This page summarises changes to the ECAT protocols since publication in December 2023. The summary includes the rationale for the decision.
The changes include:
- alignment with electronic medical record PowerPlans
- feedback received from clinicians in the Agency for Clinical Innovation networks, Clinical Excellence Commission (CEC), local health districts (LHDs) and specialty health networks (SHNs)
- alignment with related content updates, such as the NSW Medicines Formulary and the NSW Sepsis Pathways.
All changes have been reviewed by the Emergency Care Institute (ECI)'s manager and clinical director, and where relevant they have been reviewed and approved by clinical experts, the ECI’s clinical advisory committee, the CEC and the ECAT executive steering committee co-chairs.
Minor changes such as typos and minor transcription errors are not documented here.
All changes are reflected on the published protocols.
| # | Date | Protocols | Change | Rationale |
|---|---|---|---|---|
1 | Dec 2023 | A8.1 Acute behavioural disturbance | Changed protocol age range from '16 years and over' to '16 years to 65 years' | In line with consultation versions. Protocol is intended for 65 years and under |
2 | Dec 2023 | P.4.4 Seizures P6.2 Poisoning P4.3 Meningitis P4.1 Altered conscious state | For IV and buccal/IN midazolam administration, addition of wording 'Maximum single dose 10mg' and 'Maximum total dose 20mg' | For clarity and to align with PowerPlans |
3 | Jan 2024 | A7.5 Nausea and vomiting in pregnancy | Remove chewable antacid tablet from medications. | No longer included on the NSW Medicines Formulary |
4 | Jan 2024 | P1.1 Anaphylaxis P11.2 Urticarial rash and P6.1 Insect bites and marine stings | Desloratadine 6 months – 1 year: 1 mg orally, once daily 1–6 years: 1.25 mg orally, once daily 6–12 years: 2.5 mg orally, once daily 12 years of age and older: 5 mg orally once daily Loratadine 12 years of age and older, over 30kg and who can swallow tablets: 10mg orally, once only | Reflect changes to the NSW Medicines Formulary |
5 | Jan 2024 | Paediatric protocols | Medication glucose 10%. Change 'IV infusions' to 'slow IV injection' | Alignment with Paediatric Improvement Collaborative and CEC advice |
6 | Jan 2024 | A12.3 Major trauma | Remove back slab from specific treatment - limb threatening injury, changed to 'Apply splint' | Removed to maintain protocol focus on life or limb threatening issues |
7 | Feb 2024 | P7.3 Gastric tube or nasogastric tube replacement | Remove PR Panadol | PR Panadol would require dose ranges which are avoided in the ECAT protocols. Clinical experts’ decision is that the PR route is not required |
8 | Feb 2024 | P1.1 Anaphylaxis P2.2 Wheeze | Salbutamol age range Change from '1-5 years and 6 years' to '1-6 years and 6-12 years' Ipratropium age range Change from '1-5 years and 6 years' to '1-6 years and 6-12 years' | Align ages with PowerPlans age filtering (aligns to Australian Medicine Handbook) |
9 | Feb 2024 | Paediatric protocols | Medication 40% glucose gel. Change from '1-5 years and 6 years' to '1-6 years and 6-11 years' | Align with the way that PowerPlans calculate age ranges (aligns to Paediatric Improvement Collaborative guidelines) |
10 | March 2024 | A10.2 Ocular presentations | Addition of fluorescein 1% OR 2% | Variation in available strengths used between districts |
11 | March 2024 | P11.1 Minor wounds | Remove lidocaine (lignocaine) 2% | The 2% concentration is not recommended for paediatric populations |
12 | March 2024 | A7.1 Abdominal pain A8.2 Substance withdrawal A7.4 Gastrointestinal bleeding A5.2 Hyperglycaemia A5.3 Hypoglycaemia A4.5 Seizures A4.7 Unconscious person | Update thiamine wording to 'for adults at high risk of thiamine deficiency (e.g. those who drink large amounts of alcohol or who are severely malnourished)' | To provide clarity and alignment with NSW Ministry of Health clinical guidance |
13 | May 2024 | A3.4 Sepsis | Revised protocol in line with new NSW Adult Sepsis Pathway including: pathology order, fluid resuscitation and protocol wording Reorder interventions in line with order on Adult Sepsis Pathway | Alignment with updated NSW Adult Sepsis Pathway |
