED SCOPE OF PRACTICE

Page 12 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.1. Hand Hygiene
HCP’s ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR APPROVED
SCOPE OF PRACTICE  
THEORETICAL PRINCIPLES - Competency

Goals of treatment:
To prevent health care associated infections, the spread of infection and reducing
antimicrobial resistance.
Indications:
Before touching a patient, before a procedure, after a procedure or body fluid contact, after
touching a patient, after touching surroundings.
Contra-Indications / Precautions:
Nil.
Other Clinical Judgement Issues:
It is not recommended to use the hand wash & hand rub techniques simultaneously as it can
enhance skin irritation.
PRACTICAL SKILLS - Competency
Demonstrate the procedure for hand hygiene at the wash station:
 HCP removes all jewellery; rings, watches, no artificial nails/nail polish
 HCP selects the appropriate hand washing technique according to the situation
 Hand rub technique (alcohol/chlorhexidine hand rub)
 Approved hand rub is available in the location
 Hand rub is in date
 How to hand rub poster is visible
 HCP applies a palmful of hand rub in a cupped hand
 HCP rubs hands in accordance with the “how to hand rub” poster
 Hand hygiene procedure followed for 20-30 seconds
 Completed only when hands are dry
 Hand wash technique (soap & water)
 Sink with approved liquid soap, paper towel in dispenser available
 HCP adjusts water to the correct temperature
 HCP wets hands before applying soap
 HCP applies sufficient liquid soap to cover all hand surfaces
 HCP performs hand washing technique in with the “how to hand wash” poster
 HCP rinses hands in water
 HCP dries hands thoroughly with single use towel
 Washes hands for at least 20 seconds
Paper towel disposed in foot operated bin with a lid, clearly marked “general waste”.
THEORETICAL & PRACTICAL SKILLS – Correctly Demonstrated

Assessed HCP Date
Validating HCP Date
Comments:

Page 13 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.2. Systematic Approach

Goals of treatment:
A systematic & purposeful gathering of information including; current and pre-existing
conditions, to formulate a provisional diagnosis (AMPLE)
Indications:
HCP’s should use the systematic assessment approach with every patient.
Dangerous environments / situations for clinicians or patients. Not all elements of the
systematic assessment will be necessary for every patient. The collecting of patient
information should never compromise the administration of basic life support therapy or
transportation of time / transport critical patients.
Gathered information through patient’s visual presentation; neurological, respiratory &
circulatory systems. Primary & secondary survey should be completed simultaneously with
administering patient care.
Demonstrate the systematic approach on a mannequin or a simulated patient:
 Danger, response, airway, breathing, circulation, Disability, Exposure
 AVPU / GCS
 Airway: open, maintained, protected
 Adequate oxygenation & ventilation
 Adequate perfusion
 Demonstrate systematic assessment with both conscious & unconscious patents
 Treat life threatening complaints as needed
 Detailed assessment of vital systems, i.e., heart rate, respiratory rate, temperature,
BP, GCS, capillary refill & glucose
 History
 Head to toe assessment
Appropriate treatment as needed
Document the findings.

Assessed HCP Date
Validating HCP Date
Comments:

Page 14 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.3. Vital Sign Assessment (VSS)
THEORETICAL PRINCIPLES – Competency

Goals of treatment:
To systematically obtain clinical information providing a baseline for trend changes or
detection of abnormalities.
Indications:
Clinicians should use the vital sign assessment with every patient.
The VSS assessment of patient information should never compromise the administration of
basic life support procedures or the transportation of time / transport critical patients.
Gathered information through patient’s visual presentation; neurological, respiratory &
circulatory systems. Primary & secondary survey should be completed simultaneously while
administering patient care.
PRACTICAL SKILLS – Competency
Demonstrate the procedure for VSS using a simulated patient:
 Neurological assessment
 AVPU / GCS
 Pupillary reaction
 Speech
 Sensory & motor function
 Respiratory status assessment
 Conscious state
 General appearance
 Speech duration 1-2 words or complete full sentences?
 Ventilatory rate, rhythm & effort/mechanics
 Skin colour
 Chest auscultation
 Perfusion status assessment
 Palpate radial or brachial pulse
 Pulse rate rhythm & volume
 Manual Blood pressure
 Peripheral perfusion, including colour, capillary refill, skin (dry or sweaty)
 Temperature
Document the findings.

Assessed HCP Date
Validating HCP Date
Comment:

Page 15 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.4. Glucometry
Goals of treatment:
Pre-hospital blood glucose tests are performed to provide an indication of the patient’s blood
sugar level (B.S.L.)
Indications:
Patients suffering altered consciousness, post collapse, abnormal behaviour or suspected
hypo / hyperglycaemia.
Glucometry is an invasive procedure & standard precautions should be implemented
preventing infection transmission.
Consider other clinical signs & history as BSL readings should not be interpreted in isolation.
Numerous variables distort test results including; volume of blood on the sensor, O2 level of
the blood, venous or capillary blood and glucose contaminants on the skin.
Demonstrate the usage of a glucometer to obtain a BSL:
 Ensure standard precautions are applied
 Where applicable, fit disposable safety lancet to lancing device
 Without touching the ‘blood target area’, insert the test strip into the test port of the
glucometer to automatically turn it on
 Lance the side of the finger with the lancing device and obtain the hanging drop of
blood (if I.V. access is in place, blood may be drawn up from the cannula
immediately after insertion).
 By moving the glucometer to the finger, apply a drop of blood to the target area of
the test strip, covering it completely. The test will start automatically and the B.S.L.
reading will appear on the screen
Document the patient’s BSL.
 Discard the lancet and test strip into an approved sharps container.
Aseptically cover the wound
Turn off the machine.
Assessed HCP Date
Validating HCP Date
Comments:

Page 16 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.5. Temperature Assessment

Goals of treatment:
To ascertain the temperature status of a patient.
Indications:
Routine with all patients as part of the vital signs survey (VSS).
Oral temperature measurement should not be carried out in the following situations:
 Patients receiving oxygen therapy via an oxygen mask
 Patients with maxilla-facial injuries or those that have difficulty/inability to breath via their nose
 Irrational or confused patients that may bite or break the thermometer
 Neonates or babies
Tympanic temperature measurement should not be carried out in the following situations:
 Bleeding or leakage from the ear canal
 External trauma to the ear
 Any foreign body or obstruction of the ear

Not applicable.

Use a digital or tympanic thermometer:
 Place the disposable sleeve over the digital or tympanic thermometer.
 Explain the procedure to the patient.
 Turn on the digital thermometer. Tympanic thermometer will turn on automatically
after applying the disposable sleeve.
Assess the most suitable for placing the thermometer.
 Place the thermometer in the most suitable area. Leave the digital or tympanic
thermometers in place until hearing the beep indicating the completion of reading.
 Document the patient’s temperature reading.
Document the patient’s temperature reading.
 Discard the disposable sleeve appropraitley.

Assessed HCP Date
Validating HCP Date
Comments:

Page 17 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.6. Pulse Oximetry

Goals of treatment:
To non-invasively determine the percentage of oxygen saturation of the Haemoglobin.
Indications:
Routine with all patients as part of the vital signs survey (VSS) or any clinical manifestations requiring
the administration of oxygen.
The following may cause inaccurate readings:
 Carbon monoxide poisoning.
 Ambient light interference
 Motion.
 Poor distal perfusion, hypothermia
 Dirt or nail polish under the sensor.
SpO2 monitors only measure haemoglobin oxygen saturation not ventilation or tissue perfusion.

Demonstrate pulse oximetry usage:
 Place the probe sensor over the limb extremity (fingernail bed or toe).
 Ensure the probe is fitted properly to eliminate interference from movement &
ambient light.
 Turn the SpO2 monitor/device on.
Document the SpO2 (either as room air or with supplemental oxygen).
Assessed HCP Date
Validating HCP Date
Comments:

Page 18 of 134
Version 1.01
August 2020
PATIENT ASSESSMENT
4.7. Urinalysis (Dipstick)

Goals of treatment:
To exclude or detect abnormalities which are related to a wide range of diseases.
Indications:
Routine with all patients suspected or presenting with clinical manifestations consistent with acute or
chronic diabetes, liver disease, kidney disease, urinary tract infection or general health screening.
Nil.
Preferable to be a midstream urine sample.
Demonstrate taking a patient urine sample:
 Prepare PPE & equipment; gloves, plastic apron, hand sanitizer, dipstick & sample container.
 Document & check correct patient details are on the urine sample bottle. 3 points of
identification required; Patient name, Patient DOB & Patient gender
 Provide the patient with the urine sample container.
 Don gloves on both hands and a plastic apron
 Tap off any residual urine against the side of the urine sample bottle.
 Check urine dipsticks are within date (not expired). Remove test strip without touching any of
the test areas and replace the cap.
 Fully immerses the test strip in the urine sample ensuring all test areas are covered.
 Hold strip horizontally to prevent any of the testing areas running into each other and.
 After correct amount of time, hold the dipstick next to the dipstick analysis chart on the side of
the dipstick container & read the strip.
 Discards the strip, gloves and apron in the medical waste bin & wash your hands.
 Document findings on observation chart or medical record. Reports any abnormal findings.
 Retains the urine sample for laboratory analysis (if required).

Assessed HCP Date
Validating HCP Date
Comments:

Page 19 of 134
Version 1.01
August 2020
5. SECTION 2 – MOVING A PATIENT
SECTION 2
MOVING A PATIENT
1. Scoop Stretcher 20
2. Spine Board 21
3. Kendrick Extrication Device (KED) 22
4. Vacuum Mattress 24
5. Stair Chair 25
6. Standard Ambulance Stretcher 26
7. Semi-Automatic Ambulance Stretcher 27
8. Removal of a Helmet 28
HCP’s ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH

THEIR APPROVED SCOPE OF PRACTICE

Page 20 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.1. Scoop Stretcher

Goals of treatment:
To facilitate the safe & successful movement of an injured patient.
Indications:
Patients with injuries that prevent them from being rolled or slid.
Caution to avoid pinching or pulling skin, hair & clothing during the application process.
Always ensure both sides of the scoop stretcher are properly locked before lifting the
patient.

Refer to the manufacturer’s instructions for each scoop stretchers maximum load limit as
this will vary between different models. Do not exceed these limits.
Demonstrate the correct application of a scoop stretcher:
 Position & measure the required scoop length next to the patient. Adjust the length
by disengaging the locking pins on both sides & extend to the required length.
Reengage the locking pins, checking they have engaged properly.
 Disengage the superior and inferior scoop locking mechanisms and separate into
two halves.
 Place the two halves of the scoop on each side of the patient
 Apply the scoop stretcher by working the halves inward under the patient until the
superior & inferior scoop locking mechanisms come together. Engage the locking
mechanisms
Demonstrate correct hand placement on the scoop and safe lifting techniques.
The scoop stretcher can be applied without separating the two halves

Assessed HCP Date
Validating HCP Date
Comments:

Page 21 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.2. Spine Board
HCP’s ARE ONLY TO PERFORM PROCEDURES CONSISTENT
WITH THEIR APPROVED SCOPE OF PRACTICE  
Goals of treatment:
To facilitate the safe & successful movement of an injured patient.
Indications:
Injuries that prevent movement of the patient with manual lifting techniques or assistance
with extrication of patients from motor vehicles and confined spaces.
Ensure the spine board is secure to prevent slipping during extrication of patients from
motor vehicles and confined spaces. Ensure there are adequate personnel available to
perform this task.

The spine board may become uncomfortable for the patient if left in situ for extended
periods of transport time.
PRACTICAL SKILLS - Competency - Demonstrate correct usage of a spine board

 Log roll the patient onto their side ensuring control & maintenance of the c-spine.
 Place the spine board flush against the posterior aspect of the patient.
 In a single movement, return the spine board & the patient back to a supine position.
 Secure the patient by applying the belt restraints.
 Demonstrate correct hand placement on the spine board and safe lifting techniques.
 The scoop stretcher can be applied without separating the two halves
Extrication of sitting patients from motor vehicles or confined spaces:
 Place end of the spine board under the buttocks of patient & the other end on the
stretcher.
 With control of the c-spine, in a simultaneous movement, slide and lay the patient
supine on the spine board.
 Secure the patient by applying the belt restraints.
Assessed HCP Date
Validating HCP Date
Comments:

Page 22 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.3. Kendrick Extrication Device (KED)

Goals of treatment:
To provide immobilisation, support & facilitate the extrication of a patient especially when
spinal injury is suspected.
Indications:
For the extrication of patients with suspected spinal injury from motor vehicles and confined
spaces.
Do not restrict chest movement with excessive tension on the straps. Do not use the leg
restraints in cases involving fractured femurs. Do not exceed the 159 kg maximum load limit
of the KED.

The KED should be used in conjunction with other spinal immobilisation measures. With
pregnant patients, fold the chest flaps inward leaving the abdomen exposed or apply straps
loosely. The KED may be inverted & used as a hip and pelvic splint.

Demonstrate the application of the KED:

 Remove the KED from its cover along with the adjust-pad head roll & forehead / chin
straps. Place in a clean area.
 Ensure the patient has a c-spine collar in situ & dedicate an individual to
support/control the neck during application of the KED.
 Remove all articles from the patient’s shirt & trouser pockets. Slide the KED in
behind the patient.
 Release the leg straps from the retracted position & clear on each side of the patient.
 Bring the KED chest flaps around & ensure they are snug up under the patient’s
arms.
 Do up the middle strap (YELLOW STRAP) & tension accordingly.
 Do up the bottom strap (RED STRAP) & tension accordingly.
 Position the leg straps. Using a sawing motion work the straps into position under the
patient’s legs. Without twisting the straps pull both ends up between the legs &
buckle on the opposite side of the KED.
In cases of suspected groin injury the leg straps may be buckled on the same side of
the KED.
 Secure the head support. If required insert the adjust-pad either in a flat or folded
position. Bring both head flaps around & apply the strap across the patient’s

Page 23 of 134
Version 1.01
August 2020
forehead and then apply the chin strap.

The chin strap can be quickly removed if the patient vomits.
 Immobilise the patient’s extremities with the application of a figure eight bandage
around the ankles & a broad bandage above the knees.
 Check the yellow, red and leg straps are correctly buckled with the appropriate level
of tension.
 Do up the top strap (GREEN STRAP) & tension without restricting chest expansion
just prior to lifting the patient.
 Use the handles located at each side on the rear of the KED when lifting the patient.
The KED may be left in situ during transport of the spinal patient allowing them to be
rolled if vomiting occurs. Ensure the top strap (GREEN STRAP) is loosened for chest
expansion.

Assessed HCP Date
Validating HCP Date
Comments:

Page 24 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.4. Vacuum Mattress

Goals of treatment:
To provide complete immobilisation of the patient whilst preventing further injury or
complications during lifting or transferring procedures.
Indications:
The transportation of suspected spinal injuries or the packaging of patients for aero-medical
evacuations.
Conscious patients may experience feelings of anxiety or claustrophobia.

With suspected spinal injuries the vacuum mattress should be used in conjunction with other
spinal immobilisation measures.
PRACTICAL SKILLS- Competency Demonstrate the application of a vacuum mattress:

 Apply all basic patient care procedures.
 Remove the mattress from the storage bag & lay the mattress out flat alongside the
patient.
 Transfer the patient onto the mattress. If using a scoop stretcher or spine board care
should be taken not to tear the mattress.
 Mould the mattress around the patient & secure the colour coded restraints and
tighten.
 Open the air valve. Attach the manual hand pump or portable suction unit & extract
the air from the mattress, moulding the mattress around the patient’s body and head.
Continue until the mattress becomes rigid.
 Close the valve, disconnect the hand pump or portable suction & readjust the
restraints as required.
 Reassess the patient’s VSS particularly ETT placement & respiratory status with
ventilated patients.
Assessed HCP Date
Validating HCP Date
Comments:

Page 25 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.5. Stair Chair

Goals of treatment:
To safely extricate patients from confined areas, narrow hallways and stairways.
Indications:
The extrication of conscious patients whom due to their injury / illness should not walk or
due to their chronic condition are unable to walk.
Patients suffering from; unconsciousness, severe altered level of consciousness, spinal

injuries, pelvic injuries, fractured NOF or femur. Stair chairs from various suppliers have
different maximum load limitations. Clinicians should refer to the manufacturer’s instructions
for the exact limits.
Not applicable.
Demonstrate the stair chair use:
 Apply all basic patient care procedures.

 Position the patient onto the chair in a position of comfort.
 Explain the procedure to the patient
 Fasten the safety restraints. Have the patient cross their arms across their chest or
hold onto the safety restraints to prevent them reaching out and grabbing onto
anything.
 Adjust the handles allowing the chair to be lifted effectively.
 Lean the chair back to the balance/pivot point and wheel or lift as required.

Assessed HCP Date
Validating HCP Date
Comments:

Page 26 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.6. Standard Ambulance Stretcher

Goals of treatment:
To safely aid in the movement of a patient to and from an ambulance or securing the
stretcher into the patient care area of an ambulance for safe transportation.
Indications:
Any patient suffering with an illness or injury that requires movement and transportation on a
stretcher.
Caution moving the patient & stretcher over the following:
 Uneven ground surfaces
 Extreme egress
 Slippery or hazardous conditions (Ice & Snow)

The stretcher has fixed short legs close to the ground. Clinicians should ensure they have
sufficient assistance to safely lift & load the stretcher, accounting for patient size.
Clinicians should ensure they maintain a suitable posture preventing back injuries when
moving the stretcher & patient across different egresses.
Clinicians must be familiar with the stretcher controls & operating procedures.
Patient posture according to clinical condition is an important component of
treatment/management.

Demonstrate the operation of a standard ambulance stretcher:
 Correctly unload the stretcher form the ambulance

 Adjust the back rest into its multiple positions
 Secure the patient with the safety belt
 Correctly load the stretcher into the ambulance

Assessed HCP Date
Validating HCP Date
Comments:
MOVING A PATIENT
Page 27 of 134
Version 1.01
August 2020
5.7. Ambulance Stretcher Drop Wheel


Goals of treatment:
To safely aid in the movement of a patient to and from an ambulance or securing the
stretcher into the patient care area of an ambulance for safe transportation.
Indications:
Any patient suffering with an illness or injury that requires movement and transportation on a
stretcher.
Caution moving the patient & stretcher over the following:
 Uneven ground surfaces
 Extreme egress
 Slippery or hazardous conditions (Ice & Snow)

Clinicians must be familiar with the stretcher controls & operating procedures.
Patient posture according to clinical condition is an important component of
treatment/management.

Demonstrate the operation of the RC-A-1 Semi-Automatic Stretcher:
 Correctly unload the stretcher from the ambulance

 Adjust the back rest into its multiple positions
 Raise & lower thee side arms
 Raise the IV pole & disengage
 Lower the stretcher for the patient to access
 Secure the patient with the safety belt
 Raise the stretcher and move the stretcher to the ambulance.
 Correctly load the stretcher into the ambulance

Assessed HCP Date
Validating HCP Date
Comments:

Page 28 of 134
Version 1.01
August 2020
MOVING A PATIENT
5.8. Removal of a Helmet

Goals of treatment:
Two-person procedure. Remove the helmet from a patient whilst maintaining alignment of
the neck & spine throughout the procedure, avoiding hyper-flexion, extension, compression
or distraction of the c-spine & to allow application of spinal immobilisation management.
Indications:
Mechanisms indicating potential spinal injury where the patient is wearing a helmet.
Any case where penetrating trauma to the head is suspected.

