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<pre>
 
 

Policy No.:   D0474 

 

 
 
 

 

Statewide Paediatric  
Surgical Services 

Policy Directive 
 

Version No: v1.0 
Approval date:  11 October 2019 

   



 
 

 

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Contents  
 
1. Policy Statement .................................................................................................................. 3 
2. Roles and Responsibilities ................................................................................................... 3 
3. Policy Context ...................................................................................................................... 4 
4. Policy Detail .......................................................................................................................14 
5. Implementation and Monitoring ..........................................................................................25 
6. National Safety and Quality Health Service Standards .....................................................25 
7. Definitions ..........................................................................................................................26 
8. Associated Policy Directives / Policy Guidelines and Resources ......................................28 
9. Document Ownership &amp; History .........................................................................................28 
  



 
 

 

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Statewide Paediatric Surgical Services 
Policy Directive 

 
1. Policy Statement 

Purpose 
SA Health is committed to providing high quality, consistent and safe surgical services to 
all South Australians. This policy directive outlines how this will be achieved for the 
children and adolescents of South Australia (SA). 
 
Objectives 
  Efficient and consistent paediatric surgical services across South Australia for both 

emergency and elective surgery; and 
  Assurance that clinicians who provide surgical services to paediatric patients are 

appropriately trained credentialed and supervised. 
 
Benefits 
The benefits for South Australian children and adolescents requiring surgery include: 
  A systems based approach to where services are delivered which leverages the 

expertise and capacity of particular sites; and 
  Access to timely emergency and elective surgical care, reducing unnecessary 

hospital transfers and improving access. 
 
This directive does not provide information regarding surgical services for neonates.  
 
Acknowledgements 
SA Health would like to acknowledge the clinicians, managers and consumers who 
contributed to the development of the Statewide Paediatric Surgical Services Policy 
Directive. 
 
SA Health would like to specifically acknowledge the members of the Statewide Paediatric 
Surgical Governance Model of Care Expert Working Group, the Statewide Paediatric 
Surgical Services Project Board and the Statewide Paediatric Surgical Services Clinical 
Reference Group.  
 
Thank you to the members of these committees for their ongoing commitment, expertise, 
leadership and clinical advice to ensure SA Health is in the best position to provide 
equitable and quality paediatric surgery to all South Australian children and adolescents. 
 

2. Roles and Responsibilities 
This policy directive applies to all Local Health Network (LHN) and Department for Health 
and Wellbeing staff involved in the management and delivery of paediatric surgical 
services. 
 
Local Health Network (LHN) Governing Boards will take reasonably practical steps to 
ensure that effective clinical and corporate governance (where relevant) frameworks are 
in place to ensure the LHNs are compliant with this policy directive. 
 
Chief Executive Officers, Local Health Networks are responsible for ensuring that all 
staff involved with the provision of paediatric surgery are informed of this policy directive. 



 
 

 

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Chief Operating Officers, Local Health Networks are responsible for ensuring that 
required processes are in place to support the management of paediatric surgery in line 
with the provisions of this policy directive. 
 
Clinicians are responsible for ensuring that they are familiar with and work in accordance 
with the information outlined in this policy directive. 
 
Administrative staff involved in bookings, waiting list management, admission, discharge 
relating to the management of paediatric surgery should be aware of the information in 
this Policy Directive. 
 

3. Policy Context 
This Statewide Paediatric Surgical Services Policy Directive is underpinned by a number 
of National and State Standards and Principles relating to the provision of surgery to 
children and adolescents and these are outlined below. 
 
National Surgical Standards and Principles 
 
Australian Commission on Safety and Quality in Health Care National Standards 
This service standard aligns with the Australian Commission on Safety and Quality in 
Health Care National Standards, specifically Standard 1   Clinical Governance Standard. 
National Safety and Quality Health Service Standards (second edition) 
 
Standard 1 specifically considers: 
  Governance, leadership and culture; 
  Patient safety and quality systems; 
  Clinical performance and effectiveness; and 
  Safe environments for the delivery of care. 
 