14 | May 2024 | P3.3 Sepsis | Revised protocol in line with new NSW Paediatric Sepsis Pathway including: pathology order, fluid resuscitation and protocol wording Reorder interventions in line with order on Paediatric Sepsis Pathway | Alignment with updated NSW Paediatric Sepsis Pathway |
15 | May 2024 | A3.4 Sepsis A3.5 Unwell immunocompromised person | Gentamicin dosing: Reduced maximum dose in for 16–18-year-old patient to 560 mg Reduced maximum dose for known renal impairment and/or 80 years and over to 480 mg 16–18 years: 18–80 years: 80 years and over: Known kidney impairment and 18 years and over: Removed reference to local gentamicin dose advisor (GDA) as LHDs are not using the Cerner eMR GDA for ECAT. All LHDs will use the dosage calculator tool embedded in protocol | Alignment with the Therapeutic Guidelines and Australian Medicine Handbook guidance recommendations for 18 years and younger Maximum gentamicin reduced dose on advice of CEC to align with administration practice (generally rounded to 40 mg) |
16 | May 2024 | P3.3 Sepsis P3.4 Unwell immunocompromised person | Gentamicin dosing age range and maximum doses updated 1 month–10 years: 7.5 mg/kg 10–15 years: 7 mg/kg | Alignment with the Therapeutic Guidelines and Australian Medicine Handbook guidance recommendations for 18 years and younger |
17 | April 2024 | A12.1 Burns | Change wording from 'urinalysis to check for myoglobinuria' to 'urinalysis – collect and check for blood which may indicate myoglobinuria or haemoglobinuria' Changes to historical red flags:
Addition of the following to clinical red flags to adult protocol:
Change '20% TBSA' to '10% TBSA' (to align with the referral criteria in the NSW Burn Transfer guidelines In chemical burns section added 'If dry or powder chemical burn, remove or brush off before applying water.' Remove statement under hydrofluoric acid burns about using dishwashing liquid to neutralise. | Formal pathology test for myoglobinuria has been withdrawn from NSW Pathology catalogue, clearer wording. Urinalysis is still indicated as a point of care test Alignment of adult and paediatric text with advice from the ACI Burns Network |
18 | April 2024 | P12.1 Burns | Change wording from 'urinalysis to check for myoglobinuria' to 'urinalysis – collect and check for blood which may indicate myoglobinuria or haemoglobinuria' Changes to historical red flags:
In chemical burns section added 'If dry or powder chemical burn, remove or brush off before applying water.' | Formal pathology test for myoglobinuria has been withdrawn from NSW Pathology catalogue, clearer wording. Urinalysis is still indicated as a point of care test Alignment of adult and paediatric text with advice from the ACI Burns Network |
19 | April 2024 | A1.1 Anaphylaxis | Changed repeat dosage instruction for nebulised Salbutamol to 'every 20 minutes for up to 3 doses if required' Revised wording in 'Known asthma and/or wheeze' – focus on the treatment of anaphylaxis with adrenaline as a priority Revised 'switch protocol' language. | Consistency with adult asthma guideline No maximum nebulised salbutamol dose on ASCIA guidelines |
20 | April 2024 | P1.1 Anaphylaxis | Reduce dosage of nebulised salbutamol to single nebules for both age groups. 1-6 years: 2.5mg nebule AND 6 years and over: 5mg nebule Align scripting between asthma and anaphylaxis protocols. 'Consider switch protocol' text added under 'asthma and/or wheeze' | Alignment with Paediatric Improvement Collaborative and Australian Medicines Handbook updates |
21 | April 2024 | A4.5 Seizures | Removal of metoclopramide and prochlorperazine from available medications for the management of nausea and vomiting in this protocol | Decision made to reduce antiemetic options to reduce risk from potential contraindications |