The head must be stabilised and supported always throughout the procedure of helmet
removal. All clinicians performing this procedure must clearly understand their
responsibilities in stabilising the head and removing the helmet. There are a few different
helmet styles; however, the basic principles remain the same.

Demonstrate correct removal of the helmet:
 In a sitting position (conscious patient).

 In a supine position (conscious / unconscious patient).
 In a prone position (conscious / unconscious patient).
 HCP one takes control of the helmet and calls the actions.
 Clinician two takes control of the patient’s head and must clearly indicate when this
occurs
 Ensure spinal alignment when log rolling patient
 Clinician to demonstrate the application of cervical immobilisation collar with each
helmet removal.

Assessed HCP Date
Validating HCP Date
Comments:

Page 29 of 134
Version 1.01
August 2020
6. SECTION 3 – AIRWAY MANAGEMENT
SECTION 3
AIRWAY MANAGEMENT
1. Oropharyngeal Airway 30
2. Nasopharyngeal Airway 31
3. Laryngeal Mask Airway (LMA) 32
4. Laryngoscopy & Magill’s Forceps 34
5. Endotracheal Intubation 36


Page 30 of 134
Version 1.01
August 2020
AIRWAY MANAGEMENT
6.1. Oropharyngeal Airway

Goals of treatment:
To prevent airway obstruction secondary to displacement of the tongue in unconscious patients.
Indications:
Utilised for patients without a gag reflex suffering from potential or actual airway obstruction
secondary to displacement of the tongue.
May be used as a bite block with endotracheal intubation.
Should be routinely used when a patient is being ventilated using a BVM, if there is no gag reflex.
Does not protect the patient’s airway from aspirations & does not guarantee a patent airway.
May cause vomiting or obstruction in patients with a gag reflex. Caution with use in patients with
lower third facial trauma.

Must be properly sized & inserted. Ensure the patient’s natural airway is clear; remove foreign bodies,
suction blood, fluid or vomitus.
Usually leave any dentures in place.
Oropharyngeal airways do not isolate the trachea or protect the lower airway from aspiration

Procedure for the use of Oropharyngeal Airways
 Manual airway management

 Posture the patient appropriately
 Head tilt / jaw support – jaw thrust
 Visually inspect the airway
 Manual clearance where possible
 Oropharyngeal suctioning, for less than 10 seconds
 Select appropriate size airway. Measure by placing in-line with the patient’s lips to the angle
of the jaw.
 000 New born to one month old

 00 One month to six months old
 0 Six months to 3 years old
 1 Three years to ten years old
 2 Adolescent / Average adults females
 3 Average adult male/large adult male
 4 Large adult males
 Insert the airway

 Extend the patient’s head (if no suspicion of C-spine injury) & open the mouth
 Using a spatula to depress the tongue, insert the airway with the curve pointing
downwards, NOT upwards.

Page 31 of 134
Version 1.01
August 2020
 Advance airway slowly and gently downwards, following the curve of the tongue, being
careful to note the gag reflex.
 If there is any gag, remove the tube immediately. Continue until flange rests against the
lips.
 If the patient shows any signs of rejecting the airway, remove it immediately.

Assessed HCP Date
Validating HCP Date
Comments:

Page 32 of 134
Version 1.01
August 2020
AIRWAY MANAGEMENT
6.2. Nasopharyngeal Airway

Goals of treatment:
To assist in airway maintenance of a compromised airway – particularly associated with trismus, or
when the mouth cannot be opened, e.g. seizures, oral trauma, etc
Indications:
The nasopharyngeal airway is used to relieve soft tissue upper airway obstruction in cases where an
oropharyngeal airway is not advised. May be used in the presence of a gag reflex, trismus or oral
trauma.
Caution with patients suffering trauma to the nose or suspected anterior basilar skull fracture & may
also cause severe epistaxis if inserted too forcefully.
The correct sized nasopharyngeal airway is slightly smaller in diameter than the patient’s nostril and
is equal or slightly longer than the distance from the nose to the earlobe.
Incorrect measurement will result in an airway that is too small not extending past the tongue or one
that is too long passing into the oesophagus causing hypoventilation and gastric distension with
artificial ventilation.

Nasopharyngeal airways do not isolate the trachea or protect the lower airway from aspiration. They
are difficult to suction through & may kink or clog obstructing the airway. Insertion may be difficult in
patients with nasal damage. While semi-conscious patients tolerate a nasopharyngeal airway, in
some cases it may cause vomiting and laryngospasm.

Procedure for use of Nasopharyngeal Airways:
 Maintain effective patient oxygenation / ventilation function

 Choose the appropriate size airway by measuring against the patient
 Using water soluble gel, lubricate the exterior of the tube
 Push up on the tip of the nose and insert the tube into the right nostril. Do not push against
encountered resistance. If unable to utilise the right nostril use the left nostril.
 Verify airway patency. (Clear breath sounds, chest rise, reduction of cyanosis).

Assessed HCP Date
Validating HCP Date
Comments:

Page 33 of 134
Version 1.01
August 2020
AIRWAY MANAGEMENT
6.3. Laryngeal Mask Airway (LMA)

Goals of treatment:
A more definitive rescue airway management device, providing patency & some degree of airway
protection.
Indications:
Rescue oxygenation & ventilation for unconscious patients. Patients must be completely
unconscious.
LMAs are contra indicated for patients with epiglottitis or mechanical obstruction of the airway. The
LMA, while not regarded as a definitive airway, still allows more effective oxygenation & ventilation,
and protection of the airway, compared to BVM ventilation alone. In cases where airway reflexes are
not sufficiently depressed then the LMA may:
 Be rejected by the patient
 Become incorrectly placed with possible airway obstruction
 Stimulate vomiting and subsequent aspiration and or airway obstruction
The LMA is ONLY for patients who are completely unconscious.

The LMA has advantages including:
 Easy insertion
 Higher standard of airway maintenance compared to the Oropharyngeal &
nasopharyngeal airways.
 Reduces the chance of laryngospasm as there is no contact with the vocal cords.
obstruction
An accurate clinical appraisal of the patient’s LOC. & airway anatomy is critical for deciding on the
use of an LMA.
Always reassess LMA position & ventilation status every time the patient is moved.
Use low inflation pressures when ventilating patients. Consider the use of a gastric tube.
Always assess LMA cuff pressures and make sure the minimum cuff leak pressure has been
established, and, if available, the cuff pressure manometer has been used to properly inflate and
measure the cuff pressure (should be less than 60 cm H 2 O)

Demonstrate procedure for the use of LMA:
 Do not delay delivery of oxygen / ventilation during equipment set up.
 Ensure the airway is clear. (Manual airway manoeuvres, postural drainage, suctioning, or
manual removal of foreign materials Choose the appropriate size airway by measuring
against the patient).
 Check equipment and select the appropriate sized LMA.
 Continue to oxygenate / ventilate the patient.
 Prepare the LMA, deflate cuff of the mask & apply water soluble lubricant to the posterior
surface of the mask only.
 Pre-oxygenate the patient.
 Insert LMA:

Page 34 of 134
Version 1.01
August 2020
 Extend the head and flex the neck or maintain anatomical neutral position if c-spine injury
suspected.
 Position the lower jaw downwards; press the mask upwards towards the hard palate,
whilst simultaneously advancing it into the oral cavity with index finger located at the
junction of the mask & the tube, or the distal tip of the tube can be directed from the
patient’s chest, maintaining the curve on the hard palate, soft palate, and then posterior
pharynx.
If the mask tip does not flatten out or commences to roll, withdraw & recommence the
procedure
OR
Continue to advance the mask with the index finger located at the junction of the mask & the
tube.
 If resistance is encountered, remove the LMA, oxygenate / ventilate the patient & try LMA
insertion again.
 Continue to guide the LMA downwards into position until the mask tip is located against the
upper oesophageal sphincter. Grasp the tube firmly with the other hand then withdraw the
index finger from the pharynx & press gently downwards with this other hand to ensure the
mask is fully inserted.
 Inflate the cuff with the correct amount of air. (Refer to the manufacturer’s instructions on the
LMA tube for correct number of millilitres for cuff inflation).
 Connect the BVM and gently test ventilations to ensure the airway is clear.
 Insert a bite block. (OP airway CANNOT be used since this will displace the LMA laterally in
the mouth and will disrupt the cuff seal; the tube MUST be central, as indicated by the bold
central line on the LMA tube
 Secure the LMA.
 Demonstrate safe removal of an LMA.

Assessed HCP Date
Validating HCP Date
Comments:

Page 35 of 134
Version 1.01
August 2020
AIRWAY MANAGEMENT
6.4. Laryngoscopy & Magill Forceps

Goals of treatment:
Laryngoscopy: Visualisation of the glottis for the purpose of clearing the airway
Facilitate the insertion of an endotracheal tube or gastric tube
Magill Forceps: Removal of foreign bodies
Indications:
Laryngoscopy & Magill forceps are indicated in unconscious patients for the removal of foreign bodies
located in the region between the oropharynx & the lips or the insertion of ETTs.
Laryngoscopy is contraindicated in the following circumstances:
 Patients with adequate airway reflexes.
 Patients who are adequately breathing.
 Patients suspected of having epiglottitis.
 When the intubator is inexperienced / unprepared / not permitted to perform his skill.
 When the airway assessment / predictors of difficulty suggest that ETI will be difficult – an
alternative should be sought.
Caution is required when spinal injury is suspected
Care should be taken to avoid complications including; laryngospasm, hypoxia from delayed
oxygenation, damage to teeth, dentures, lips or larynx.

Contact with the anatomy distal to the epiglottis including, both the posterior surface of the epiglottis
or any part of the laryngopharynx may trigger laryngospasm.
Extended periods of laryngoscopy in conjunction with lack of oxygenation / ventilation will result in
patient hypoxia & hypercarbia.
Hyperventilation may result in several dire consequences, and must be avoided.
Damage to lips, teeth, dentures and upper respiratory tract tissue can occur if the laryngoscope and
Magill forceps are used incorrectly, such as using teeth as a pivot point or trapping the lips between
the teeth and blade.

Demonstrate the procedure for Laryngoscope and Magill Forceps use:
 Attach a pulse oximeter (SpO 2 monitor), ECG & BP monitor to the patient.
 Administer 100% oxygen, via non-rebreather oxygen face mask if the patient is
spontaneously breathing, or via bag-mask ventilator if apnoeic, prior to commencing the
procedure increasing oxygen saturation to the patient.
 Place nasal cannula to provide high-flow nasal oxygen during intubation
 Have equipment ready and functioning:
 Laryngoscope blade fixed securely to the handle.
 Laryngoscope light functional – check batteries not flat. Ensure spare batteries, spare
additional blades and spare laryngoscope are all available.
 Magill forceps ready.

Page 36 of 134
Version 1.01
August 2020
 Position the patient properly: i) place in sniffing position, with pillow / towel behind head, ii)
vertex of head at rescuer’s umbilicus. If c-spine injury is suspected, maintain neutral
alignment of head & neck
 Hold the laryngoscope at the junction of blade and handle; don’t handle the handle!
 Insert the laryngoscope into the right side of the mouth & displace the tongue to the left with a
sweeping action. Advance the blade, and centralise it to the base of the tongue and lodge it
in the groove between the tongue and the epiglottis (vallecula). This end-point position is
central.
 Lift the laryngoscope up and out at an angle of approximately 45 degrees to the ground
(usually in the direction of the handle) allowing inspection of the upper respiratory tract & any
foreign body obstruction located down as far as the larynx. Do 3 things with 2 hands on the
st
1 attempt (head tilt/lift; ELM; double handed laryngoscopy)
Do not use the laryngoscope as a lever, as damage to lips, teeth and dentures will occur.
 Once a foreign body is detected, insert the Magill forceps to remove the foreign material
under vision. The Magill forceps should be gripped by the right hand and inserted in the
closed position. Visual contact with the foreign body must be maintained throughout the
procedure.
This procedure should be applied in conjunction with endotracheal intubation criteria where
applicable.
Assessed HCP Date
Validating HCP Date
Comments:

Page 37 of 134
Version 1.01
August 2020
AIRWAY MANAGEMENT
6.5. Endotracheal Intubation

Goals of treatment:
The securing of a patent and protected airway. Advantages of endotracheal intubation (ETI):
 Isolates the trachea giving complete control of the airway, i.e. opens, maintain and
protects airway
 Limits gastric insufflation and aspiration
 Eliminates the need to maintain a mask seal.
 Affords a direct route for suctioning of the respiratory passages.
Indications:
To provide protection of the airway in unconscious patients to facilitate ventilation.
Caution should be taken with patients suspected of having C-spine injuries or an airway obstruction
not permitting safe passage of an endotracheal tube (ETT).
Complications of ETI may include:
 Hypoxia due to delays in oxygenation – this is unacceptable & must be avoided at all
costs!
 Damage to patient’s teeth, dentures, lips, larynx.
 Mal-positioning of the tube into either the oesophagus or the right main stem bronchus
 Hyperventilation
Reassess tube placement and oxygenation and ventilation status regularly, especially after patient
movement.
If ETI is not possible or unsuccessful within the time for the SpO 2 to fall below 90%, stop, and initiate
bag-mask ventilation with 100% O 2 immediately.
Re-evaluate & change something! Options include repositioning the patient, etc. A second attempt
must involve a change in approach / equipment, etc.
A second attempt must include a bougie, Maximum of three attempts at intubation permitted.

Page 38 of 134
Version 1.01
August 2020

Confirm position of the tube using at least 3 of the following:
 Visualisation of entire cuff passing between vocal cords.
 Increase of oxygen saturation on the monitor. Beware, this does NOT apply to cardiac
arrest. Do not use sats in cardiac arrest.
 End tidal carbon dioxide monitor approx. 35 mmHg or more.
 In cardiac arrest, the ETCO 2 should be greater than 10mmHg, which also confirms good
quality compressions Fogging within the tube during expiration.
 Bilateral chest rise and fall.
 Equal bilateral air entry with chest auscultation.
 Auscultation of the epigastrium - No sounds of air entry.

Demonstrate the procedure for Endotracheal Intubation:
 Conduct airway assessment, incl predictors of difficulty for BMV, ETI, SGD 1
 Prepare all equipment (including stylet/introducer pre-loaded into ETT, 5mL syringe already
attached, suction equipment, stethoscope, difficult airway rescue devices, bougie, monitoring
devices [pulse oximeter, capnography, ECG, BP], etc).
 Plan is communicated to & reviewed with team, including plan for difficult / failed airway.
 Apply SpO 2 monitor recording baseline oxygen saturation where possible. (Patient SpO 2
should not fall below this base level).
 Pre-oxygenate patient using non-rebreather mask (spontaneously ventilating patient) or BVM
(apnoeic patient). Add CPAP & PEEP if required & available.
Position the patient sitting upright 30°, with head flexed and neck extended (sniffing position)
to facilitate laryngoscopy. Head should be horizontal.
Maintain neutral alignment of head & neck for patients with suspected spinal injury.
 Do 3 things with 2 hands on the 1st attempt: i) head lift / tilt / sniffing, ii) ELM [external
laryngeal manipulation], iii) Colleague Assisted Laryngospcopic Manoeuvre [CALM]
 Insert the laryngoscope into oral cavity, once positioned, lift upwards to view larynx. Tip of
blade must be positioned in vallecula or lifting up epiglottis, depending on technique selected.
 Insert appropriately sized endotracheal tube.
 Ensure cuff is placed approx. 1 cm distal to the vocal cords.
 Reposition tube if necessary.
 Note and record position of tube at teeth.
 Inflate the cuff with sufficient air to prevent air leak (min cuff leak pressure test), or use a cuff
pressure manometer if available. this should be less than 30cmH 2 O
 Secure the tube.
 Insert a bite block.
Demonstrated steps:
 Insert laryngoscope into the right side of the patient’s oral cavity with a sweeping action
moving the tongue to the left out of your line of vision & advance until the distal end of the
blade is at the base of the tongue, centrally in vallecula.
 Displace the jaw by lifting the laryngoscope handle slightly and moving it forward. Suctioning
1
BVM = bag mask ventilation; ETI = endotracheal intubation; SGD = supraglottic device
Page 39 of 134
Version 1.01
August 2020
of vomitus or secretions visualised pooling in the posterior pharynx may be required, to clear
airway.
 No teeth are broken during attempt (no sound on airway simulation manikin), and head on
intubation simulation manikin should lift to reflect proper technique
 Visualise the tip of the epiglottis placing the laryngoscope blade into its proper position.
 Lift the mandible & tongue with a force aligned with the direction of the handle, until the glottis
or at least the arytenoids, are exposed. With the stylet-loaded endotracheal tube in your right
hand, advance the tube through the right corner of the patient’s mouth. Usually you must
direct the distal end up or down in order to pass it into the larynx.
 With direct observation, insert the endotracheal tube into the glottic opening, passing it
through until the distal cuff is advanced 1 cm beyond the vocal cords. Retain the tube in place
preventing accidental displacement. Insert an OPA. Connect the bag-valve device to the end
of the tube.
 Inflate the cuff with 5mL of air initially, to allow ventilation. Thereafter listen for air leakage
around the tube and adjust the cuff appropriately in response to findings. The cuff should be
filled just 1-2 mL above the point where leakage ceases.
 Check for proper tube placement by watching the chest rise and fall during ventilation. Listen
for equal, bilateral breath sounds in the chest. No sounds over the gastric region should be
heard during ventilations.
 Ventilate the patient with 100% oxygen initially and insert a bite block.
 Continue ventilations & secure the tube with tape or a commercial tube-holding device.
 Reassess tube placement, distal tube condensation during exhalation, breath sounds & chest
rise & fall, and pulse oximetry and capnography.
Assessed HCP Date
Validating HCP Date
Comments:

Page 40 of 134
Version 1.01
August 2020
7. SECTION 4 – OXYGEN THERAPY
SECTION 4
OXYGEN THERAPY
1. Nasal Cannula 39
2. Nebuliser Mask / Nebulisation 40
3. Simple Face Mask 42
4. Non- Rebreather Mask 43
5. Intermittent Positive Pressure Breathing (IPPB) 44
6. Intermittent Positive Pressure Ventilation (IPPV) 46
7. Oxylog 1000 Ventilator 47
8. Oxylog 2000 Ventilator 49
9. Oro-Naso Pharynx Suctioning 51
10. ETT Suctioning 52
11. Capnography 54
HCP’s ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR

APPROVED SCOPE OF PRACTICE

Page 41 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.1. Nasal Cannula
HCPs ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR APPROVED

Goals of treatment:
Prevention of hypoxia / hypoxemia thereby, maintaining cellular oxygenation in patients with poor
perfusion.
Indications:
Patients who receive oxygen therapy for chronic conditions over long periods of time or patients
requiring the delivery of low flow, low concentration supplemental oxygen to maintain normal oxygen
saturation.
Administration of oxygen is contra-indicated in cases of Paraquat poisoning
Patients with suspected Acute Coronary Sydrome ONLY require supplemental oxygen IF their SpO 2
is less than 90%. Other medical patients (not trauma) should have oxygen sats titrated to 94% but
less than 100% (oxygen toxicity).
Caution with fire or explosive hazards as oxygen is an oxidising agent that vigorously supports
combustion.