National Standards for the Care of Children and Adolescents in Health Services 
The National Standards for the Care of Children and Adolescents in Health Services 
outlines the requirements for facilities in relation to accommodation and care that are to be 
incorporated into the provisions of surgical services to children and adolescents. 
 
The Standards for the care of children and adolescents in health services have been 
developed for use in the Australian healthcare system. The goal of the standards is to 
ensure that quality care is provided in an environment that is safe and appropriate for the 
age and stage of development of the child or adolescent. 
 
The medical and psychosocial needs of children and adolescents differ from those of 
adults requiring health services and as a result children and adolescents have unique 
vulnerabilities and patient safety risks. Consequently, it is critical to provide separate 
facilities for children and adolescents in all areas of the health service where they are 
cared for. 
 
Potential risks arising from co-locating children / adolescents with adults in health services 
include; 





 
 

 

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  The rights of children and young people are not respected; 
  physical, psychological or sexual harm from other patients, staff or visitors; 
  compromises in quality of care for children/adolescents if care is provided by staff 

without education and training in the care and treatment of children and young 
people or if the available equipment is inappropriate in size or design; 

  inadequate or inappropriate parent/carer and family support and involvement in 
care; 

  interruptions to normal development if opportunities for play, leisure and education 
are not provided; 

  unnecessary trauma from witnessing distressing sights and sounds; 
  compromises in the care of children/adolescents when paediatric staff and 

resources are  diverted to provide care for adult patients; 
  compromises in quality of care for adults if they are placed on a paediatric ward 

and staff are not experienced in caring for adults; and 
  compromises in quality of care for adults if adults feeling ill are disturbed by either 

noisy children or the continued presence of the child s family, which is a key 
component of family-centred care. 

 
Royal Australasian College of Surgeons (RACS) Surgery in Children 
SA Health advocates for the Royal Australasian College of Surgeon s Surgery in Children 
Position Paper including the ten (10) recommended surgical principles. These principles 
are appropriate for both emergency and elective surgery and should take precedence in 
the event of any misunderstanding about appropriateness of location or treatment: 

1. Provide quality treatment for the child appropriate for their age, condition, and local 
health network capability at the closest health service to their home. 

2. Ensure regional and rural surgeons and anaesthetists are adequately trained to 
assess and treat children within their community. 

3. Provide predictable and evidence based clinical care. 
4. Establish collaborative networks between tertiary paediatric services and other SA 

Health services that provide paediatric services. 
5. Ensure communications between health care providers are accurate, at the correct 

level, and puts the safety of the child paramount. 
6. Develop transfer guidelines between health services. 
7. Encourage out-reach specialist paediatric surgical teams that support local surgeons 

and other peri-operative staff. 
8. Develop transition plans for older children with complex paediatric conditions. 
9. Develop combined sub-specialist adult and paediatric expertise for complex adult 

conditions that also affect children. 
10. Treat older children and adolescents presenting with non-paediatric specific surgical 

conditions in an adult facility by an adult surgeon. 
 
State Strategic Plans, and Relevant Policies and Procedures 
 
SA Health Strategic Plan 2017-2020 
The SA Health Strategic Plan 2017   2020 will fulfil its roles of Lead, Partner and Deliver 
through the following strategic objectives: 

1. Reshape governance structures to deliver our objectives and foster internal 
collaboration. 






 
 

 

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2. Use evidence to inform clinical planning and policy to deliver safe and reliable care. 
3. Create strategic and business plans to implement the SA Health strategic plan. 
4. Cultivate a learning culture that is supportive and productive across SA Health. 
5. Increase the roles of consumers and communities in policy, design, planning, delivery 

and practice. 
6. Strengthen partnerships through a coordinated approach to relationship management. 
7. Facilitate wider translation of research into practice and transfer of innovation across 

our business. 
The SA Health Statewide Paediatric Surgical Service Policy Directive aligns with the SA 
Health Strategic Plan. 
 