22 | April 2024 | P7.3 Gastric tube or nasogastric tube replacement P7.4 Urinary tract infection (suspected) P11.1 Minor wounds | Nitrous oxide The age limit for administration changed from '6 months and over' to '12 months and over' | Aligns with changes in the Paediatric Improvement Collaborative and advice from paediatric clinical advisors |
23 | May 2024 | A10.1 Minor wounds P10.1 Minor wounds | Laceraine gel has changed from blue shaded and triangle to pink shaded and diamond. Addition of wording 'For painful minor wounds, less than 7 cm, that are likely to require closure or to assist with thorough cleaning and irrigation.' | Better alignment with current practice and current standing orders. This allows RNs who have not completed the wound closure package, to still apply laceraine gel for wound irrigation or to prepare the wound for closure by a qualified clinician |
24 | May 2024 | A8.1 Acute behavioural disturbance P8.1 Acute behavioural disturbance | Change in wording for personal safety program requirements. 'This protocol is only to be used by nurses who have completed the NSW Health Violence Prevention Management Personal Safety program.' | This aligns with the relevant Violence Prevention Management programs across all facility levels. |
25 | May 2024 | P2.2 Wheeze (including viral-induced or suspected asthma) | Reduced dosage of oral prednisolone from '2 mg/kg' to '1 mg/kg'. | Aligns with changes to the Paediatric Improvement Collaborative and to the Australian Medicines Handbook and Children’s Dosing Companion |
26 | May 2024 | A7.4 Gastrointestinal bleeding | Removal of metoclopramide Removal of long-acting carbohydrate in glucose management as patient is NBM | Decision made to remove antiemetic option to reduce risk of potential contraindications Transcription error |
27 | May 2024 | A2.1 Shortness of breath | Criteria: include flu-like illness Signs and symptoms: add 'sore throat and runny nose' Circulation: add 'prompt to consider sepsis in signs of shock' Radiology: update CXR criteria to remove infective cause | Expanded criteria to include flu-like illness as no protocol to address flu, COVID, or general respiratory disease. Initial patient management is the same so protocol suitable for inclusion of these without changes to PowerPlans |
28 | May 2024 | A2.2 Shortness of breath with a history of asthma | Updated criteria for chest x-ray from 'If life-threatening or concern for pneumothorax or infective cause: CXR' to 'If life-threatening or concern for pneumothorax: CXR' | In line with changes to A2.1 |
29 | May 2024 | A11.1 Minor wounds | Changed pathology criteria for FBC, UEC to include systemic features of infection | Enable pathology to be collected for wounds with suspected infection |
30 | May 2024 | P11.1 Minor wounds | Added 'Wound more than 24 hours old' to historical red flags | Consistent with adult red flags |
| 31 | June 2024 | A3.4 Sepsis A3.5 Unwell immunocompromised person | Adjust wording on gentamicin BMI calculator (web) and instructions and dosing tables (print) to emphasise maximum dose and provide additional clarity on when to use adjusted or actual body weight. | Change to be more inline with the Therapeutic Guidelines wording and to improve human factors and safe administration |
| 32 | June 2024 | A7.1 Abdominal pain | Inclusion of a stop box at the top of the protocol prompting the nurse to consider epigastric pain and switching to the chest pain protocol to rule out ACS. Addition of lethargy into the red flags. | Improve prompts to consider atypical ACS in patients presenting with epigastric pain and to consider the chest pain protocol. |
| 33 | June 2024 | P3.2 Fever of unknown origin | Change the name to P3.2 Fever. Broaden the description to Any person, 4 weeks to 15 years, presenting with a fever or history of fever. Add sore throat, runny nose, cough into signs and symptoms. | A proportion of paediatric population were missing the opportunity to have a protocol started as the original fever protocol was for “unknown sources” only. Nurses reported that in cases where they are confident of the source or have a letter from a GP identifying the source, they were unable to start this protocol. |