Nasal cannulae & oxygen tubing are single use only & either remains with the patient or is disposed
of after usage.
Administration can cause drying of the mucous membrane of the nasal passage and airway.

Demonstrate the application of a nasal cannula:
 Explain to the patient what you are going to do.
Apply SpO 2 monitor recording baseline oxygen saturation where possible.
 Attach tubing to the oxygen regulator. A flow rate of 2-4Lpm delivering approx. 30% to 45%
oxygen concentration.
 Insert the nasal prongs into the nasal passage and loop the tubing behind the ears. Adjust to
under the chin to secure & for comfort.
Reassess the respiratory status assessment of the patient & document the findings.

Assessed HCP Date
Validating HCP Date
Comments:

Page 42 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.2. Nebulising Mask / Nebulisation
HCP’s ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR APPROVED SCOPE OF PRACTICE  

Goals of treatment:
To deliver atomized particles of aerosol medication (and oxygen) to a patient i.e. Glucocorticoids,
bronchodilators, antibiotics, mucus hydration agents, and mucolytic agents to enhance airway
humidification and bronchodilatation and enhance mucus removal.
Indications:
Bronchospasm, asthma, symptomatic allergic reactions, croup, tenacious secretions
SARS or suspected SARS patients
Hypoxic patients
Unconscious patients
Correct medication for the specific medical condition
Using jet nebuliser (oxygen driven) or ultrasonic nebuliser
Patients with a saturation <95% might require oxygen therapy simultaneously
 Performs Hand Hygiene

 Checks Patient identification; Name/DOB/gender with prescription and medical records
 Dons PPE gloves, face shield (mask and goggles)
 Prepares environment, PPE, equipment and medication. Oxygen Signage evident
o Nebulising mask, prescribed nebulisation medication, oxygen source, nebuliser if
applicable
 Checks prescription and medication – verifies correct name of the patient, correct medication,
correct dose, correct time, correct route, expiry date of the medication, correct diluting
solution
 Explains the procedure to the patient, requests to breathe normally throughout the procedure
 Assesses the patient, lung auscultation, SpO 2 (continuous SpO2 monitoring depending on
patient status)
 Attaches oxygen tube to the nebulising mask
 Prepares the nebulising medication in the chamber for the mask, follows correct mixing
 Attaches mask to patient face to fit comfortably over nose and mouth
 Adjusts oxygen flow to cause misting
 Administers entire dose – approximately 10 minutes
 Closes oxygen flow and removes mask
 Offers paper tissue to dry face and water to rinse mouth

Page 43 of 134
Version 1.01
August 2020
 Disposes of gloves, apron and face shield (mask and goggles) in medical waste
 Takes care of the mask if to be re-used, rinses, dries and marks with patient identifier
 Ensures patient comfort
 Performs hand hygiene
 Records the nebulisation on medication chart and medical records, observation of patient
status, effect of the nebulisation

Assessed HCP Date
Validating HCP Date
Comments:

Page 44 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.3. Simple Face Mask

Goals of treatment:
Prevention or reversal of hypoxia / hypoxemia thereby, maintaining cellular oxygenation in patients
with poor perfusion.
Indications:
Any patient with clinical manifestations resulting with mild shortness of breath.
Patients with suspected Acute Coronary Syndrome ONLY require supplemental oxygen IF their SpO 2
is less than 90%.
Titrate and limit supplemental oxygen to maintain a SpO 2 reading of 94% - 98%. Ensure SpO 2
reading is less than 100%. EXCEPTIONS: Trauma, scuba injuries, carbon monoxide and cyanide
poisoning
combustion.
Consider using a NRBM in cases when the baseline SpO2 reading has not increased.
Demonstrate the usage of a simple face mask:
 Position the patient appropriately or in a position of comfort.

Undertake a patient respiratory status assessment. Apply SpO 2 monitor recording baseline
oxygen saturation where possible.

 Attach the tubing to the oxygen regulator. Select the desired flow & oxygen concentration
rates:
 6lpm = 40%
 8lpm = 50%
 12lpm = 60%.
 Apply the mask to the patient covering their nose & mouth, secure the elastic strap.
 If required, press & mould the soft metal strip over the patient’s nose, ensure comfortable fit.

Assessed HCP Date
Validating HCP Date
Comments:

Page 45 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.4. Non – Rebreather Mask

Goals of treatment:
Prevention or reversal of hypoxia / hypoxemia thereby, maintaining cellular oxygenation in patients
with poor perfusion.
Indications:
Any patient with clinical manifestations of hypoxia, and shortness of breath / difficulty breathing.
Patients with suspected Acute Coronary Syndrome ONLY require supplemental oxygen IF their SpO 2
is less than 90%.
Titrate and limit supplemental oxygen to maintain an SpO 2 reading of 94% - 98%. Ensure SpO 2
reading is less than 100%. EXCEPTIONS: Trauma, scuba injuries, carbon monoxide and cyanide
poisoning
combustion.

Careful management of patients with chronic COPD to prevent issues related to their hypoxic drive.
Do not withhold oxygen in a dyspnoeic patient.
Close monitoring of oxygen cylinder levels to ensure oxygen does not run out whilst mask is applied.
Recommend patients are not left unattended whilst mask is applied. Ensure one valve on the side of
the mask is removed for safety.
Demonstrate the usage of a simple face mask:
 Position the patient appropriately or in a position of comfort.
Undertake a patient respiratory status assessment. Apply SpO2 monitor recording baseline
oxygen saturation where possible.

 Attach the tubing to the oxygen regulator.
 Select the oxygen flow rate that is sufficient to keep the reservoir partially inflated throughout.
It should never collapse completely.Prior to attaching mask to patient, ensure reservoir bag is
full placing index finger over the inside of the reservoir inlet.
 Apply the mask to the patient covering their nose & mouth, secure the elastic strap.
 If required, press & mould the soft metal strip over the patient’s nose to ensure a comfortable
fit.

Assessed HCP Date

Page 46 of 134
Version 1.01
August 2020
Validating HCP Date
Comments:

Page 47 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.5. Intermittent Positive Pressure Breathing (IPPB)

Goals of treatment:
Assist with the depth or rate of a patient’s ventilations during the inspiratory phase.
Indications:
Patients whose oxygenation &/or ventilation is inadequate, e.g. inter alia:
 Cardiogenic & non-cardiogenic pulmonary oedema.
 Hypoventilation from infection or trauma, etc.
 Chronic obstructive pulmonary disease (COPD), Chronic TB fibrosis, cystic fibrosis.
 Any other respiratory condition resulting in hypoventilation or inadequate oxygenation
Avoid apprehension/resistance when assisting the respirations in conscious patients.
combustion.

Securing a definitive airway in unconscious patients remains paramount.
In the conscious patient careful timing (to synchronise with spontaneous breaths) and patient
reassurance is essential to minimise patient anxiety, agitation or combativeness when providing
ventilation.
Demonstrate the procedure for administration of IPPB:
With a conscious patient:

 Reassure the patient and explain the procedure, if conscious
Initially apply high flow oxygen via a NRBM.
Apply an SpO 2 monitor to record a baseline.
 Position the patient in a 30°upright sitting position.

 Set up the BVM. Attach high flow 100% supplemental oxygen, inflating the reservoir bag
 Establish an effective seal between the BVM & the patient’s face, carefully observing the
patient’s inspirations & expirations.
 During the inspiratory phase gently compress the recoil bag to assist with increasing the
patient’s tidal volume. Via the resistance felt through the recoil bag, determine the correct
depth of assistance required.
 Allow for the completion of each expiratory phase & recompress the recoil bag at the
commencement of each inspiratory phase
With an unconscious patient:

Page 48 of 134
Version 1.01
August 2020
 Place the patient in the supine position.

 Ensure the airway is patent. (Manual airway manoeuvres, OP/Nasopharyngeal airway, LMA
or ETT).
 Initially apply high flow oxygen via a NRBM.
Apply a SpO 2 monitor to record a baseline.
 Set up the BVM. Attach high flow 100% supplemental oxygen, inflating the reservoir bag.
 Establish a seal between the BVM mask and the face or remove the mask & attach to the
LMA or ETT).
 Carefully observe the rate and pattern of patient ventilations
 During pauses of ventilations gently compress recoil bag to ventilate the patient.
 Gauge the amount of recoil bag compression required to ventilate the patient by feeling the
resistance of the recoil bag & adequate rise and fall of the patient’s chest.
 Increase the patients’ ventilations to a rate between 12-14 per minute.
 Document the procedure.

Assessed HCP Date
Validating HCP Date
Comments:

Page 49 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.6. Intermittent Positive Pressure Ventilations (IPPV)

Goals of treatment:
Provision of artificial ventilatory support to maintain adequate oxygen cellular perfusion for apnoeic
patients or those experiencing insufficient respiratory function.
Indications:
Respiratory insufficiency or respiratory arrest
Caution with pressures exerted during ventilations. Be aware of pneumothorax complications.

combustion

Always visualise rise and fall of chest & the airway remains patent.
Allow adequate expiration (long expiratory phase with asthmatics).
Demonstrate IPPV on an airway mannequin:
Identify the clinical manifestations that determine the need for IPPV.
 Ensure the airway is patent. (Manual airway manoeuvres, Oropharyngeal airway,

Nasopharyngeal airway, LMA or ETT).
 Set up the BVM. Attach high flow 100% supplemental oxygen, inflating the reservoir bag
 Establish an effective seal between the BVM & the patient’s face or remove the mask &
attach to the LMA / ETT.
 Gently compress recoil bag to ventilate the patient.
 Gauge the amount of recoil bag compression required to ventilate the patient by feeling the
resistance of the recoil bag & adequate rise and fall of the patient’s chest.
 Ventilate the patient, in general, starting at a rate of 1 breath every 5 seconds.
Assessed HCP Date
Validating HCP Date
Comments:

Page 50 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.7. Oxylog 1000 Ventilator

Goals of treatment:
To administer mechanical ventilatory support to maintain adequate alveolar ventilation, carbon
dioxide removal & oxygen delivery to the cells.
Indications:
 Respiratory Arrest
 Acute lung injury (including ARDS & trauma)
 COPD.
 Paralysis of the diaphragm (Guillain-Barre’ syndrome, Myasthenia Gravis, spinal cord
trauma, effects of anaesthesia & muscle relaxant medications).
 Sepsis, shock or CCF.
 Neurological injury or disease with a GCS < 8.
 Inability to maintain a patent airway.
Documented refusal for mechanical ventilation or a Do Not Resuscitate Order (DNR), signed by the
patient, appointed legal guardian or Health Authority.

Potential clinical complications include; pulmonary barotrauma, ventilator associated pneumonia,
cardiovascular compromise & increased intra-cranial pressure.
Patients must be sedated & sedation maintained to prevent them fighting with the ventilator or the risk
of further lung injury.
Demonstrate the set up and utilisation of the ventilator:
 Identify the requirement for mechanical ventilation.

 Connect the Oxylog regulator to the cylinder.
 Connect the black high-pressure hose to the regulator.
 Open the cylinder and charge line.
 Connect the patient circuit to the ventilator.
 Set the air mix or no air mix.
 Set the frequency.
 Set minute volume.
 Consult the table contained on the silver plaque on the top of the ventilator to adjust other
settings.
 Attach the test lung.
 Test the patient circuit.
 Attach a Pall or bacterial Filter.
 Attach the Capnography.
 Connect the patient circuit to the patient.
 Reassess your ventilator settings & the patient.
Document the ventilator settings.

Page 51 of 134
Version 1.01
August 2020
Oxygen calculation formula:
1 bar = 100kpa or 14.5psi.
WC = Wet Capacity.
WP = Working Pressure
RR = Respiratory Rate.
TV = Tidal Volume
Cylinder Volume = WC x WP = Litres of Oxygen Per Cylinder = (A)
Minute Volume= RR x TV = Litres Per Minute = (B)
Operating Time = Cylinder Volume = (A) = (minutes of oxygen per

cylinder)
Minute Volume + 1 L/min (B) + 1 L/min

Assessed HCP Date
Validating HCP Date
Comments:

Page 52 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.8. Oxylog 2000 Ventilator

Goals of treatment:
To administer mechanical ventilatory support to maintain adequate alveolar ventilation, carbon
dioxide removal & oxygen delivery to the cells.
Indications:
 Respiratory Arrest
 Acute lung injury (including ARDS & trauma)
 COPD.
 Paralysis of the diaphragm (Guillain-Barre’ syndrome, Myasthenia Gravis, spinal cord
trauma, effects of anaesthesia & muscle relaxant medications).
 Sepsis, shock or CCF.
 Neurological injury or disease with a GCS < 8.
 Inability to maintain a patent airway.
Documented refusal for mechanical ventilation or a Do Not Resuscitate Order (DNR), signed by the
patient, appointed legal guardian or Health Authority.

Potential clinical complications include; pulmonary barotraumas, ventilator associated pneumonia,
cardiovascular compromise & increased inter-cranial pressure.
Patients must be sedated & sedation maintained to prevent them fighting with the ventilator or the risk
of further lung injury.
Demonstrate the set up and utilisation of the ventilator:
 Identify the requirement for mechanical ventilation.

 Connect the Oxylog regulator to the cylinder.
 Connect the black high-pressure hose to the regulator.
 Open the cylinder and charge line.
 Connect the patient circuit to the ventilator.
 Set the FiO2.
 Set the (TV) tidal volume (6-8ml/kg).
 Set the (RR) Respiratory Rate
 Set the inspiratory to expiratory ratio.
 Set the PEEP.
 Set the alarm parameters.
 Test the circuit with a test lung.
 Attach a Pall or bacterial Filter.
 Attach the Capnography.
 Connect the patient circuit to the patient.
 Reassess your ventilator settings & the patient.
Document the ventilator settings.

Page 53 of 134
Version 1.01
August 2020
Oxygen calculation formula:
1 bar = 100kpa or 14.5psi.
WC = Wet Capacity (L)
WP = Working Pressure (bar)
RR = Respiratory Rate.
TV = Tidal Volume
Cylinder Volume = WC x WP = Litres of Oxygen Per Cylinder = (A)
Minute Volume= RR x TV = Litres Per Minute = (B)
Operating Time = Cylinder Volume = (A) = (minutes of oxygen per

cylinder)
Minute Volume + 1 L/min (B) + 1 L/min

Assessed HCP Date
Validating HCP Date
Comments:

Page 54 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.9. Oro-Naso Pharynx Suctioning

Goals of treatment:
To maintain a patient airway
Indications:
 Ineffective cough and unable to clear own airway
 Retained secretions causing distress
 Maintain airway patency by clearing secretions
 When other less invasive strategies have failed e.g. cough assist, better positioning etc.
 To stimulate cough
 To obtain a sputum sample for microbiology
 Severe bleeding disorder and haemoptysis
 Severe irritable airway (sever broncho or laryngospasm)
 Epiglottitis or croup
 Base of skull fracture
 Severe facial injury
 Recent nasal, oral or oesophageal surgery
 Occluded nasal passage
 Severe nasal bleeding
 Increased ICP
 Severe gag reflex
 Haemodynamic instability
 Trachea oesophageal fistulas
 Patients with hypoxia
 Severe bradycardia
 Cardiac arrhythmias (stimulation of vagal nerve)
Demonstrate the procedure for Suctioning:
 Implement standard precautions.

 Set up the suction machine & connect the suction tubing
 Choose & attach either a soft suction catheter or a Yankauer sucker to the suction tubing
 Open the patient mouth & place the suction catheter / Yankauer sucker next to the cheek,
leaving the suction control port open
 Closing the suction control port, suction for a maximum of 10 second duration removing all
fluids/vomitus
 Oxygenate the patient
 Repeat suctioning for a further 10 seconds if required to remove all fluids/vomitus
 Ensure patient is ventilated & oxygenated in between suctioning attempts
Document the procedure.

Assessed HCP Date
Validating HCP Date

Page 55 of 134
Version 1.01
August 2020
Comments:

Page 56 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.10. ETT Suctioning

Goals of treatment:
Aseptic removal of tracheal secretions to prevent decrease air entry or airway obstruction
Indications:
Assist in maintaining a patent airway
Clear and prevent tracheal secretions for intubated and ventilated patients
Audible secretions present
Clinical indicators: Desaturation, increased peak inspiratory pressure, increased work of breathing of
the ventilated patient
Aseptic technique to prevent infection
Haemodynamic and / or respiratory status assessment to prevent and manage possible instability

Patient assessment prior to performing the procedure; respiratory and haemodynamic status, pain
and anxiety levels
Procedure is only performed if competency is proven
Non-touch aseptic technique applied throughout the procedure
Two persons to perform the procedure together
Closed suction systems are the preferred method for bronchial toilet

Demonstrate the procedure for ETT Suctioning
 Prepares required equipment, work surface area / trolley and PPE – apron, gloves, mask and
goggles (or face shield)
 Sterile dressing pack, 2 pairs of appropriate size sterile gloves, sterile NaCl 0,9%
ampules, sterile water or saline (bottle) 20 cc syringe, hand sanitizer, appropriate
size suction catheters for endotracheal (less than half the size of ETT diameter) and
naso-pharynx suctioning, Yankauer suction catheter
 Checks suction apparatus functionality, connects connecting tube for the suction
catheter
 Performs hand hygiene, don goggles, plastic apron and mask
 Checks the correct patient - 3 identifiers of identification required, name, DOB, gender /
corresponding prescription / doctors notes
 Ensures patient is connected to cardiac monitor with SaO 2 monitoring
 Assesses the patient to identify the need for suctioning, auscultates lungs prior to the
procedure
 Informs the patient about the invasive procedure and discomfort during the procedure – even
if sedated
 Positions the patient in semi-upright position where possible
 Performs pre-oxygenation (supplemental oxygen FiO 2 of 100 %) for 2 to 3 minutes prior to
commencing the procedure

Page 57 of 134
Version 1.01
August 2020
 Opens sterile pack aseptically to generate a sterile field on the work surface / trolley, opens
consumables on the sterile field, pours sterile water / saline into the sterile container of the
pack. Peels outer packaging of catheters open - keeping the catheters in sterile packaging
 Second person available to assist with the procedure
 Performs surgical hand hygiene and dons sterile gloves (double glove dominant hand)
 Removes naso-pharynx suction catheter aseptically from the packaging, connects to
connecting tube from the suction apparatus, activates suction and performs naso-pharynx
suction with dominant hand, repeat for both nostrils
 Discards suction catheter and outer glove of the dominant hand into medical waste
 Removes endo-tracheal suction catheter from packaging and connects it aseptically to the
connecting tube from the suction apparatus
 Wets catheter into sterile water or normal saline prior to inserting it into the endo-tracheal
tube (ET tube).
 Second person to disconnect (and re-connect) ventilator circuit aseptically from the ETT
during procedure
 Gloved person carefully inserts the suction catheter into the ETT and advances to the correct
length - to the point of resistance or until cough is stimulated, then withdraws 1-2 cm prior to
application of suction
 Places the thumb over the suction vent (side of the catheter) to activate suctioning (releases
intermittently when removing the catheter)
 Maximum occlusion suction pressure is limited to -80 to 150mmHg or 20 kPa)
 Does not leave the suction catheter in the ETT tube for longer than 15 seconds before the
catheter is withdrawn
 Reconnects the ventilator circuit and allows patient to breath / ventilator to ventilate the
patient between each suctioning attempt
 Wipes the suction catheter with a sterile gauze when removing it from the ETT, performs
rinsing of the catheter by suctioning of sterile water or saline through the catheter after each
withdrawal of the catheter
 Repeats suction attempts until secretions are cleared whilst continuously monitoring the
SaO2 and haemodynamic status.
 Monitors patient throughout procedure, terminates if patient becomes unstable
 Disposes of the suction catheter and glove by grasping the cuff of the glove with the non-
dominant hand, and peel the glove off - inside out over the glove
 Performs oro-pharyngeal care with Yankauer suction catheter, mouth wash / tooth paste and
brush
 Discards non-dominant hand glove and other consumables into the medical waste and
cleans environment
 Checks ventilator settings – reset if indicated
 Documents patient status, haemodynamic and respiratory, lung sounds post suctioning,
colour and consistency of mucus in patient medical records

Assessed HCP Date
Validating HCP Date
Comments:

Page 58 of 134
Version 1.01
August 2020
OXYGEN THERAPY
7.11. Capnography

Goals of treatment:
To continuously measure the levels of CO 2 contained within exhaled respirations, allowing
appropriate minute volume to produce the desired arterial CO 2 (35mm Hg).
Indications:
Any patient that is Intubated & ventilated via either a BVM (IPPV) or a mechanical ventilator.
Used to confirm correct placement of the ETT
Used to assess efficacy of external cardiac compressions
There are no absolute contraindications to capnography in mechanically ventilated patients provided
that the data obtained are evaluated with consideration given to the patient’s clinical condition.
Capnography should not be used in cardiac arrest cases, to confirm correct placement of the ETT.