Children and Young people (Safety) Act 2017 
Under the Children and Young People (Safety) Act 2017, SA Health sites are required to 
ensure child safe environments that promote the health, wellbeing and safety of children 
and adolescents. This involves, wherever possible that children and adolescents are 
assessed, treated and accommodated separately to adults to ensure that their unique 
needs are met and risks of harm are minimised. 
Across South Australia, surgical services for children and adolescents will be provided in 
both adult and dedicated children s services. 
 
The location of where a child or adolescent is to undergo a surgical procedure is a 
decision based on a range of factors as described in the SA Surgical Services Taskforce s 
minimum requirements for safe surgical services underpinned by the site s capacity and in 
alignment with the SA Health Clinical Services Capability Framework. 
 
SA Health Consent to Medical Treatment and Healthcare Policy Guideline 
The SA Health Consent to Medical Treatment and Healthcare Policy Guideline deals with 
various matters relating to obtaining consent for the provision of medical, surgical and 
dental treatments and other related medical practices by medical practitioners and, in 
some cases, other health practitioners. It represents a best practice model for all health 
practitioners. The policy provides guidance regarding gaining consent including: 
  Consent and refusal to medical treatment; 
  Valid forms of consent; 
  How and when consent can be obtained; and 
  Medical treatment/treatment of children (under 16 years of age) 
 
In addition, the SA Health Policy Directive - Providing assessment and or medical 
treatment where patient consent cannot be obtained provides guidance regarding 
situations where patient consent cannot be obtained for example emergency situations or 
situations where the patient is unable to consent and therefore requires consent to be 
provided on their behalf. 
 
Child Safe Environment Policy Directive 2018 
The SA Health Child Safe Environments (Child Protection) Policy Directive 2018 provides 
the overarching framework for protecting children from physical, sexual, emotional and 
psychological abuse and neglect, as well as promoting their health and wellbeing. 
 









 
 

 

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The Child Safe Environments (Child Protection) Policy Directive fulfils SA Health s 
obligations under the Children and Young People Safety Act 2017 and in particular the 
provisions outlined in Chapter 8 of the Act - Providing safe environments for children and 
young people. 
 
The Child Safe Environment Policy Directive has been developed to demonstrate the 
strong commitment of SA Health to children s safety, protection and wellbeing and to 
emphasise the importance for the organisation of maintaining child safe and friendly 
environments. A child safe organisation takes a preventative, proactive and participatory 
stance on child protection issues. 
 
Across SA Health, the safety and well-being of children is a paramount consideration 
when developing activities, policies and management practices. Our organisation values 
and embraces the opinions and views of children, encourages and assists children to 
build skills that will assist them to participate in the health system and takes action to 
protect children from physical, sexual, emotional and psychological abuse and neglect. 
 
This Policy Directive articulates an overarching set of principles at the centre of which is 
that all children have the right to feel safe and protected when accessing health services. 
Implementation of the principles in the policy will influence organisational culture to ensure 
staff, no matter their role within a health network or service, value children and their views 
and are committed to acting in children s best interests. 
 
Moreover, this Policy Directive is aligned to Child Protection, A Fresh Start the 
Government of South Australia s response to the Child Protection Systems Royal 
Commission report: The life they deserve (2016). 
 
Transition from Paediatric to Adult Healthcare Services Clinical Procedure 
Patients who are aged 16 years and over, including those with chronic/complex medical 
conditions, with long term care plans should begin the transition process from the 
paediatric to adult health care setting. Transition is a process that needs to acknowledge 
the developmental stage of the child. 
 
Preparation for transition may start between the ages of 14 - 16 with the aim of transition 
being completed by the age of 18 or completion of year 12 (whichever is later). 
 