Asthma patients will usually initially present with below normal CO 2 levels. A high CO 2 reading in
these cases indicates impending respiratory arrest.
With COAD patients the aim is to maintain the CO 2 levels below 45mm Hg & a SpO 2 > 93%.
Demonstrate the procedure for Capnography:

 Implement appropriate airway management (refer to ETT procedure).
 Remove the capnography tubing from its packet.
 Connect the sampling tube into the capnography module of the cardiac monitor.
 Connect the sensor end of the sampling tube between the pall filter & the ventilation circuit or
BVM.
 Ventilate the patient & check the monitor ensuring you have normal capnography reading of
35mm Hg & a normal waveform.

Assessed HCP Date
Validating HCP Date
Comments:

Page 59 of 134
Version 1.01
August 2020
8. SECTION 5 – CARDIO PULMONARY RESUSCITATION

SECTION 5
CARDIO PULMONARY RESUSCITATION
1. Adult CPR / AED 56
2. Child CPR AED 57
3. Infant CPR 58
HCPs ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH


Page 60 of 134
Version 1.01
August 2020

8.1. Adult CPR / AED

Goals of treatment:
To sustain life through artificially maintaining the functions of the respiratory & circulatory systems
when they have ceased, i.e. no definite pulse & no normal breathing
Indications:
Any patient in cardiac arrest
Scene safety is always paramount
In situations when determining patient potential viability, clinicians should initially commence CPR
until the criteria for discontinuation can be proven: start early so you can stop early, if required.
DO NOT commence CPR in the following:
 Gross trauma incompatible with life / decapitation
 Rigor mortis or lividity
 Multi-casualty incidents when the capacity to resuscitate is overwhelmed by the staff
available
 Environments dangerous or life threatening to the HCP.
Reasons for withholding CPR or reasons for withdrawing / discontinuing CPR
Demonstrate the procedure for Adult CPR using a mannequin:
 Ensure the scene is safe.
 Check victim unresponsive & Shout for help.
 Activate Emergency Response System (if appropriate) & Send for or get the nearest AED /
manual defib.
 Recognition that CPR is required (Check for breathing & palpable pulse concurrently within 5-
10 seconds).
 Single person rescuer to retrieve the AED before commencing CPR if cardiac cause
suspected
 Compressions, Airway, Breathing (C-A-B).
 Commence external cardiac compressions 30 compressions followed by 2 breaths; push
hard & fast. Use a metronome set at 110/min.
 AED arrives, CPR continues if 2 rescuers present; immediately with on AED, attach pads,
plug in connector, and follow the AED prompts; shock if AED advises to shock.
 Immediately resume CPR starting with chest compressions [30 compressions and 2
ventilations for 2 minutes].
 Reassess rhythm with AED & follow prompts shock/no shock advised.
 Continue CPR for a 2-minute cycles of 30 compressions / 2 breaths.
 Demonstrate recognition of criteria to discontinue CPR.

Assessed HCP Date

Page 61 of 134
Version 1.01
August 2020
Validating HCP Date
Comments:

Page 62 of 134
Version 1.01
August 2020

8.2. Child CPR / AED

Goals of treatment:
when they have ceased or are inadequately functioning.
Indications:
Any child in cardiac arrest or when the pulse rate is less than 60/min, despite 1 min of oxygenation &
ventilations.
Scene safety is paramount
In situations when determining patient potential viability, clinicians should initially commence CPR
until the criteria for discontinuation can be proven.
 Gross trauma incompatible with life / decapitation
 Multi-casualty incidents when the capacity to resuscitate is overwhelmed by the staff
available
 Environments dangerous or life threatening to the HCP.
A child is defined as 1 year of age to puberty.
Child cardiac arrests often have a respiratory aetiology. Ventilations are essential – compression-only
CPR is futile. Paediatric cardiac arrests however may also have a shockable rhythm present –
ensure the AED / defib is applied as in the adult.

Demonstrate the procedure for Child CPR using a mannequin:
defib.Recognition that CPR required (Check for normal breathing & definite palpable pulse
concurrently within 5-10 seconds).
 Witnessed sudden collapse (Yes) retrieve AED / defib immediately while CPR continues if 2nd
rescuer present
 Non- witnessed collapse - send for AED & commence CPR.
 Single person rescuer 30 compressions / 2 breaths until AED arrives.
 2-person rescuer: 15 compressions / 2 breaths until AED arrives.
 Continue administering as per 1 or 2 person rescuer protocol above for 2 minutes.
 Continue CPR for a 2-minute cycles & follow AED prompts.

Assessed HCP Date
Validating HCP Date

Page 63 of 134
Version 1.01
August 2020
Comments:

Page 64 of 134
Version 1.01
August 2020

8.3. Infant CPR

Goals of treatment:
when they have ceased or are inadequately functioning.
Indications:
Any patient in cardiac arrest or when the pulse & respirations are inadequate to sustain life.
Any infant in cardiac arrest or when the pulse rate is less than 60/min, despite 1 min of oxygenation &
ventilations.
Scene safety is paramount particularly with cardiac arrests from electrocution.
 Gross trauma/ decapitation
 Multi-casualty incidents, when lack of local resources to resuscitate exceeds and
overwhelms capacity to care for all patients.
 Environments dangerous or life threatening to the HCP, that cannot be made safe.
An infant is from 1 month to 1 year of age.
Infant cardiac arrests often have a respiratory aetiology; therefore CPR with ventilations are essential
in these cases – compression-only CPR is futile. Paediatric cardiac arrests however may also have a
shockable rhythm present – ensure the AED / defib is applied as in the adult, with paediatric pads (at
4J/kg and then increasing to 6J/kg, and then 8J/kg and then maximally, 10J/kg according to AHA
guidelines)

Demonstrate the procedure for Infant CPR using a mannequin:
defib.Recognition that CPR required (Check for normal breathing & definite palpable pulse
concurrently within 5-10 seconds).
 Place infant on a firm flat surface.
 Single person rescuer 30 compressions / 2 breaths with BMV until AED arrives.
 Place 2 fingers in the centre of the infant’s chest, just below the nipple line, on the lower half
of the breastbone.
 Compressions with 2 fingers to start with, but may use 3 fingers, or more, to ensure
compression depth of at least ⅓ diameter of the chest.
 Ensure full chest recoil after each compression (chest re-expansion)
 Compression rate at 100 – 120 / min, using a metronome
 2-person rescuer: 15 compressions / 2 breaths with infant/child bag-mask ventilation (BMV)
device until AED arrives. The transition time, form the last compression of the cycle, to the
first compression of the next cycle, must be less than 10 seconds
 Continue administering as per 1 or 2 person rescuer protocol above for 2 minutes.
 Continue CPR for a 2-minute cycles & follow AED prompts.
Page 65 of 134
Version 1.01
August 2020

Assessed Date
HCP
Validating Date
HCP
Comments:

Page 66 of 134
Version 1.01
August 2020
9. SECTION 6 – DEFIBRILLATION / CARDIAC MONITORING

SECTION 6
DEFIBRILLATION / CARDIAC MONITORING
1. Cardiac Monitoring 3 Lead / 12 Lead 60
2. Cardiac Monitoring Recording 12 Lead ECG 61
3. Defibrillation 64
4. Synchronised Cardioversion 67
5. Transcutaneous Cardiac Pacing (TCP) 69


Page 67 of 134
Version 1.01
August 2020

9.1. Cardiac Monitoring 3 Lead / 12 Lead

Goals of treatment:
Graphically record & study the electrical action of the myocardium to identify underlying arrhythmias
or evidence of myocardial ischemia.
Indications:
Any patient suspected or displaying the clinical manifestations consistent with a cardio-respiratory
event or any patient with abnormal vital signs.
Beware of artefact. Causes include:
 Incomplete electrode contact with skin due to sweat, oil or chest hair.
 Patient movement, breathing, muscle tremor or movement of the leads.
 AC electricity / 50 or 60 Hz interference.
 Broken cable or malfunctioning machine.
Always check the electrodes are in date and have sufficient gel & confirm correct electrode
placement on chest.
For patients in cardiac arrest or imminent cardiac arrest use defibrillation pads (MFE – multi function
electrodes). Follow cardiac arrest / defibrillation procedures.

Demonstrate 3 or 12 lead cardiac monitoring:
 Wipe and dry skin surface to ensure the electrodes will adhere.
Shave chest hair if required.

 Attach the monitoring electrode to the lead’s cable snaps.
 Attach the electrodes to the patient chest either in the configuration for a 3 lead or 12 lead
ECG.
 Monitor the patient & print a rhythm strip in accordance with machine specifications.
 Demonstrate ability to effectively convey relevant information from cardiac monitoring to
appropriate personal at a patient receiving facility.
 Demonstrate an understanding of 3 lead or 12 lead rhythm interpretation.
 When printing out the 12-lead ECG for STEMI, monitor must be in diagnostic frequency
response mode, NOT monitor frequency response.

Assessed HCP Date
Validating HCP Date
Comments:

Page 68 of 134
Version 1.01
August 2020

9.2. Cardiac Monitoring Recording 12 Lead ECG

Goals of procedure:
To ensure a high qualify resting ECG recording is obtained for the purpose of diagnosis, assessment
and health screening.
The standard 12-lead ECG records potential differences between prescribed sites on the body
surface that vary during the cardiac cycle; it reflects differences in trans membrane voltages in
myocardial cells that occur during depolarization and repolarization within each cycle.
Indications:
 Chest pain suggestive of ischemia
 Known or suspected arrhythmias
 Changes in rhythm (e.g. atrial fibrillation to sinus rhythm, new bundle branch block)
 Post cardiac arrest/resuscitation
 Post syncopal episodes to assess arrhythmia ST/T wave changes consistent with
metabolic and electrolyte disturbances
 Preoperative assessment
 Post insertion of pacemaker (permanent or temporary)
 Routine requirements
 Assessment of medications known to cause cardiac arrhythmia
Nil.
Other Clinical Judgement Issues: use of the ECG machine; recording of the 12 lead ECG;
recognition of significant and life-threatening arrhythmias; appropriate response to significant and life-
threatening arrhythmias.
Demonstrate the 12 Lead ECG Competency Assessment on a patient who has provided
consent or alternatively utilise a full-size mannequin:
 HCP prepares ECG machine ensuring adequate supplies of consumables are included such
as ECG paper, electrodes, hair removal device, skin prep, cleaning wipes.
 Greets the patient and adequately explains the procedure to be performed including the
requirement for unrestricted access to the chest area. Obtains verbal consent.
 Confirms patient’s identity and enters correct patient details in the as required.
 Performs hand hygiene.
 Makes sure the patient is comfortable and positioned correctly in the supine position on bed,
trolley with all limbs supported.
 Ensures the patient’s privacy, dignity, rights and confidentiality are maintained by:
 Curtains drawn, or door closed
 Patient covered with a sheet or blanket
 Support person or Chaperone if requested
 HCP can explain the location and types of emergency resuscitation equipment if required.
 When printing out the 12-lead ECG for STEMI, monitor must be in diagnostic frequency
response mode, NOT monitor frequency response.
 Ensure Diagnostic Frequency Response setting is on: set the low-frequency filter no higher
than 0.05 Hz to avoid distortion of the ST segment.

Page 69 of 134
Version 1.01
August 2020
 Set the high frequency filter no lower than 100 Hz to prevent loss of high frequency
information.
 Identifies the chest electrode sites correctly according to AHA guidelines and diagram below
 Prepare patients skin to ensure adequate electrode contact.

 Shave the hair at the electrode placements site if necessary (patient consent
required) and disposes of any sharps in the sharps container immediately after use.
 Clean the skin with mild soap or alcohol wipe.
 Exfoliate if necessary with light abrasion using a paper towel or gauze swab
 Limb leads are placed correctly.
 RA (Right arm) Right forearm, proximal to the wrist
 LA (Left arm) Left forearm, proximal to the wrist
 LL (Left leg) Left lower leg, proximal to the ankle
 RL (Right leg) Right lower leg, proximal to the ankle
 Applies suitable electrodes firmly to the patient’s skin to minimise artefact.
 Attaches correct leads to electrodes.
 Ensure visual confirmation of an artefact free ECG trace on the display before pressing the
appropriate record or print button on the ECG machine to obtain a resting 12 lead ECG.
 Records a 12 lead ECG at 25 mm/sec printer speed with a gain setting of 10 mm/mV
 Takes steps to modify the procedure if a suitable ECG recording cannot be made and re-
record if necessary.
 Checks the correct patient details, date and time are recorded on the ECG tracing.
 Removes leads and electrodes and cleans skin if required. Disposes of waste correctly.
 Informs the patient of the next steps in the review process and treatment plan.
 Allows the patient privacy to dress
 Checks the ECG for abnormalities (HCP where this is in scope of practice) and informs the
treating physician.

Page 70 of 134
Version 1.01
August 2020
 Cleans and restocks the ECG machine.
 Paper towel disposed in foot operated bin with a lid, clearly marked “general waste”.

Assessed HCP Date
Validating HCP Date
Comments:

Page 71 of 134
Version 1.01
August 2020

9.3. Defibrillation

Goals of treatment:
The delivery of an electrical current, to terminate life-threatening ventricular arrhythmias, stopping
electrical activity within the myocardium, allowing the heart’s intrinsic pacemaker to regain control &
regulation of the heart rate and rhythm.
Indications:
Unconscious, pulseless patients presenting with ventricular fibrillation or pulseless ventricular
tachycardia.
The attachment of the defibrillator should not impede or interrupt continuous chest compressions.
Safety with defibrillation:

 A non-conductive environment.
 A non-explosive environment.
 No contact with the patient.
 No movement.
Ensure BVM ventilation ceases & is faced away from the patient prior to administration of
defibrillation.
The 2015 AHA guidelines require:
 Delivery of defibrillation shock as soon as possible, as per the defibrillator manufacturer’s
recommended energy joule setting.
 Biphasic 120 – 200 joules / Monophasic 360 joules.
 If you don’t know the machine, choose the maximum defib energy setting.
 Subsequent defibrillation shocks should be escalated to higher joule settings.
Defibrillation pads application; smoothed on from one edge eliminating air bubbles and poor surface
contact.

Demonstrate the procedure for defibrillation using a simulator or mannequin:
Adult defibrillation:
 Follow the adult CPR protocol.
 Prepare the patient exposing the chest / shaving if required.
 Attach the defibrillation pads / paddles & analyse the patient rhythm while compressions are
temporarily stopped
 If VF or pulseless VT rhythm or machine advises (semi auto mode or AED).
 Ensure the 4 safety points for defibrillation.
 Select joules as per manufacturer’s settings & charge.
 Confirm scene safe for defibrillation & deliver one (1) shock (1st shock)
 Immediately resume compressions. Limit time off the chest to less than 10 seconds (and
even better much less!) Continue CPR: 30 compressions / 2 breaths for 2 minutes.
 Reanalyse the rhythm; If VF or pulseless VT rhythm or machine advises (semi auto mode or
AED).

Page 72 of 134
Version 1.01
August 2020

 Select escalated energy dose as per manufacturer’s settings & charge. Continue chest
compressions while charging for manual defibrillator or as advised by AED
 Confirm scene safe for defibrillation & deliver one (1) shock (2nd shock)
 Drug therapy Adrenaline / Epinephrine IV or IO - 1mg every 4minutes i.e. after every 2nd
shock / analysis
 Continue CPR 30 compressions / 2 breaths for 2 minutes.

 Reanalyse the rhythm; If VF or pulseless VT rhythm or machine advises (semi auto mode or
AED).
 Select Biphasic or Monophasic joules as per manufacturer’s settings & charge.
 rd
Confirm scene safe for defibrillation & deliver one (1) shock. (3 shock)
 nd
Drug therapy Amiodarone IV or IO – 300mg initial dose (2 dose 150mg after 5 shock).
th
 Lignocaine is an alternative to amiodarone.

 Search for and manage reversible causes (H’s & T’s) -these should be considered early in,
and throughout the resuscitation.
 Establish an advanced airway early in the resuscitation if possible, without interrupting CPR.
This could involve placement of an LT / LMA. Thereafter, the compressions are not
interrupted for ventilations, which should continue at a rate of 1 breath every 6 seconds, and
not faster! End tidal CO2 shouldread at least 10 mmHg, reflecting effective compressions.
 If a non-shockable rhythm, continue CPR.
 Continue the defibrillation / CPR / Drug protocol if indicated.
Paediatric defibrillation:

 Follow the child CPR protocol.
 Prepare the patient exposing the chest.
 Attach the defibrillation pads / paddles & analyse the patient rhythm.
 If VF or pulseless VT rhythm or machine advises (semi auto mode).
 Estimate child’s body weight using a length based tape (PAWPER XL). This tape weight
estimation must be performed early.
 Set the joule setting 2 – 4 joules per kg.
 st
 Continue CPR 30 compressions / 2 breaths for 2 minutes (single rescuer)
Or 15 compressions / 2 breaths for 2 minutes (two rescuers) or continuous compression /
ventilation CPR if advanced airway in place
 Re-analyse the rhythm; If VF or pulseless VT rhythm or machine advises (semi auto mode).
 Set the joule setting joules per kg.
 nd
 Drug therapy Adrenaline / Epinephrine IV or IO – 0.01 mg per kg (0.1ml per Kg 1:10 000)
every 4minutes.
 Continue CPR 30 compressions / 2 breaths for 2 minutes single rescuer
Or 15 compressions / 2 breaths for 2 minutes two rescuers.
 Reanalyse the rhythm; If VF or pulseless VT rhythm or machine advises (semi auto mode).
 Set the joule setting 6 joules per kg.
 rd
 Drug therapy Amiodarone IV or IO – 5mg per kg (may repeat up to two (2) times)
Or Lidocaine IO or IV 1mg per kg loading dose.
 Continue CPR 30 compressions / 2 breaths for 2 minutes single rescuer
Or 15 compressions / 2 breaths for 2 minutes two rescuers.

Page 73 of 134
Version 1.01
August 2020
 Reanalyse the rhythm; If VF or pulseless VT rhythm or machine advises (semi auto mode).
 Set the joule setting equal to 8 joules per kg or / up to 10 joules per kg or / Adult joule setting.
 th
Confirm scene safe for defibrillation & deliver one (1) shock. (4 shock) and hen give another
adrenaline bolus dose, followed by 10 mL flush
 Search for and manage reversible causes (H’s & T’s) -these should be considered early in,
and throughout the resuscitation.
 Establish an advanced airway early in the resuscitation if possible, without interrupting CPR.
This could involve placement of an LT / LMA. Thereafter, the compressions are not
interrupted for ventilations, which should continue at a rate of 1 breath every 6 seconds, and
not faster!
 If a non-shockable rhythm, continue CPR.
 Continue the defibrillation / CPR / Drug protocol if indicated.

Assessed HCP Date
Validating HCP Date
Comments:

Page 74 of 134
Version 1.01
August 2020

9.4. Synchronised Cardioversion

Goals of treatment:
To restore a normal heart rhythm through the delivery of a controlled current synchronised with the R
wave.
Indications:
Patients presenting with SVT or VT (exceeding 150/min) associated with severely compromised
cardiac output:
 Ventricular Tachycardia.
 Supraventricular Tachycardia.
 Atrial fibrillation & atrial flutter (associated with severely compromised cardiac output &
fast ventricular rate).
Synchronised cardioversion is contra-indicated in the following:
 Ventricular fibrillation.
 Arrhythmias with adequate patient perfusion.
 When the ventricular rate is within normal parameters.

Non-sedated or conscious patients.

Demonstrate the procedure for synchronised cardioversion on an ALS mannequin:
 Determine the requirement for synchronised cardioversion. Typical presentation >150 bpm.
 Maintain patent airway, assist breathing where required, O 2 delivery for hypoxic patients,
cardiac monitor to identify rhythm, BP monitoring & oximetery.
 Gain IV access; prepare resuscitative medications, airway & ventilation equipment.
 Consider cardioversion in patients presenting with persistent tachyarrhythmia causing any
signs of shock. Any causes for the tachycardia should be quickly identified and resolved,
while the patient is being assessed and first line therapy is being instituted.
 If conscious with poor perfusion, consider sedating the patient.
 If patient presents with regular narrow complex tachycardia, consider Adenosine:
st
 1 dose 6mg IV rapid push with normal saline flush
nd
 If required 2 dose 12 mg rapid push with normal saline flush
 However, this adenosine should NOT delay the synchronised cardioversion.
 Attach the defibrillation pads/paddles (shave the chest if required).
 Ensure synchronising button is on and marker is seen on the R waves.
 Cardiovert the patient:
 Narrow & regular rhythm 50 – 100 joules.
 Narrow & irregular rhythm 120 – 200 joules Biphasic machine or 200 joules monophasic
machine.
 Wide & regular rhythm 100 joules.
 Wide & irregular rhythm – follow defibrillation protocol.
 If ventricular fibrillation results from cardioversion, disable the synchroniser & proceed as per
ACLS guidelines.

Page 75 of 134
Version 1.01
August 2020

Assessed Date
HCP
Validating Date
HCP
Comments:

Page 76 of 134
Version 1.01
August 2020

9.5. Transcutaneous Cardiac Pacing (TCP)

Goals of treatment:
To provide the cardiac muscle with an artificial pacemaker, through the delivery of external electric
currents, maintaining cardiac output and cellular perfusion.
Indications:
Patients with poor perfusion resulting from severe sinus bradycardia, heart block, or idioventricular
rhythm, & can generate a pulse with cardiac contractions.
Any causes for the bradycardia should be quickly identified and resolved, while the patient is being
assessed and first line therapy is being instituted.
Hemodynamically unstable – Atropine – TCP – Adrenaline. However, pacing or adrenaline are

equivalent therapies; an adrenaline infusion may be used if no pacing is available or if pacing is
ineffective.
TCP is contra-indicated with asystole

Demand pacing sense inherent QRS complexes, only delivering electrical stimuli when needed.

Demonstrate the procedure for transcutaneous cardiac pacing on an ALS mannequin:
 Determine the requirement for transcutaneous cardiac pacing.

 Prepare the patient.
 Gain IV access.
 Sedate or analgesia if necessary, especially once BP increases following successful pacing
 ECG electrode and pacing electrode placement.
 Select mode (synch or asynch / demand or fixed), rate (60-70) and current.
 Assess for 3 captures: electrical, mechanical and physiological capture.
 Assess adequate sensing of demand pacemaker by ensuring ECG size is properly adjusted.
 Ensure the current is 10% above the threshold of capture.

Assessed HCP Date
Validating HCP Date
Comments:

Page 77 of 134
Version 1.01
August 2020

Page 78 of 134
Version 1.01
August 2020
10. SECTION 7 – DRUG/FLUID ADMINISTRATION

SECTION 7
DRUG/FLUID ADMINISTRATION
1. Oral Medication Administration 71
2. Vaccination 73
3. Subcutaneous Injections 75
4. Intramuscular Injections 76
5. Intravenous Injections 77
6. Intraosseous Cannulation 79
7. Extra Jugular Venous Cannulation 80
8. Fluid Replacement 81
9. Syringe Driver 83


Page 79 of 134
Version 1.01
August 2020
DRUG / FLUID ADMINISTRATION

10.1. Oral Medication Administration

Goals of treatment:
To safely administer prescribed medication to the patients
Indications:
.
.

.

Demonstrate the procedure for transcutaneous cardiac pacing on an ALS mannequin:
 HCP performs hand hygiene

 Greets patient and explains the procedure.
 Correctly identifies the patient using three approved identifiers. Identifiers include patient
name (family and given names), date of birth, gender, address. (1) (6)
 Matches the patient’s identity to details on the prescription or medication chart (1)
 Checks the patient’s allergies and adverse drug reactions
 Matches the medicine with the order on the prescription or medication chart (2)
 Ensures that the medicine name, dose, route, frequency, time of day, indication and duration
of therapy are correct (2)(3) (4)
 Checks the medication has not expired.
 Ensures the medicine is safe and appropriate for the patient (5)
 Check with medicines information resources (MIMS or BNF) if unfamiliar with, or
unsure about, the medicine
 Double checks medicines in accordance with:

 local procedure requirements
 Requirements for 2 persons check of controlled or restricted medication
 Confirms medical order meets legal requirements e.g. dated and signed by a medical officer,
order is legible (6)
 Places the lid of the container upside down to prevent contamination
 Demonstrates correct technique for removing tablets/capsules from bottles/blister packs.
 Demonstrates correct technique for pouring a specific amount of liquid from a bottle
Page 80 of 134
Version 1.01
August 2020
 Checks patient is not nil by mouth (NBM) and patients’ compatibility of route of administration
 Completes final medication check.
 Informs the patient what medications are being administered and satisfactorily answers any
questions from the patient or carer.
 Gives the patient sufficient fluids to swallow medication
 Witnesses ingestion of medication
 Signs the drug order
 Reports significant finding
 Prepare the patient.
Perform the SEVEN RIGHTS x 3 (this must be done with each individual medication):
The right patient

The right medication (drug)
The right dose
The right route
The right time
The right reason
The right documentation

Assessed HCP Date
Validating HCP Date
Comments:

Page 81 of 134
Version 1.01
August 2020

10.2. Vaccination

Goals of treatment:
To pro-actively immunize patients against known preventable diseases.
Indications:
Correct medication order.
Only HCP’s who have been approved to administer vaccines by the Medical Director or CMO may
complete this competency.
Known allergy to the medication being administered.
HCP’s must be set up prior to administration to manage an anaphylactic reaction.

The legal and regulatory requirements for administering vaccines in the location must be known and
understood by the HCP.
Ensure the administration of a vaccine is within the HCP’s scope of practice.

Demonstrate the correct procedure for vaccination administration:
During clinical assessment the HCP will be automatically failed if the seven rights are not
performed as required.
 Reviews Patient history

 Identifies any risk categories as per the relevant and approved reference and
resource material.
 Identifies which specific vaccines are recommended and scheduled
 Confirms vaccine history through checking all vaccination records
 Identifies if catch up vaccines are necessary and plans appropriately
 Correctly identifies the patient using three approved identifiers. Identifiers include patient
name (family and given names), date of birth, gender, address.
 Greets the patient and explains the procedure

 Conducts pre-vaccination screening using approved checklist.
 Correctly identifies any contraindications to vaccination and responds appropriately.
 Obtains documented and informed consent
 Provides required information to Patient or Guardian on: \
 Risks and benefits of each vaccine including common and rare reactions
 Advice on what to do if they are concerned about a reaction following a
vaccination
 How to report an adverse reaction
 The requirement to remain under surveillance for 15-20 minutes following

Page 82 of 134
Version 1.01
August 2020
vaccination
 Satisfactorily responds to questions or concerns raised.
 Ensures there is a fully stocked anaphylaxis kit available.
 Ensures there is an oxygen supply available
 Can explain the correct management of anaphylaxis including recognising an anaphylaxis
reaction.
 Can explain the Intl.SOS guidelines for vaccine storage and handling
 Can correctly identify a breach of vaccine storage conditions.
 Confirms the correct vaccines and dose required prior to selection
 Selects the correct vaccines and confirms suitability for use
 Cold chain maintained
 Expiry date
 Manufacturer & Batch No
 Prepares all required equipment.
 Reconstitutes vaccines correctly where required.
 Identifies correct injection site
 Effectively communicates with parent/caregiver regarding suitable position and holding of
children and infants
 Effectively positions patient to allow good access to the injection site.
 Identifies and selects appropriate needle size and length as required for specific individuals
 Selects correct route of administration for each vaccine
 Uses correct administration technique for each vaccine
 Disposes of all sharps directly into a sharps container.
 Documents all required information in the medical record and vaccine register
 Records vaccines given into Patient Vaccine Record/Book
 Ensures patient is observed for 15 minutes following procedure.
 If the patient refuses to wait requests they sign a refusal of medical treatment and documents
in the medical record.

Assessed HCP Date
Validating HCP Date
Comments:

Page 83 of 134
Version 1.01
August 2020

10.3. Subcutaneous Injections

Goals of treatment:
To inject medications into the subcutaneous tissues for the body to absorb & metabolise.
Indications:
Any patient that requires a slower medication absorption rate than the administration via the IM or IV
route. When the medication manufacturer specifies administration via subcutaneous route only.
DO NOT administer subcutaneous injections:

 Over a septic wound site.
 Where a haematoma is present.
 Where cellulitis is present.
HCP’s should be aware & take the necessary precautions to avoid needle stick injury / puncture.

Subcutaneous injections are painful for the patient.

Demonstrate the procedure for a subcutaneous injection:
 Determine the need for administration of a subcutaneous injection.

 Implement standard precautions & choose the appropriate tissue injection site.
 Prepare the necessary equipment & injection site; Alcohol wipe, syringe & safety needle with
drawn up medication.
 Insert the needle at a 45-degree angle at the base of the raised skin, draw back the syringe
plunger to ensure no entry into a vessel & inject the medication.
 Activate the safety device and dispose of the syringe & needle into the sharps container.
 Cover the injection site with a sterile dressing or cotton wool/tape.

Assessed HCP Date
Validating HCP Date
Comments:

Page 84 of 134
Version 1.01
August 2020

10.4. Intramuscular Injections

Goals of treatment:
To inject medications into the subcutaneous tissues for the body to absorb & metabolise.
Indications:
Any patient that requires the administration of medication specifically for delivery via the IM route or
when IV access is not available, or IV administration is contra-indicated.
DO NOT administer intramuscular injections:

 Over a septic wound site or limb.
 Over a muscle where a haematoma is present.
 Over a fracture site or a fractured limb.
 Distal to an injury.
 When the limb has cellulitis.
 When a limb has potential or existing lymphedema
The volume of medication being administered will determine the appropriate body muscle injection
site.

 Determine the need for administration of an intramuscular injection.
 Implement standard precautions & choose the appropriate muscle injection site.
 Prepare the necessary equipment & injection site; Alcohol wipe, syringe & safety needle with
drawn up medication.
 Spread the skin over the injection site, insert the needle at a 90-degree angle, draw back the
syringe plunger to ensure no entry into a vessel & inject the medication.
 Activate the safety device and dispose of the syringe & needle into the sharps container.
 Cover the injection site with a sterile dressing or cotton wool/tape & document the procedure.
Assessed HCP Date
Validating HCP Date
Comments:

Page 85 of 134
Version 1.01
August 2020

10.5. Intravenous Injections

Goals of treatment:
To gain access to the venous circulation system for the administration of medications or fluids.
Indications:
For the actual or potential requirement to administer fluid replacement.
For the actual or potential requirement for drug administration.
HCP’s are only to attempt:
 3 x cannulations in adults.
 2 x cannulations in paediatrics.
 1 x extra jugular cannulations.
DO NOT insert the cannula distal to or over fractures. DO NOT insert the cannula distal to
haemorrhage sites.
DO NOT cannulate in the following situations:

 Lower limbs when pelvis, abdominal or thoracic trauma is suspected.
 In a limb with compartment syndrome.
 Limb with a fistula present.
 When an extremity has phlebitis or cellulitis.
 When a limb has potential or existing lymphedema.
 When there exists venous occlusive oedema of a limb.

Cannulation complications include; nerve damage, arterial puncture, haematoma, air emboli, cannula
shear or breakage, drug/fluid extravasation (tissuing), haemorrhage from site, infection, phlebitis, and
vasovagal syncope.
The age of the patient, vein location & size, should be considered when selecting the correct sized
cannula for the required task.

Demonstrate the procedure for intravenous injection:
 Determine the need for IV Cannulation.

 Select the correct gauge of safety cannula for the required task:
 14 gauge
 16 gauge
 18 gauge
 20 gauge
 22 gauge
 24 gauge

Page 86 of 134
Version 1.01
August 2020
 Prepare the items necessary for IV cannulation:

 Alcohol wipes
 Tourniquet
 IV cannula
 Op Site
 IV bung
 10 ml syringe with a blunt cannula or needle
 10 mil saline flush
 Sharps container
 Surgical tape (if required)
 Sam splint (if required)
 Giving set & IV fluid bag (if required)
 Select a cannulation site suitable for the required administration of medications or fluids,
ensuring the vein is suitable to accommodate the gauge of the cannula.
 Prepare the puncture site. (tourniquet & alcohol wipe.
 Insert the cannula:
 Stabilise the vein applying distal pressure and tension below the intended point of entry
keeping hands behind the cannula.
 With the bevel of the needle facing up, insert the cannula into vein from the side or directly
on top, at an angle the clinician is comfortable with (ranging between flat & a 45 degree
angle)
 Slide the cannula sheath over the needle & into the vein Tourniquet
 Withdraw the needle (activate the safety device) while applying pressure over the vein &
sheath, stabilizing the vein & disposing the cannula into the sharps container.
 Release the tourniquet & attach an IV bung or a primed giving set.
 Flush the cannula to ensure patency using a 10ml syringe with saline flush or run the
primed giving set IV bung.
 Cover the puncture site with an Op site & anchor the cannula sheath with tape if required

Assessed HCP Date
Validating HCP Date
Comments:

Page 87 of 134
Version 1.01
August 2020

10.6. Intraosseous Cannulation

Goals of treatment:
To obtain IV access via the bone marrow.
Indications:
Intraosseous cannulation is indicated with both paediatrics & adults when IV access is time critical &
no other venous access points are viable / obtainable.
HCP’s are only to attempt 1 x Intraosseous cannulation per lower limb
DO NOT cannulate via the intraosseous route in the following situations:

 Unable to palpate the landmark.
 In a limb with compartment syndrome.
 Distal to or over fractures.
 Distal to haemorrhage sites.
 When an extremity has phlebitis or cellulitis.
 When a limb has potential or existing lymphedema.
Extreme caution (especially with the IO gun) should be taken by clinicians to avoid needle stick injury
/ puncture.

Intraosseous infusions rarely flow freely usually requiring a syringe push for fluid or medication
administration.

Demonstrate the procedure for intraosseous cannulation:
 Determine the need for IO Cannulation.

 Locate the puncture site. The medial aspect of the tibia distal to the epiphyseal line or
proximal to the inferior epiphyseal line.
 Puncture the bone.
 Aspirate the needle to confirm correct placement.
 Attach fluids & secure or administer the medications as required.
Assessed HCP Date
Validating HCP Date
Comments:

Page 88 of 134
Version 1.01
August 2020

10.7. Extra Jugular Venous Cannulation

Goals of treatment:
To obtain IV access to the body’s venous circulation for drug / fluid administration.
Indications:
Extra jugular venous cannulation is indicated when the usual cannulation access sites are
unobtainable.
Extra jugular venous cannulation is contra-indicated for patients with cellulites at the insertion site.
Only 1 attempt at extra jugular venous cannulation.
Caution with agitated or combative patients due to the risk of damage to other structures.
Clinicians should be aware & take the necessary precautions to avoid needle stick injury / puncture.

Be aware of pneumothorax complication.
All venous complications are the same, refer to IV cannulation procedure.

Demonstrate the procedure for Extra Jugular Venous Cannulation:
 Determine the requirement for extra jugular venous cannulation.

 Select an appropriately sized cannula
 Prepare the items necessary for IV cannulation (refer to IV cannulation procedure).
 Locate the external jugular vein.
 Insert the cannula and secure (refer to IV cannulation procedure.