The transition process will ensure continuity of quality care is delivered in the most 
appropriate setting for the patient. The transition will also allow the patient to move into 
the role as the primary decision maker in the management of their condition(s). 
 
Transition from Paediatric to Adult Healthcare Services should be carried out in 
accordance with the principles and guidelines outlined in the WCH Transition from 
Paediatric to Adult Healthcare Services Clinical Procedure. 
 
Children and Adolescents in Adult Health Services Policy Guideline 





 
 

 

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SA Health is committed to ensuring that children and adolescents are able to access and 
receive health services in an appropriate, safe and child friendly environment. 
 
Children and adolescents may receive health care within an adult health care setting 
which may require additional clinical and health service considerations for safe and secure 
treatment and care. The provision of a child safe environment for the treatment of children 
and adolescents in adult health services will be guided by a risk management approach, 
as set out in the Children and Adolescents in Adult Health Services Policy Guideline. This 
Policy Directive aligns to and should be considered in conjunction with the SA Health 
Child Safe Environment Policy Directive. 
 
This Directive applies to all SA Health adult services and staff working within those 
services, in the provision of treatment and care to children and adolescents. Specific to 
this Policy Directive, child means a person less than 16 years of age consulted by a health 
service as a patient and adolescent means a person aged 16-18 years consulted by a 
health service as a patient. 
 
Elective Surgery Policy Framework and Associated Procedural Guidelines 
The SA Health Elective Surgery Policy Framework and Associated Procedural Guidelines 
aim to provide a consistent, structured approach to support the provision of elective 
surgery within SA Health public hospitals. The Policy Framework provides information and 
guidance to all SA Health employees and other practitioners involved in the provision of 
elective surgery services. The Policy Framework includes a number of policy statements 
and procedural guidelines dealing with specific aspects of elective surgery systems and 
processes. 
 
SA Health Paediatric Clinical Practice Guidelines 
The SA Health Paediatric Clinical Practice Guidelines are designed to assist clinicians 
with decisions about appropriate health care for children and young people aged 0-18 
years, not including management of neonatal conditions. 
The guidelines are designed to: 
  Improve the quality and consistency of health care; 
  Reduce the use of unnecessary, ineffective or harmful interventions; 
  Facilitate treatment with the maximum chance of benefit, minimum risk of harm, and at 

an acceptable cost; and 
  Assist decision-making in acute care of conditions were inappropriate care may lead to 

serious adverse consequences. 
 
The Guidelines are underpinned by evidence-based clinical practice principles which take 
into account patient s preferences and clinician s professional judgement. They are 
primarily aimed at clinicians working in primary care, local, regional, general or tertiary 
hospitals and should be used within the context of offering individualised care for patients. 
 
The ongoing management and development of these guidelines will be undertaken as a 
statewide collaboration between all LHNs and their clinicians. 
 






 
 

 

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The SA Health Trauma Model of Care 
The purpose of the SA Health Trauma Model of Care is to ensure that every South 
Australian who suffers major trauma gets the right care at the right time. It provides a high 
level model for trauma care throughout the patient journey and a framework for improving 
the delivery of care in South Australia.  
 
The model of care is designed to work in conjunction with care models for the treatment of 
specific injury types (e.g. spinal injuries, burns); it is not intended to replace them. The 
model of care is designed to work alongside the South Australian Trauma System Clinical 
Governance Framework and provides the following definitions and service delineations: 
 
Major Trauma   
All trauma patients with injury as their principal diagnosis (irrespective of age) who meet 
any of the   following criteria: 
  death after injury 
  Injury Severity Score (ISS) greater than 12 
  admission to an intensive care unit for more than 24 hours and requiring 

mechanical ventilation 
  urgent surgery for intracranial, intrathoracic or intraabdominal injury, or for fixation 

of pelvic or spinal fractures 
  injury being the principal diagnosis (irrespective of age) and satisfying any of the 

South Australian Trauma Registry (SATR) patient inclusion criteria. 
 