Assessed HCP Date
Validating HCP Date
Comments:

Page 89 of 134
Version 1.01
August 2020

10.8. Fluid Replacement

Goals of treatment:
Fluid replacement to maintain tissue perfusion.
Indications:
 Therapeutically to keep the vein open (TKVO).
 Controlled haemorrhage or dehydration with poor perfusion.
 Unconscious head injury to maintain a normal systolic blood pressure or a blood pressure at
the bottom of the estimated normal range.
 Burns patients.
 Maintenance of consciousness in cases of uncontrolled haemorrhage (extreme caution in
this situation).
 Known allergy to the fluid being administered.
 Fluid overload may result in pulmonary oedema (especially with CCF patients).
 Fluid replacement with uncontrolled haemorrhage may exacerbate haemorrhage having a
negative effect on the patient.

Fluid administration should be modified according to individual requirements including; age,
mechanisms of injury / illness, time of insult, transportation time & underlying medical / surgical
conditions.
Demonstrate on an IV arm or mannequin the procedure for fluid replacement:

 Gain & secure patent IV access with appropriate gauge cannula.
 Secure the limb with a Sam if required.
 Aseptically prime the IV giving set, removing any air bubbles.
Drip Rate = Drip factor (20/60) x volume to be infused (ml)

Drops/minute Time (minutes)
 Assess the patient for any adverse reactions.

 Assess IV giving set for problems that may indicate poor flow rate.
Document the quantity of fluids administered.

Page 90 of 134
Version 1.01
August 2020
Paediatric drip rate calculations:
Age Weight 10mls/kg 20mls/kg

Neonate 3.5 kg 35mls 70mls
6/12 months 7kg 70mls 140mls
1 10kg 100mls 200mls
10 29kg 290mls 580mls
11 31kg 310mls 620mls
12 33kg 330mls 660mls
Adult time / drip rate calculations:
Giving Set Time 500ml 1000ml

20 dp/ml 2 hours 83dpm 167dpm
Giving Set Time 500ml 1000ml


Assessed HCP Date
Validating HCP Date
Comments:

Page 91 of 134
Version 1.01
August 2020

10.9. Syringe Driver

Goals of treatment:
To administer an electronically measured dosage of medication at a specific rate & time frame.
Indications:
Any patient whose condition requires a medication / sedation infusion.
The syringe driver line must be properly primed to avoid an air embolism.
When using multiple syringe drivers ensure each is clearly marked with the medication name being
infused.
The syringe driver must be sufficiently charged to maintain the infusion for the duration of the
transport/transfer time.

Ensure that both clear & opaque syringes are carried especially for the administration of light
sensitive medication.
Demonstrate the correct procedure for syringe driver usage:

 Refer to and apply the IV cannulation procedure.
 Prepare the syringe & prime the extension set.
 Turn the syringe driver on allowing the driver arm to completely extend.
 Correctly place the syringe into the syringe driver.
 Program the appropriate syringe type into the syringe driver’s electronic index program.
 Allow the syringe driver arm to locate & grip the syringe plunger.
 Program the required millilitres to be infused per hour
 Press the start button.
 Document the procedure & quantity/types of medications infused.
Document the quantity of fluids administered.

Assessed HCP Date
Validating HCP Date
Comments:

Page 92 of 134
Version 1.01
August 2020
11. SECTION 8 – PROCEDURES

SECTION 8
PROCEDURES
1. Phlebotomy 85
2. Urinary Catheter Insertion – Female 87
3. Urinary Catheter Insertion - Male 90
4. Nasogastric Tube Insertion 93
5. Suturing 96
6. Vision Testing 99
7. Eye Examination / Eye Irrigation / Foreign Object Removal 101


Page 93 of 134
Version 1.01
August 2020
PROCEDURES
11.1. Phlebotomy

Goals of procedure:
Obtain prescribe blood specimens correctly and safely with necessary safety precautions
Indications:
Blood sampling for specific diagnostic indications
Safety precautions to prevent occupational exposure, accurate patient identification,
maintain aseptic technique, safe and correct management of the specimens

Demonstrates knowledge of standard and advance safety precautions, first aid in case of an
occupational health exposure, reporting and escalation and follow up of the incident

The skill is preferably performed the dedicated phlebotomy room / area
 Prepares required equipment and PPE:
 Gloves, plastic apron, goggles, hand sanitizer, tourniquet, safety-needle
blood collection system / retractable needle system / approved safety
engineered devices e.g. vacutainers, appropriate specimen tubes within date,
specimen labels, lab request form (if relevant), leak proof self-sealing double
pouch bag, alcohol swabs, plaster / plaster strips, gauze / cotton wool swabs,
sharps container and waste bin
 Checks the correct patient details are on the request form and specimen tubes,
identifiers on the tube and request form - name, DOB, gender, date of collection and
unique lab number
 Explains procedure and obtain verbal / implied consent
 Ensures patient comfort / immobilises arm as appropriate – special precaution for
immobilising of children
 Checks tests to be done, select correct sampling tubes for testing, correctly applies
patient identification to tubes
 Performs hand hygiene and dons gloves, goggles and plastic apron
 Selects and prepare safety needle / blood collection system - appropriate needle
size
 Opens and maintains needling system aseptically throughout puncture procedure
 Selects siting of the most appropriate vein, correctly applies the tourniquet, cleans
area with alcohol swab
 Punctures vein with bevel up, collects appropriate sampling with correct order of the
tubes and management of the tubes
 Releases tourniquet prior to withdrawing of the needle / collection system

Page 94 of 134
Version 1.01
August 2020
 Discards the blood collection / safety needle systme into approved sharps container
 Manages puncture sit correctly to obtain homeostasis
 Manages and transports specimens safely and correctly with request form – plastic
pouch bag and covered container
 Removes gloves, goggles and apron
 Performs Hand Washing
 Cleans environment as per Infection Control standards

Assessed HCP Date
Validating HCP Date
Comments:

Page 95 of 134
Version 1.01
August 2020
PROCEDURES
11.2. Urinary Catheter Insertion – Female Patient

Goals of treatment:
Insertion of a catheter trans urethral into the bladder for urine drainage
Indications:
Acute urinary retention e.g. prostatic hypertrophy, blood clots
Unconscious / critically ill or injured patient who becomes incontinent
Initiation of continuous bladder irrigation
Intermittent decompression for neurogenic bladder
Chronic obstruction
Incontinent patients
Urinary tract infection - maintain aseptic technique during insertion and after care
Haematuria due to urethral / prostatic damage caused by traumatic insertion
Incorrect placement; observe free urine drainage
Absolute contraindication is the presence of urethral injury typically associated with pelvic
trauma
Maintain aseptic technique throughout the procedure
 Prepares required equipment, trolley and PPE on instruction / prescription for insertion of
a urethral catheter
o Sterile catheterization pack (with gauze / cotton wool balls/ gallipot/sterile
drape/sterile receiver), 2 pairs of sterile gloves, plastic apron, hand sanitizer,
appropriate size urinary catheter, urine drainage bag, 20 cc syringe, lubricating /
anaesthetic gel, 10 - 30cc vial sterile water, tape / dressing to secure the catheter
 Performs hand hygiene and prepares equipment and patient, dons apron
 Discusses the option of a chaperone with the patient / arranges a chaperone
 Checks the correct patient; 3 identifiers of identification required, name, DOB, gender,
corresponding prescription / doctor’s notes
 Informs patient about the invasive procedure and discomfort during insertion, obtain
verbal consent
 Positions patient in supine or semi-upright position
Setting up the sterile field
• Removes outer packaging from the catheter pack, opens it aseptically to create a
sterile field
• Opens / empties various equipment from packaging onto sterile field aseptically
• Pours 0.9% saline / aseptic solution over the cotton balls located within the Galli pot
Positioning the patient
 Adjusts bed to appropriate height
Page 96 of 134
Version 1.01
August 2020
 Ensures privacy, positions the patient correctly – knees flexed, hips abducted with heels
together
 Uncovers / exposes patient genitalia (requests chaperone)
 Performs surgical hand wash and don sterile gloves
 Places sterile absorbent pad underneath patient’s genital area with aseptic approach
 Cleans genitalia with correct method / sequence, front to back – holds labia apart with
non-dominant hand, cleans with wet cotton balls using each ball once only
 Discards used gloves after cleaning, wash hands and dons a new pair of sterile gloves
 Places another sterile drape over the patient’s genital area and places sterile receiver
between legs
Inserting anaesthetic gel

 Locates urethral meatus, informs patient of initial sting with numbing effect, places
nozzle of gel into urethral meatus and places gel into urethra with caution. Allows for
anaesthetic gel to take effect
Inserting the catheter

 Removes tear-away portion of the sterile catheter wrap near the catheter tip without
touching the catheter
 Holds labia apart with non-dominant hand
 Inserts the exposed catheter tip into the urethral meatus informing the patient prior to
insertion
 Advances catheter slowly whilst removing the sterile wrap to expose more catheter,
allows urine to drain into kidney dish
 Observes possible resistance or extreme discomfort and discontinues insertion, informs
treating doctor
 Advances catheter carefully on entering of the bladder, indicated by urine drainage from
the catheter, until fully inserted with continues drainage
 Inflates catheter balloon with amount of sterile water as indicated on the catheter,
withdraws catheter until resistance is felt – confirms catheter position
 Attaches catheter bag tubing to end of the catheter, ensures tight seal
 Secures the catheter with appropriate dressing to the inner thigh, prevents tension on
the catheter
 Immobilises catheter bag on the side of the bed, below patient level
 Cleans patient and resumes comfortable position
Completing the procedure
 Disposes of equipment and removes gloves correctly, dispose of into medical waste
 Monitors urine output and records on fluid balance sheet and patient notes; residual
volume/colour

Page 97 of 134
Version 1.01
August 2020
 Documents the procedure in patient notes with reference to:

o Date and time
o Verbal consent
o Aseptic technique used
o Type and size catheter, volume used for balloon inflation
Assessed HCP Date
Validating HCP Date
Comments:

Page 98 of 134
Version 1.01
August 2020
PROCEDURES
11.3. Urinary Catheter Insertion – Male Patient
HCP’s ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR
APPROVED SCOPE OF PRACTICE  

Goals of treatment:
Insertion of a catheter trans urethral / penis into the bladder
Indications:
Acute urinary retention e.g. prostatic hypertrophy, blood clots
Unconscious / critically ill or injured patient who becomes incontinent
Initiation of continuous bladder irrigation
Intermittent decompression for neurogenic bladder
Chronic obstruction
Hygienic care of incontinent patient
Urinary tract infection - maintain aseptic technique during insertion and after care
Haematuria due to urethral / prostatic damage caused by traumatic insertion
Incorrect placement; observe free urine drainage
Absolute contraindication is the presence of urethral injury typically associated with pelvic
trauma – presence of blood at the meatus
Consider alternatives to urinary catheterisation
Early removal if initial indication is resolved
 Prepares required equipment, trolley and PPE on instruction / prescription for insertion of
a urethral catheter
o Sterile catheterization pack (with gauze / cotton wool balls/ gallipot/sterile
drape/sterile receiver), 2 pairs of sterile gloves, plastic apron, hand sanitizer,
appropriate size urinary catheter, urine drainage bag, 20 cc syringe, lubricating /
anaesthetic gel, 10 - 30cc vial sterile water, tape / dressing to secure the catheter
 Performs hand hygiene and prepares equipment and patient, dons apron
 Discusses the option of a chaperone with the patient / arranges a chaperone
 Checks the correct patient as per prescription / instruction - 3 identifiers of identification
required, name, DOB, corresponding prescription / doctor’s notes
 Informs the patient about the invasive procedure and discomfort during insertion, obtain
verbal consent
 Positions patient in supine or semi-upright position

Page 99 of 134
Version 1.01
August 2020
Setting up the sterile field
 Removes outer packaging from the catheter pack, opens it aseptically to create a sterile
field
 Opens / empties various equipment from packaging onto sterile field aseptically
 Pours 0.9% saline / aseptic solution over the cotton balls located within the Galli pot
Positioning the patient
 Adjusts bed to appropriate height
 Ensures privacy of the patient and positions the patient correctly – knees flexed, hips
abducted with heels together
 Uncovers / exposes patient genitalia (requests chaperone)
 Performs surgical hand wash and don sterile gloves
 Places sterile absorbent pad underneath patient’s genital area with aseptic approach
 Cleans penis with correct method and sequence – holds penis with non-dominant hand,
cleans with wet cotton balls, in direction away from the meatus using each ball once
only. Ensures foreskin is retracted if applicable
 Discards used gloves after cleaning, wash hands and dons a new pair of sterile gloves
 Places another sterile drape over the patient’s penis and place sterile receiver below
penis
Inserting anaesthetic gel

 Holds penis, locates urethral meatus, informs patient of initial sting with numbing effect,
places nozzle of gel into penile urethral meatus and places gel into urethra with caution.
Allows for anaesthetic gel to take effect
Inserting the catheter

 Removes tear-away portion of the sterile catheter wrap near the catheter tip without
touching the catheter
 Holds penis in vertical position with sterile gauze with non-dominant hand
 Inserts the exposed catheter tip into the urethral meatus informing the patient prior to
insertion
 Advances catheter slowly whilst removing the sterile wrap to expose more catheter
 Allows urine to drain into kidney dish
 Observes possible resistance or extreme discomfort and discontinues insertion, informs
treating doctor
 Advances catheter carefully until fully inserted, entering of the bladder indicated by urine
drainage from the catheter with continues drainage
 Inflates catheter balloon with amount of sterile water as indicated on the catheter,
withdraws catheter until resistance is felt – confirms catheter position
 Attaches catheter bag tubing to end of the catheter, ensures tight seal
Page 100 of 134
Version 1.01
August 2020
 Replaces the retracted foreskin – if appropriate

 Secures the catheter with appropriate dressing to the inner thigh, prevents tension on
the catheter
 Immobilises catheter bag on the side of the bed, below patient level
 Cleans patient and resumes comfortable position
Completing the procedure
 Disposes of equipment and removes gloves correctly, dispose of into medical waste
 Monitors urine output and records on fluid balance sheet and patient notes; residual
volume/colour
 Documents the procedure in patient notes with reference to:
o Date and time
o Verbal consent
o Aseptic technique used
o Type and size of catheter, volume used for balloon inflation

Assessed HCP Date
Validating HCP Date
Comments:

Page 101 of 134
Version 1.01
August 2020
PROCEDURES
11.4. Nasogastric Tube Insertion

Goals of treatment:
Effective decompression, aspiration / drainage of gastric content
Indications:
Persistent / refractory vomiting, haematemesis / upper GI bleeding - prevention of aspiration
Management of bowel obstruction – GI decompression i.e. small bowel / gastric outlet
obstruction, paralytic ileus, severe pancreatitis with obstruction, gastric lavage (for drug
overdose)
Aspiration and evaluation of gastro-intestinal fluid, bleeding / gastric lavage
Route to administer nasogastric feeds or medication
Contra-indicated in cases of head trauma with concerns of possible base skull fractures (the
tube could potentially enter the intracranial space) and oesophageal varices
Recent nasal re-construction, additional caution in cases with previous nose reconstruction
Requires thorough patient information to obtain cooperation, continuous comforting and
support
Safe naso-gastric insertion technique with least discomfort / distress, preventing any
possible trauma
A very uncomfortable / distressing procedure; possible gagging, vomiting, aspiration and / or
tissue trauma of the nasal – oro-pharyngeal passage
 Prepares required equipment and PPE on instruction / prescription for insertion of a NG
tube
 Gloves, plastic apron, hand sanitizer, disposable paper towels, appropriate size NG
tube, drainage bag, 50 cc catheter tip syringe, lubricating gel, drinking water, tape /
dressing to secure the NG tube, pH testing strips, protecting sheet, kidney dish
 Performs hand hygiene and dons gloves and plastic apron
 Checks the correct patient as per prescription / instruction - 3 identifiers of identification
required, name, DOB, corresponding prescription / doctor’s notes
 Informs the patient about the invasive procedure and discomfort during insertion
 Positions patient in upright position – if possible
 Measure desired length of the tube to be inserted (tip of the nose to ear lobe, down to
the xiphi sternum)
Insertion of the NG Tube
 Places a protective sheet on the chest and assesses the nasal passage to confirm a
clear passage for insertion. Reviews history of previous nasal surgery or injuries where
indicated
 Lubricates tip of the NG tube (use of anaesthetic spray to the back of the throat)
 Inserts the NG tube through a nostril, pointing to the back of nasal cavity after informing
the patient of insertion
Page 102 of 134
Version 1.01
August 2020
 Gently advances the tube through the nasopharynx, not too slowly to prevent extended
discomfort
 Rotates the NG tube if resistance is met, DO NOT force NG tube down
 Pauses if the patient becomes distressed or gagging

 Checks inside the patient’s mouth intermittently for NG coiling
 Asks patient to swallow / take sips of water to ease swallowing if deemed safe
 Continues to advance the NG tube down the esophagus up to the desired insertion
length
Confirmation of the NG tube position
 Attempts aspiration of gastric content with large syringe, test the pH ( pH <4 if correctly
placed) immediately after placement – repeat with dislodgement or migration of the tube
Completion of the Procedure
 Connects the drainage bag for drainage (as indicated)
 Offers paper towel to patient to clean nose
 Fixes the NG tube to the nose with dressing in comfortable place – prevents pull action
onto the nose
 Immobilises the drainage bag for effective drainage, pin tube to patient gown
 Demonstrates safe management of the drainage bag to mobile the
 Discards the gloves, apron, paper towels in the clinical waste bin, packaging papers into
general
 Records procedure and drainage – volume, colour - on the fluid balance chart or medical
record, monitors fluid losses
 Reports unsuccessful attempt to treating doctor - indicates when / if CXR may be
required
 Continuously monitors drainage, records drainage 4-6 hourly if the tube remains in situ
Removal of the NG tube
 Removes the NG tubes only on prescription / instruction of the treating doctor when the
indications for insertion have been resolved
 Prepares patient for removal
 Performs hand hygiene and don gloves
 Provides tissues and place protective sheet on chest
 Unpins tube from the gown, loosens tape / dressing onto the nose
 Disconnects NG tube
 Holds tube close to nostril and removes with continues, steady pull, covering tube with
Page 103 of 134
Version 1.01
August 2020
paper towel whilst removing tube

 Cleans nares and offers oral hygiene
 Discards tube, drainage bag, gloves, tissues and protective sheet in medical waste
 Removes gloves and performs hand hygiene
 Records procedure in patient records

Assessed HCP Date
Validating HCP Date
Comments:
Nasogastric tube measuring Insertion Technique
ClinicalKey