Major Trauma Service (MTS) 
ADULT (?16 years): 
  The Royal Adelaide Hospital (RAH) 
  Flinders Medical Centre (FMC) 
PAEDIATRIC (&lt;16 years)  
  The Women s &amp; Children s Hospital (WCH) 
  Flinders Medical Centre also has the ability to provide care to paediatric trauma 

patients within its Service Capability Framework. 
1 definition adapted from the Review of Trauma and Emergency Services Victorian 1999 (ROTES) report 
 
Metropolitan Trauma Service  
ADULT (?16 years) 
  Lyell McEwin Hospital (LMH) 
LMH also has the ability to provide trauma care to obstetric and paediatric patients within 
its Service Capability Framework. 
 
Rural, Regional and Remote Trauma service 
All other metropolitan and all country sites are designated as Rural, Regional &amp; 
Metropolitan Health Care Services (RACS level 4).  

 
SA Health Paediatric Trauma Team Activation Criteria 
The South Australian Trauma System s Paediatric Trauma Team Activation 
Criteria describes a two-tiered trauma team response; Level 1 and Level 2. 
Following notification of a traumatic injury that meets the Criteria, a Level 1 or Level 2 
trauma response is initiated. This includes ensuring that the relevant trauma team is 






 
 

 

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assembled, assessment/resuscitation and operating rooms will be available when needed, 
and pathology, diagnostic imaging, staff, resources and equipment are ready prior to the 
arrival of the patient. 
 
For those patients assessed as requiring secondary transfer and/or the resources of a 
Major Trauma Service the SA Trauma System outlines the following service designations:  
  Patients who have had their 16th Birthday (?16yrs) should be referred &amp; 

transferred to the Adult Major Trauma Services (RAH or FMC)  
  Patients who are under 16 years of age (&lt;16yrs) should be referred &amp; transferred 

to the Paediatric Major Trauma Service (WCH).  
 
NOTE: In contrast to the definitions presented in this document, the SA Trauma System 
Paediatric Trauma Team Activation Criteria defines an adolescent as a patient that is 
aged 12 years or older and less than 18 years at the time of admission.  
 
Women s and Children s Hospital Paediatric Emergency Trauma Manual 
The Women s and Children s Hospital, as the South Australian tertiary paediatric service 
have established a Paediatric Emergency Trauma Manual, which details the standards 
and guidelines of care to be provided to paediatric trauma patients, including patients who 
may require an emergency surgical intervention. This document is written and designed 
for use within the WCHN only. 
 
A statewide paediatric trauma manual detailing referral network and service capability is 
under development by the SA State Trauma Committee. 
 
Credentialling and Defining the Scope of Clinical Practice for Medical and Dental 
Practitioners Policy Directive 
The Credentialling and Defining the Scope of Clinical Practice for Medical and Dental 
Practitioners Policy gives guidance on the requirements and processes for ensuring 
medical and dental practitioner credentials are reviewed and an appropriate scope of 
practice defined. 
 
Authenticating allied health professional credentials including access appointment 
policy directive 
SA Health is committed to ensuring that all AHPs have the appropriate and recognised 
credentials to provide services relevant to their area of professional responsibility. The SA 
Health Authenticating Allied Health Professionals (AHP) Credentials including Access 
Appointments policy outlines the minimum requirements to credential AHPs employed by 
SA Health or accessing SA Health facilities. 
 
SA Health Clinical Services Capability Framework 
The SA Health Clinical Services Capability Framework (CSCF) sets out the planned 
structure of public health services across South Australia. It is an important tool for 
statewide strategic planning and will support implementation of health initiatives by 
providing a comprehensive picture of clinical services across the state. 
The CSCF outlines indicative service requirements, workforce requirements and support 
services for health services to deliver safe and appropriately supported clinical service 












 
 

 

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delivery. It aims to provide planners and clinicians with a consistent approach to the way 
clinical services are described, and identify inter-dependencies which exist between 
clinical areas.  
 