Page 104 of 134
Version 1.01
August 2020
PROCEDURES
11.5. Suturing

Goals of treatment:
Effective suturing applying aseptic technique throughout the procedure
Indications:
Closure of surgical incisions, obtaining homeostasis in lacerations, minimising bacterial
contamination
Superficial wounds that could heal without significant scarring, infected wounds, wounds
that will cause too much tension across the suture line, animal bites
Careful evaluation of stab wounds for depth, underlying structures
Effective debridement of the wound prior to suturing
Apply sterile technique throughout the procedure to prevent infection
Handle tissues gently to obtain excellent cosmetic results
 Checks patient identification name/DOB/gender and corresponding medical records
 Assesses patient and wound area, obtains written informed consent
 Checks patient tetanus immunisation, considers vaccination if appropriate
 Considers and performs x-ray in case of a suspicion of a fracture or foreign body
 Prepares the environment, work surface area or trolley, PPE, equipment and
consumables required. Opens sterile suturing pack and sterile gloves with aseptic
technique, prepares solution and other consumables aseptically onto the tray
o PPE – apron, face shield (mask/goggles), sterile suturing pack (syringe for
local anaesthetic, non-adrenaline anaesthetic ampule(s) needle holder,
toothed forceps, scissors, gauze), NaCl 0,9% or aseptic solution, sterile
gloves – suitable size, suturing material suitable for the wound and
anatomical layers, sterile wound dressing
 Dons apron, goggles, surgical mask
 Opens sterile pack aseptically, generates sterile field
 Performs surgical hand wash and dons sterile gown (optional if available) and gloves
– takes care not to touch external surface of the gown or gloves
 Opens / empties all instruments, consumables, cleaning solution onto the sterile field
 Loads needle holder; placing needle in the tip of the holder, 2/3 distance from the tip
of the tread
 Superficially cleans surrounding skin and the wound, assessing patient discomfort
and pain

Page 105 of 134
Version 1.01
August 2020
 Draws up non-adrenaline anaesthetic, infiltrates the wound with local anaesthetic

before intervention, taking care not to inject into venous system and prevents
distortion of normal anatomy in cosmetically sensitive areas. Allows for anaesthetic
to take effect
 Thoroughly wash the wound bed and surrounding skin with normal saline or aseptic
solution after anaesthetic infiltration, examines wound for internal damage to
underlying tissue and foreign objects
 Assesses entry and exit of the sutures on either side of the wound
 Places sterile drape around the cleaned skin and wound surface
 Debrides wound edges in case of wound contamination, performs primary closure if
no deep tissue damage
 Applies simple interrupted sutures for wounds with well-approximated skin edges
without tension with an ‘In to Out ‘or ‘Out to In ‘approach
 Sutures to be perpendicularly across the wound with equal depth and distance from
the wound edges
 Performs layered suturing with appropriate suturing material if deep tissues are
damaged
 Cuts the sutures after knotting between 5-6mm in length preventing knots to be
become undone, trapped within other knots
 Accounts for all sharps and dispose of immediately in sharps container on
completion of the procedure
 Cleanses the wound, dries and dresses appropriately (steristrips or waterproof
dressing)
 Dispose of disposables, gloves, mask and apron (re-usable instruments to be taken
for special care / sterilisation), cleans environment
 Considers antibiotic prescription, checking allergic history
 Arrange a for follow up of the wound, suture removal (if non-absorbable) 5-7 days
post procedure
Suture Removal
 Prepares working environment and equipment
o PPE. dressing pack, sterile gloves if indicated, stitch cutter, appropriate
dressing if required, cleaning solution – normal saline
 Identifies patient with correct identifiers; name/DOB/gender and corresponding
prescription/medical notes
 Removes cover dressing (if applicable), assesses suture line for abnormalities and
reports to treating doctor
 Performs Hand Hygiene again, don sterile gloves
 Cleans the wound with normal saline
 Removes sutures alternatively using a non-contaminating approach, observes for

Page 106 of 134
Version 1.01
August 2020
possible wound gaping. Reports to treating doctor if observed

 Applies sterile dressing post removal of stitches if indicated
 Discards of all unused consumables, sharps in appropriate medical waste / sharps
container
 Records the procedure in patient notes referencing to the procedure, condition of the
wound / wound healing
Assessed HCP Date
Validating HCP Date
Comments:
Suturing Material Classification
See below website for practical demonstration

Simple interrupted suture - Wound suturing - OSCE guide | Geeky Medics
Additional reading:
https://www.uptodate.com/contents/minor-wound-preparation-and-irrigation?topicRef=6319&source=see_link

Page 107 of 134
Version 1.01
August 2020
PROCEDURES
11.6. Vision Testing

Goals of the testing:
Determine the smallest letters one can read on a standardized chart (Snellen chart) held (6
meters/20 feet) away
Testing of colour blindness using the Ishihara Chart
Indications:
Health screening and diagnostic tool / baseline data - visual ability test for safe and effective
job performance pre-employment
Red Eye Cases
Injury to or foreign object in the eye
None
Vision testing must be done and documented for every patient presenting with an eye
complaint – red eye, eye lid disorder, conjunctival process, corneal abrasion, or foreign body
cases or suspected cases.
Enquire about a change in vision with all eye compliant cases
Examine / test each eye separately
Reduced vision acuity in the presence of a red eye should alert the clinician to more
worrisome diagnoses: infectious keratitis, iritis, or angle-closure glaucoma which requires
referral for initial eye therapy
Ample light in the room, no glare on the Snellen Chart

 Prepares equipment and environment;
o Snellen and Ishihara Charts, pinhole. Ophthalmoscope if vision test is not
performed for health screening
 Checks patient identification; name, date of birth and gender with medical records
 Explains the procedure
 A patient who normally wears glasses or contact lenses should wear glasses /
lenses for all vision testing
 Positions the patient 6 meter from the Snellen chart – pre-measured, marked area
 Requests patient to cover one eye with the hand palm / small occluding device –
avoids pressure on the eye
 Requests patient to read the Snellen chart form the top until the lowest line that could
still be read clearly, records that as visual acuity
 Repeats above steps with the other eye
 Indicates / records vision testing as unaided (UN), with glasses or with a pinhole (PH)

Page 108 of 134
Version 1.01
August 2020
– as appropriate
 Records visual acuity as a ratio – distance to chart (numerator) and the line
containing the smallest letter the patient could read (denominator) – 6/6 (20/20)
 If the patient reads the 6/6 line, but gets 2 letters incorrect, records the visual acuity
as normal - 6/6 (-2)
 If more than 2 letters are wrong the previous line on the Snellen chart is recorded as
the visual acuity
Colour vision testing – Ishihara Chart
 Uses Ishihara charts (‘test plate’ first), requests patient to cover one eye and read the
coloured numbers from the charts
 Repeats colour vision testing of the other eye
 Gives a score out of the number of plates read correctly i.e. 13/13 if all could be read
correctly
 Inability to read the test plate is recorded as ‘unable to read the test plate’
Difficulties reading the Snellen chart
 Use near vision testing - allows the patient to use his or her usual reading correction
if possible, hold a near card or ordinary reading material at a comfortable distance
and reports on small versus large print reading
 Uses pin hole for vision testing if patient does not reach 6/6 line or fine print reading
 Moves patient forward to 3 meters mark if the patient cannot see the top line of the
Snellen chart.
 Assesses counting of the number of fingers - records as “Counting Fingers” (“CF”,
Gross hand movements - records as “Hand Movements” (“HM”)
 Assesses light perception / detection from a pen torch through light shone into each
eye, records as “Perception of Light”/”PL” or “No Perception of Light”/”NPL”

Assessed HCP Date
Validating HCP Date
Comments:
Recording of Snellen Results:

Results are recorded as a friction
The Top Number of the results equates to the distance (in metres) at which the test chart was
presented (6 metres)
The Bottom Number identifies the position on the chart of the smallest line read by the patient e.g. 6/60
indicates the patient 6 meters distance from the chart and the person could only identify the top letter of
the chart
Note: Records if glasses was worn during the test

Page 109 of 134
Version 1.01
August 2020
PROCEDURES
11.7. Eye Examination / Eye Irrigation / Removal of Foreign Object
Goals of treatment:
Thorough, accurate eye examination
Safe removal of foreign body
Rinsing of the eye(s)
Indications:
History of eye irritation
Red Eye
Eye injury
Foreign body in the eye
Possible eye infection
None – caution throughout the procedure
Procedure to be done according to the scope of practice and competency of the HCP
Extra caution with corneal abrasion cases
Extreme caution required when a possible open globe rupture or laceration of the eye is
expected
Snellen Chart vision testing is always done as part of an eye examination / fundoscopy
Enquire about change in vision with all cases presenting with an eye compliant
Examine / test each eye separately
Document every patient presenting with an eye complaint i.e. eye lid disorder, conjunctival
process, corneal abrasion, or foreign body cases or suspected cases.
Reduced vision acuity in the presence of a red eye should alert the clinician to alarming
diagnoses: i.e. infectious keratitis, iritis, or angle-closure glaucoma – refer these patients for
initial eye therapy
Red Eye cases must be escalated to the relevant Assistance Centre – as per the Escalation
procedure and Escalation protocol for Doctors, Nurses and Paramedics
Perform fluorescein examination if corneal abrasion or foreign body in the eye is suspected
Thorough irrigation of the eye must be done for caustic or other substance exposure prior to
initiating examination
Slit Lamp
Slit Lamp examination is indicated for magnification to assess anterior segment and / or
posterior segment of the eye, assist in ocular foreign body removal
Slit lamp examination should ONLY be done by doctors who are competent in the procedure
and practised it as part of the doctor scope
Considers topical ophthalmic anaesthetic agent and sedation when performing eye
examination for acute ocular condition
Slit lamp examination - UpToDate

 Performs Hand Hygiene, don gloves
 Prepares equipment:
Page 110 of 134
Version 1.01
August 2020
o Pinhole, ophthalmoscope, pen torch, mydriatic eye drops, fluorescein

strips/fluid (check expiry date) - arrange material within reach
 Checks patient identification and medical notes
 Obtains thorough history and documents findings
 Explains procedure and counsels the patient, obtains verbal consent
 Positions patient appropriately in sitting or supine position
Check Visual Fields

 Dons gloves
 Sits or stands directly opposite the patient – 1 metre distance
 Examines outer eye areas; lids, lashes, conjunctiva, cornea, anterior chamber and
lens
 Requests patient to cover one eye with the palm of the hand
 Requests patient to focus on a close by area, not to move head or eyes during
assessment
 Locates blind spot with a red hat pin or fluorescein stained cotton bud
 Assesses peripheral visual field starting from the periphery and moves object
towards the centre until the patient can see it
 Repeats this process for each quadrant (up/down/left/right), then repeats the entire
process for the other eye
 Documents findings
Performs Pupil Inspection

 Checks size, shape, symmetry, reaction to light Performs reflex assessment in dimly
lit room: Direct pupillary reflex and consensual pupillary (contralateral pupil) reflex
 Performs Swinging Light Test by rapidly moving pen torch between two pupils
 Performs Accommodation Reflex Test by requesting patient to focus on distant
object, placing finger approximately 15 cm in front of eyes, patient to switch from
distant to nearby object - observes pupils to evaluate constriction and convergence
bilaterally
Performs Cover Test

 Requests patient to focus on a target – corneal reflexes in the centre of the pupil,
request if one or more lights are seen, where the other light(s) are seen
 Covers one eye, observes uncovered eye for movement – normal, temporally or
nasally
 Repeats Cover Test on the other eye
Performs Eye Movement Test

 Holds finger / pen torch 30cm directly in front of the patient’s eyes, eyes focus on the
object to evaluate primary position for any deviation or abnormal movements
 Requests patient to keep head still and follow your finger with their eyes – patient to

Page 111 of 134
Version 1.01
August 2020
report any double vision

 Moves finger through the various axes of eye movement (“H” shape)
 Observes for restriction of eye movement or nystagmus
Ophthalmoscopy and Preparation

 Examines eyelids, conjunctiva; observes for any pruritis, discharge, hyphema,
hypopyon and ptosis
 Darkens the room
 Pupils dilation with short-acting mydriatic eye drops is administered, informs patient
about affect and restriction of activities
 Requests patient to fixate on a distant object, assesses the anterior segment of the
eye using the ophthalmoscope. Applies Fluorescein dye to stain and view under ultra
violet light to observe corneal abrasion
 Assesses Red Reflex – 30cm distance
 Uses ophthalmoscope to observe for a reddish/orange reflection in the pupil
 Moves in closer and examine the eye with ophthalmoscope, maintaining the red
reflex and examine the retina with the ophthalmoscope from a slight temporal angle
– Identifies blood vessels and branching blood vessels towards optic disc; changes
focus wheel as needed
 Assesses the optic disc – colour / margin / cupping
 Assesses retinal vessels – cotton wool spots / AV nipping / neovascularization /
haemorrhages
 Assesses the macula by asking the patient to look directly into the light
 Documents all findings in medical records
 Arranges follow up
 Refers for further investigations if appropriate
Eye Irrigation
 Checks indication / prescription for eye irrigation
 Prepares environment, equipment, PPE and irrigation fluid at room temperature
 Positions patient in sitting or supine position with head turned towards affected eye
 Dons apron, gloves and face shield / mask and goggles
 Performs eye assessment
 Places receiving container under patient’s cheek on the side of the affected eye
 Gently separates eyelids
 Gently rinses the affected eye holding irrigation device 2-3cm from the eye from the
inner canthus
 Requests patient to move eyes periodically, holds rinsing intermittently to allow

Page 112 of 134
Version 1.01
August 2020
blinking of the eye

 Continues rinsing process until reason for rinsing is cleared +/- 20 minutes
 Swipes and dries eye with sterile cotton swab from inner canthus outwards
 Disposes of gloves and consumables in medical waste
 Assists patient into comfortable position
 Cleans environment
 Re-assesses the eye
 Documents the procedure in medical records
Foreign Body Removal

 Prepares environment, equipment - ophthalmoscope, PPE – gloves, apron
 Fluorescein eye dye strips/fluid, cotton balls
 Performs eye assessment
 Positions patient in sitting / supine position
 Applies adequate topical anaesthesia
 Explains procedure and re-assures patient and obtains written consent
 Emphasizes the need for maximal position cooperation
 Uses removal device carefully and correctly (burr drill or needle); away from the eye,
whilst stabilizing the hand
 Adjusts light source 3-5 mm in front of the eye, identifies foreign body
 Uses removal device to scrape FB tangential to cornea, removes only what is easily
scraped away
 Re-examines the eye post foreign body removal

Assessed HCP Date
Validating HCP Date
Comments:
https://www.uptodate.com/contents/slit-lamp-
examination?search=eye%20examination&source=search_result&selectedTitle=3~15
0&usage_type=default&display_rank=3
https://gmsrc.internationalsos.com/PROCEDURESMS/Escalation%20Procedure%20fo
r%20Medical%20Services.pdf

Page 113 of 134
Version 1.01
August 2020
12. SECTION 9 – FRACTURE MANAGEMENT

SECTION 9
FRACTURE MANAGEMENT
1. Vacuum Splints 106
2. Sager Bilateral S304/TRAC 3 (HARE) Traction Splints 107
3. Cervical Collar 108


Page 114 of 134
Version 1.01
August 2020
FRACTURE MANAGEMENT
12.1. Vacuum Splints

Goals of treatment:
To provide rigid fracture immobilisation without circumferential pressure, reducing pain, whilst
maintaining distal circulation.
Indications:
Suspected fractures of the extremities or pelvis.
Caution when realigning fractures ensuring distal circulation is maintained & closed fractures do not
become open fractures.

Using aseptic techniques cover open fractures & apply haemorrhage control.
Consider administration of analgesia.

Demonstrate the procedure for Capnography:

 Apply basic cares
Consider analgesia
 Select the appropriate splint & open the air valve.
 Place the fractured limb into the vacuum splint & mould the splint to the contours of the limb
securing the Velcro straps.
 Attach the hand pump or suction unit to the valve outlet & remove the air until the splint
becomes rigid. Close the valve & disconnect the hand pump/suction unit.
 Support the limb whilst extracting the air from the splint.
 Readjust the Velcro straps if required.
 Check the distal perfusion. Elevate the limb or apply a sling as required

Assessed HCP Date
Validating HCP Date
Comments:

Page 115 of 134
Version 1.01
August 2020
FRACTURE MANAGEMENT
12.2. Sager Bilateral S304 / TRAC 3 (HARE) Traction Splints

Goals of treatment:
Apply traction to the fractured femur, decreasing tissue & muscular damage, haemorrhage & pain.
Indications:
Any patient with a fractured femur.
Correct application of the traction splint is essential to ensure patient comfort and distal limb perfusion
is maintained.
Once the traction splint has been applied it must remain in situ with the patient until removed during
surgery.
Caution with the placement of the broad elastic leg straps too close to fracture site & splint usage in
cases with upper third femur fractures.
Correct application of a traction splint will substantially decrease pain. Caution should be taken with
analgesia quantities administered prior to splint application.
Demonstrate the application of the traction splint on a simulated patient:
 Apply basic cares, consider analgesia & remove the patient’s footwear & socks.
 Remove the traction splint & broad elastic leg straps from the carry cover
 Place the splint between the patient’s legs & drop down the elevation bar.
 Secure the groin strap around the fractured limb (both limbs for bilateral fractures). Do not
tighten.
 Adjust the splint length, ensuring the silver tension shaft extends beyond the patients feet.
 Apply the ankle harnesses bilaterally & tighten leaving a 5cm distance between the inferior
aspect of the foot & the bracket of the tension shaft.
 Tighten the groin strap.
 Apply tension to the splint.
 Apply the broad leg straps at the ankles, below the knees & superior to the fracture site.
 Check the distal pulses, capillary refill, sensation & pain assessment.
If required, apply a blanket or jacket over the patient’s feet to ensure maintenance of
normothermia.

Assessed HCP Date
Validating HCP Date
Comments:

Page 116 of 134
Version 1.01
August 2020
FRACTURE MANAGEMENT
12.3. Cervical Collar

Goals of treatment:
To assist with immobilisation of the c-spine, preventing further movement & secondary injury.
Indications:
Any patient where the mechanisms of injury or clinical manifestations indicate the potential or
confirmation of a spinal injury.
Caution should be exercised with cervical collar application in patients with confirmed spinal fractures.
Application of the cervical collar must not obstruct the airway or impede ventilations. Be aware of the
vomiting patient.
Cervical collars should be used in conjunction with other spinal immobilisation equipment/procedures
to achieve complete c-spine immobilisation.
Procedure for application of cervical collars:
 Manually immobilise the c-spine.
 Sitting position
 Supine position
 Prone position
 Prepare the multi-size collar for application. Separate the Velcro strap & undo adjustable
mechanism at the front of the collar.
 Correctly apply multi-size collar to the patient:
 Maintain manual immobilisation of the c-spine.
 Slide the edge of the collar under the posterior of the patient between the occipital
region of the skull & the shoulders.
 Bring the other side around the anterior of the patient fitting the moulded area under
the mandible & onto the clavicles. Adjust to the correct alignment.
 Secure the Velcro strap & do up the adjustable mechanism.
 Correctly demonstrate the procedure for log rolling a patient located in a supine & a prone
position.
 Demonstrate this procedure in conjunction with other spinal immobilisation equipment. (Head
blocks, spinal board, scoop stretcher, vacuum mattress, K.E.D).