The delineation of services into six levels will guide the development of SA Health service 
profiles and assist LHNs to develop localised clinical service plans. The CSCF 
complements existing frameworks, policies and models of care, but in doing so does not 
replace safety and quality standards from relevant legislation, regulations and guidelines. 
The CSCF is presented in a modular form, which allows users to navigate between 
modules using links embedded within each module. Not all clinical areas are represented 
with a stand-alone module, as the requirements for many specialties are sufficiently 
covered within broad modules such as medical and surgical services. 
 
Application of the CSCF will facilitate the collaborative planning process. It will enable 
services to be mapped across the system as a mechanism to identify gaps, 
interdependencies and service development priorities.  
 
The CSCF has been designed to guide and coordinate an integrated approach to health 
service planning and delivery in South Australia. It applies to public health facilities and 
will enhance the provision of safe, quality services by providing health service planners 
and service providers with a standard set of indicative clinical capability criteria. 
 
The CSCF s purpose is to: 
  Describe a set of capability criteria that identifies minimum requirements by service 

level; 
  Provide consistent language for healthcare providers and planners to use when 

describing and planning health services; 
  Assist health services to identify and manage risk; 
  Guide health service planning; 
  Provide a component of the clinical governance system, credentialling and scope 

of clinical practice of health services; and 
  Instil confidence in clinicians and consumers that services meet minimum 

requirements for patient safety and guide health service planning. 
 
The CSCF is intended for a broad audience including clinical staff, managers and health 
service planners. It is not intended to replace clinical judgement or service-specific patient 
safety policies and procedures, but to complement and support the planning and/or 
provisions of acute and sub-acute health services. 
 
  



 
 

 

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CSCF Clinical Service Levels by Complexity of Care (Figure 1.) 
 
Within the CSCF, clinical services are categorised into six service levels with Level 1 
managing the least complex patients and Level 6 managing the highest level of patient 
complexity. However, complexity of care may vary between modules. The size of the 
service and diversity of health care managed at each level will be greater as service levels 
increase. 
 

 
 
Clinical Services Capability Framework - Children s Services 
Children need distinct and tailored health services providing care and treatment that is 
safe, and suited to their age and stage of development. The Universal Declaration of 
Human Rights states  the child, by reason of his [sic] physical and mental immaturity, 
needs special safeguards and care . 
 
The medical, therapeutic, developmental, social and psychosocial needs of children 
requiring health services differ from those of adults. There are unique vulnerabilities and 
patient safety risks. Consequently, it is critical to provide age-appropriate healthcare in a 
service designed, furnished and decorated to meet the needs and developmental age of 
children. In certain cases, flexible approaches may be adopted when including the view of 
the child about where they would prefer to receive care. 
 
Where children are treated in an adult health service environment, the service must: 
  Comply with the relevant components of the children s services CSCF; 
  Ensure all medical staff have credentials and a defined scope of clinical practice 

enabling them to provide services to children, and demonstrating currency of 
practice. this must be: 



 
 

 

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  noted on their privileging document; and must  
  comply with local LHN policy regarding credentialling and scope of practice; 
  Ensure all staff have the appropriate clearance to work with children; 
  Ensure all health workers are aware of the need to report any reasonable 

suspicions of child abuse and neglect to the Families SA child abuse report line; 
  Ensure a clear documented process for child protection reports; and 
  Ensure all other staff involved in the care of children have qualifications and 

experience commensurate with the service being provided. 
  Where services are provided to children who require sedation, paediatric 

resuscitation equipment must be available and clinicians must be competent with 
its use. 