Assessed HCP Date
Validating HCP Date
Comments:

Page 117 of 134
Version 1.01
August 2020
13. SECTION 10 – DRESSINGS & BANDAGES

SECTION 10
1. Aseptic Dressings 110
2. Apply a Sling 112
3. Burns Dressing 114
4. Haemorrhage Control 115
5. Envenomation 117


Page 118 of 134
Version 1.01
August 2020

13.1. Aseptic Dressings

Goals of treatment:
To eliminate contamination and reduce the risk of infection during the wound care and / or application
or redressing of a wound.
Aseptic technique followed throughout the procedure
Indications:
Any wound encountered within the pre-hospital environment.
Any previously treated wound that requires redressing.
Burns debridement should not be attempted within the pre-hospital environment.
Large wounds requiring sutures should be referred to a medical officer or definitive care facility.
Failure to implement standard precautions may cause cross contamination from the patient to the
clinician.
Aseptic hand washing must be performed prior to aseptic procedures
Standard Precautions and PPE to be applied / used as indicated
Collection and preparation of the consumables once patient / wound assessment was done
Preparation of the patient, environment and work surface areas
Aseptic opening of consumables – no touch technique.
Surrounding areas of a sterile field are considered contaminated.
Swabbing of wounds are done from top to bottom, in one direction only
Demonstrate the Procedure for the application of an aseptic dressing:
 Aseptic hand washing - application of PPE as indicated – after preparation.

Attach a biological waste bag to receive soiled materials / move medical waste bin near of the
work area.
 Place the wound dressing pack on the clean work surface area and open aseptically
 Include any additional instruments or required dressings and saline cleaning solution
 Do not place any non-sterile items on the sterile pack / field
 Use the supplied forceps to arrange the contents of the pack.
 Use forceps to pick up a gauze swab, immerse in the saline solution, swabbing the wound &
discard into the bio hazard bag. Repeat the process until the wound site is clean.
 Apply solution / ointment as per doctor’s prescription / allow wound to dry (dry surrounding
skin area).
 Apply the wound dressing and advise to the patient on care of the dressing / return for
dressing renewal.
 Discard used items correctly in the medical waste and remove gloves
 Perform hand washing

Page 119 of 134
Version 1.01
August 2020

Assessed HCP Date
Validating HCP Date
Comments:

Page 120 of 134
Version 1.01
August 2020

13.2. Apply a Sling

Goals of treatment:
A sling is used to support and immobilize the forearm. It also serves to immobilize the elbow
and upper arm. A sling is normally made from a triangular bandage
Indications:
Injury to forearm, elbow or upper arm.
Injury to shoulder
A swathe is normally applied to further immobilize the casualty's injured arm.
Demonstrate the procedure for sling application on a simulated patient:

 Greets patient and explains the procedure. Obtains verbal consent.
 Prepares equipment
 Positions patient in standing or seated position that enables required access.
 Checks circulation
 Inserts the triangular bandage between the injured arm and the casualty's chest so
the arm is in the centre, the apex of the sling is beyond the elbow, and the top corner
of the material is over the shoulder of the injured side.
 Positions the injured forearm so the hand is slightly higher than the elbow. About a
10-degree angle.
 Folds the material along the base (the long side opposite the apex) back to the
casualty's fingers, forming a cuff.
 Brings the lower portion of the material over the injured arm so the bottom corner
goes over the shoulder of the uninjured side (see diagram C). The elbow should be
inside the sling.
 Brings the top corner behind the casualty's neck and ties the two corners together in
a non-slip knot at the "hollow" at the neck on the uninjured side (see diagram D). If
the casualty's right arm is fractured, for example, ties the knot so it will rest in the
hollow on the left side of the neck.
 Secures the apex of the sling to keep the elbow and forearm from slipping out of the
sling.
 Checks circulation
 Ensures patient comfort and adjusts sling positioning as necessary
 Re-checks circulation
Document the procedure in the medical record.

Page 121 of 134
Version 1.01
August 2020

Assessed HCP Date
Validating HCP Date
Comments:

Page 122 of 134
Version 1.01
August 2020

13.3. Burns Dressing

Goals of treatment:
To reduce the severity of burn injuries & prevention against secondary infection.
Indications:
Any patient who has sustained burn injuries.
Be aware of airway burns / oedema with patients that have sustained severe burns or have black soot
marks surrounding the oral & nasal cavity.

Consider analgesia administration.
Demonstrate the procedure for burn management:

 Apply basic cares.
 Remove any jewellery or clothing not stuck in the burn.
 Apply burn gel dressings (size according to BSA) & secure with a bandage if required.
 Consider analgesia if appropriate.
 Transport to definitive care if required.
Document the procedure in the medical record.

Assessed HCP Date
Validating HCP Date
Comments:

Page 123 of 134
Version 1.01
August 2020

13.4. Haemorrhage Control

Goals of treatment:
To arrest a haemorrhagic bleed, preventing further loss of circulating volume, sustaining cellular
perfusion.
Indications:
Any patient suffering an arterial or venous haemorrhagic bleed.
Do not remove previously applied pressure bandages to apply clotting agent.
Do not use IV tourniquets to arrest a haemorrhage.
IV fluids are only administered to reach a palpable radial pulse (80 systolic).
Loss of circulation to limb regions distal to the bleed for extended periods of time may cause
irreversible cellular damage.

Clinicians should exercise care to prevent self-injury when treating haemorrhagic open fractures.
Celox or Quick clot agents may cause burning to the patient at the haemorrhage site.
In extreme circumstances, clinicians may have to decide between sustaining life, by arresting a life-
threatening haemorrhage or maintaining some distal perfusion to the keep the distal limb viable.

Demonstrate the procedures for haemorrhage control:
 Implement standard precautions & if required, additional precautions.
Pressure & Elevation
 Apply direct pressure over the haemorrhage site.
 Apply a sterile non-stick dressing, pressure bandage & elevate the limb.
 Apply additional pressure bandages to arrest the haemorrhage if required.
Coagulation
 Apply pressure superior to the haemorrhage & apply the coagulation agent to the
haemorrhage site.
Arterial Pressure Points:
 Apply Celox or Quick clot agent to the haemorrhage site.
 Manually apply pressure to the brachial or femoral arteries to arrest the haemorrhage.

Page 124 of 134
Version 1.01
August 2020
Tactical tourniquet:
 Apply Celox or Quick clot agent to the haemorrhage site.
 Manually apply pressure to the brachial or femoral arteries to arrest the haemorrhage.
 Apply the tactical tourniquet in a position 4 fingers superior to an amputated limb.
 Apply the tactical tourniquet in a position 4 fingers superior to the haemorrhaging wound.

Assessed HCP Date
Validating HCP Date
Comments:

Page 125 of 134
Version 1.01
August 2020

13.5. Envenomation

Goals of treatment:
To reduce the movement of venom from the site of puncture to the vital organs.
Indications:
Any patient that is suspected or confirmed from sustained Envenomation.
.
DO NOT attempt to catch dangerous animals for identification (take a photograph).
Some land & marine animals inject a combination of neurotoxin & cytotoxins.
PRACTICAL SKILLS – Competency in Envenomation Management
Neurotoxins: Implement standard precautions.
 Apply basic cares & posture the patient appropriately.

 Apply a pressure immobilisation crepe bandage to the limb. Apply the bandage over the site
working to the distal limb. Apply secondary bandages continuing to the distal limb & then all
the way back up the limb, covering as much of the limb as possible.
 Apply a splint to the limb where possible.
 Transport to definitive care.
Cytotoxins:

 Apply basic cares & posture the patient appropriately.
 Apply an ice pack to the envenomation site, securing with a bandage.
 Transport to definitive care.
Consider analgesia & document the procedure.

Assessed HCP Date
Validating HCP Date
Comments:

Page 126 of 134
Version 1.01
August 2020
14. SECTION 11 – OTHER EMERGENCY PROCEDURES

SECTION 11
OTHER EMERGENCY PROCEDURES
1. Emergency Chest Decompression 119
2. Chest Drain Insertion 121
3. Cephalic Delivery
123
4. Breech Delivery
124


Page 127 of 134
Version 1.01
August 2020
PROCEDURE
14.1. Emergency Chest Decompression

Goals of treatment:
Needle insertion into the pleural space to release a tension pneumothorax through needle
decompression in emergency situations
Indications:
Clinical deterioration; including haemodynamic deterioration and de-compensation, shock,
severe dyspnoea (decreased SaO2 if measured) with decreased air entry on auscultation
(mostly uni-lateral)
Decreased chest wall movement on the affected side
Trachea displacement
None if there is a life-threatening tension pneumothorax

Never remove the decompression needle once inserted, more / repeated needle
decompression might be needed until a chest tube can be inserted
Options for catheters / needles to be used for emergency decompression:
10G Pneumo-catheter or 14 G IV catheter (connected to a 3 way stop cock / pulled through
a glove finger)

 Prepares PPE, consumables
o (Preferable 10G 4 Inch Pneumo-catheter – if available or a 4G IV catheter
attached to a 3-way stop cock, sterile gloves, disinfecting solution / swabs
 Dons PPE – apron, face shield or mask and goggles
 Assesses patient, identifies side for needle insertion, performs lung auscultation
bilateral, chest x-ray – if situation allows
 Informs patient, obtains informed consent - if possible
 Identifies land mark; fourth or fifth intercostal space mid-axillary line is used instead
of the second intercostal space mid-clavicular line in adult patients
 Quick cleaning of the skin
 Holds catheter / needle on the hub and insert perpendicular / 90 degrees into the
landmark area of the chest wall
 Slides the catheter off the needle once the thoracic cavity is entered - gush of air is
expelled / heard – removes the needle
 Performing a finger thoracostomy can ensure adequate decompression of the chest
and eliminate tension pneumothorax as the cause of decompensation Checks for

Page 128 of 134
Version 1.01
August 2020
kinking of the catheter, insert another catheter if indicated

 Continuous patient monitoring
 Follows emergency decompression with chest tube insertion
 Records the procedure and patient status prior and post needle insertion
Assessed HCP Date
Validating HCP Date
Comments:
Websites for practical demonstrations:

Own the Chest Tube! • LITFL • Life in the Fast Lane Medical Blog
Emergency Thoracentesis

Page 129 of 134
Version 1.01
August 2020
PROCEDURES
14.2. Chest Drain Insertion

Goals of treatment:
Tube insertion into the pleural space to release a pneumo- and / or hemothorax
Drainage of intra pleural fluids
Indications:
Pneumothorax / Tension Pneumothorax
Haemothorax
Pleural effusion
Coagulopathy
Damage to surrounding structures / puncture of lung tissue
Pain, discomfort
Bleeding
Aseptic technique
Correct tube placement and securement of the tube

 Checks patient identification name/DOB/corresponding medical records
 Assesses patient, performs lung auscultation bilateral, chest x-ray, identifies correct
side for chest insertion
 Obtains written informed consent
 Positions the patient in a semi-upright position, arm over the head
 Considers analgesia
 Prepares the environment, work surface area or trolley, PPE, equipment and
consumables required.
 Opens sterile suturing pack and sterile gloves with aseptic technique, prepares
solution and other consumables aseptically onto the tray
o PPE, Sterile suturing pack dissecting forceps, needle holder, artery forceps,
scissors, gauze), (syringe for local anaesthetic, non-adrenaline anaesthetic
ampule(s), surgical blade, alcohol disinfecting solution, sterile gloves –
suitable size, suturing material, chest tube, drainage system, sterile wound
dressing, plaster
 Dons on apron, goggles, surgical mask and identify anatomical landmarks for chest
tube placement - fifth intercostal - mid-axillary line
 Performs surgical hand wash and dons sterile gown (optional if available) and gloves
– not to touch external surface of the gown or gloves

Page 130 of 134
Version 1.01
August 2020
 Cleans the skin with alcohol disinfecting solution, allows to dry

 Applies sterile field to the chest wall
 Infiltrates the surrounding skin and layers of the chest wall along the line of tube
insertion with local anaesthetic, angles needle above the rib and advances into
pleural space when air is aspirated
 Makes incision onto the skin in the identified land mark space, following rib
orientation
 Uses blunt forceps to open the incision area and dissects, spreads
 Punctures the parietal pleura
 Uses finger to sweep inside to confirm punctured pleura and no lung adhering
 Places chest tube on blunt forceps and inserts the chest tube to desired depth –
proximal whole of the tube inside the chest cavity
 Clamps the chest tube
 Checks for kinks by moving the tube circularly around
 Performs suturing, tie knot, wrap around chest tube secure
 Connects chest tube to connecting tube and drainage system
 Checks the drainage system for bubbling, asks patient to cough
 Applies sterile dressing, secure tube to chest
 Dispose of gloves, gown, goggles, mask and consumables into medical waste,
sharps into sharps container
 Cleans the environment
 Performs chest x-ray to confirm tube position
 Monitors drainage, air leak
 Records the procedure, patient status and x-ray confirmation of tube placement
Assessed HCP Date
Validating HCP Date
Comments:

Page 131 of 134
Version 1.01
August 2020

14.3. Cephalic Delivery

Goals of treatment:
The safe & effective obstetric management of a cephalic delivery.
Indications:
When the birth of a baby is imminent by the cephalic presentation.
Clinical presentations including; placenta Previa, cord prolapse, foetus arm or leg presentation &
transverse lie are not appropriate for, per vaginal delivery & require immediate time critical
transportation to a definitive care facility.
Clinicians should initiate infection control procedures to prevent disease transmission from contact
with patient blood & body fluids.
An understanding of the foetal movements during delivery assists the clinician with early recognition
and rectification of problems including; explosive deliveries, cord presentation around the neck &
post-partum haemorrhage.
Consideration should be given to cultural & religious beliefs as they are an important part of the
overall patient care process.
Demonstrate the procedure for cephalic delivery:
 Implement standard precautions & when required additional precautions

 Identify that a delivery is imminent.
 Make both maternal and foetal physiological assessments.
 Aseptically prepare the maternity kit equipment.
 Demonstrate a cephalic delivery using an obstetric mannequin.
 Demonstrate care for the neonate including:
 APGAR scoring system.
 Suctioning & airway maintenance.
 Cord care.
 Care of the skin & eyes.
 Maintenance of maternal & neonatal normothermia.

Assessed HCP Date
Validating HCP Date
Comments:

Page 132 of 134
Version 1.01
August 2020

14.4. Breech Delivery

Goals of treatment:
The safe & effective obstetric management of a breech delivery presentation.
Indications:
When the birth of a baby is imminent by the breech presentation.
Clinical presentations with a breech delivery including; cord prolapse, or presentation of the foetus
arm or leg are not appropriate for, per vaginal delivery & require immediate time critical transportation
to a definitive care facility.
Breech presentations present risks including; pre-term birth, neonatal intra-cranial haemorrhage &
hypoxia, prolapsed cord & physical injuries sustained by the neonate during the delivery procedure.
Clinicians should consider when possible, immediate transportation to a definitive care facility with
breech presentations positioning the patient in a left lateral position & non-invasively monitoring foetal
condition.
Clinicians should understand all 3 breech delivery methods (Burns Marshall method, Loveset
Manoeuvre & the Mauriceau-Smellie-Veit Manoeuvre).
Demonstrate the procedure for breech delivery:
 Implement standard precautions & when required additional precautions

 Identify that a breech delivery is imminent.
 Aseptically prepare the maternity kit equipment.
 Demonstrate the Burns Marshall Delivery method using an obstetric mannequin.
 Demonstrate care for the neonate including:
 APGAR scoring system.
 Suctioning & airway maintenance.
 Cord care.
 Care of the skin & eyes.
 Maintenance of maternal & neonatal normothermia.

Assessed HCP Date
Validating HCP Date
Comments:

Page 133 of 134
Version 1.01
August 2020
15. ENFORCEMENT AND REPORTING BREACHES

Breaches of this Procedures may have serious legal and reputation repercussions
and could cause material damage to International SOS. Consequently, breaches
can potentially lead to disciplinary action that could include summary dismissal and
to legal sanctions, including criminal penalties.
All employees are expected to promptly and fully report any breaches of the
Procedures. A report may be made to the employees’ supervisor or the Group
General Counsel. Reports made in good faith by someone who has not breached
this Policy will not reflect badly on that person or their career at Intl.SOS. Reports
may be made using the following e-mail
address: Compliance@internationalsos.com.
© 2018 All copyright in these materials are reserved to AEA International Holdings
Pte. Ltd. No text contained in these materials may be reproduced, duplicated or
copied by any means or in any form, in whole or in part, without the prior written
permission of AEA International Holdings Pte. Ltd.

Page 134 of 134

Clinical Skills Assessment Manual

Uploaded by

Document Informationclick to expand document information

Document Informationclick to expand document information

Copyright:

Available Formats

Clinical Skills Assessment Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Clinical Skills Assessment Manual

Uploaded by

Copyright:

Available Formats

International SOS

L4 MS CORP Clinical Skills Assessment

Document Owner: Medical Services

For Intl.SOS Internal Use Only

9.1. Cardiac Monitoring 3 Lead / 12 Lead ................................................................................ 68

For Intl.SOS Internal Use Only

Medical Services International SOS Templates

Abbreviations and Definitions

For Intl.SOS Internal Use Only

COPD Chronic Obstructive Airway Disease

For Intl.SOS Internal Use Only

For Intl.SOS Internal Use Only

2. CLINICAL SKILL LEVELS

Procedure / Skill Ambulance Basic Life Intermediate Advanced

For Intl.SOS Internal Use Only

Procedure / Skill Ambulance Basic Life Intermediate Advanced

For Intl.SOS Internal Use Only

Procedure / Skill Ambulance Basic Life Intermediate Advanced

For Intl.SOS Internal Use Only

Procedure / Skill Ambulance Basic Life Intermediate Advanced

DRESSINGS & BANDAGES

For Intl.SOS Internal Use Only

3. GUIDELINES FOR USE

Goal of treatment: What am I trying to achieve?

Indications: When can I perform this procedure?

Contra-Indications / Precautions: When don’t I apply this procedure / What do I

Practical Skills Assessment:

 Indicates the mandatory clinical standard required to be achieved.

Skill Assessment Completion:

• Name of the HCP being assessed & assessment date.

For Intl.SOS Internal Use Only

4. SECTION 1 – PATIENT ASSESSMENT

HCPs ARE ONLY TO PERFORM PROCEDURES CONSISTENT WITH THEIR

For Intl.SOS Internal Use Only

THEORETICAL PRINCIPLES - Competency

THEORETICAL & PRACTICAL SKILLS – Correctly Demonstrated

Validating HCP Date

For Intl.SOS Internal Use Only

THEORETICAL PRINCIPLES - Competency

Appropriate treatment as needed

Document the findings.

THEORETICAL & PRACTICAL SKILLS – Correctly Demonstrated

Validating HCP Date

For Intl.SOS Internal Use Only

THEORETICAL PRINCIPLES – Competency

Document the findings.

THEORETICAL & PRACTICAL SKILLS – Correctly Demonstrated

Validating HCP Date

For Intl.SOS Internal Use Only

Validating HCP Date

For Intl.SOS Internal Use Only

THEORETICAL PRINCIPLES - Competency

Other Clinical Judgement Issues:

PRACTICAL SKILLS - Competency

THEORETICAL & PRACTICAL SKILLS – Correctly Demonstrated

Validating HCP Date

For Intl.SOS Internal Use Only

THEORETICAL PRINCIPLES - Competency