 
CSCF Children s Services Modules 
Within the CSCF there are eight modules that encompass services provided to children in 
residential, ambulatory and/or acute settings, as well as sections within the Mental Health 
Services module specific to children.  These are: 
 
Anaesthetic Services   Children s 
Cancer Services   Children s 
Child Protection Services 
Emergency Services   Children s 
Intensive Care Services   Children s 
Medical Services   Children s 
Radiation Oncology Services   Children s 
Surgical Services   Children s 
 
The full CSCF Module: Children's Services - Preamble provides further information. The 
full modules for all other areas are available with the links provided. Modules specific to 
paediatric surgery are outlined below. 
 
CSCF Surgical Services   Children s module 
The SA Health Clinical Services Capability Framework recognises five levels (Levels 2-6) 
of service delineation for children s elective surgical services and these are detailed in 
the Surgical Services   Children s module. These five levels determine the degree of 
complexity of the paediatric elective surgical care each health service is capable of 
providing.  
 
 
 
CSCF Emergency Services   Children s module 
The Emergency Services   Children s module recognises 3 levels of emergency surgery 
(Levels 4-6) service delineation and these are detailed in the Emergency Services   
Children s module. These three levels determine the degree of complexity of emergency 
paediatric surgical care that each health service is capable of providing. 
 
Paediatric surgical capability of SA Health services 
Each Local Health Network is required to complete a Clinical Services Capability 
Framework   Self Assessment annually. This self-assessment indicates each health 

















 
 

 

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services capability across the full range of clinical services including emergency and 
elective surgery and is included in each LHN s annual Service Level Agreement which is 
published on the SA Health Intranet.  
 
Aboriginal and Torres Strait Islander children and adolescents 
The Cultural Respect Framework 2016   2026 for Aboriginal and Torres Strait Islander 
Health takes a National approach to building a culturally respectful health system. The 
vision laid out in the Framework is of a health system that is accessible, responsive and 
safe for Aboriginal and Torres Strait Islander people.  
 
For Aboriginal and Torres Strait Islander children and adolescents requiring surgery, 
consideration should always be given to the provision of accessible, culturally appropriate 
care. This may include linking patients and families with an Aboriginal Hospital Liaison 
Service or Aboriginal Health Worker to support culturally safe and appropriate inpatient 
care, patient transfers and discharge from hospital after surgery. 
 

4. Policy Detail 
 
Paediatric Emergency Surgery Pathways 
The Statewide Paediatric Surgical Services Policy Directive provides the following 
pathways to guide the management of both elective and emergency surgery referrals and 
presentations for the children and adolescents of South Australia: 
  Paediatric Emergency Surgery Pathway for children and adolescents aged &lt;16 

years 
  Paediatric Emergency Surgery Pathway adolescents aged 16-18 years 
  Paediatric Elective Surgery Pathway 
 
The Paediatric Emergency Surgery Pathway for children and adolescents aged &lt;16 years 
(figure 1.) and for adolescents aged 16-18 years (figure 2.) integrate the following 
principles to enable appropriate, timely and consistent clinical decision making and 
treatment for non-planned child and adolescent presentations: 
  Emergency Paediatric Surgery will be provided in alignment with the receiving 

hospitals capability as per the SA Health Clinical Services Capability Framework  
 Emergency Surgery   Children s module. 

  Responsibility for clinical decision making about the emergency surgical treatment 
of children and adolescents will be with the surgeon on-call for the relevant 
surgical specialty. 

  Appropriate escalation mechanisms will support timely clinical decision making for 
complex patients. 

  When decisions are made about the location of care for complex surgical patients, 
consideration will be given to the required treatment plan and previous episodes of 
care to best facilitate continuity of care. 

  WCHN as the state wide level 6 paediatric surgery hospital will provide both on call 
and out-reach services 24/7 to support other SA Health hospitals as a point of 
escalation and clinical support. 

  Consultant level surgical support and advice are available via a 24/7 on-call 
service that is accessible via the WCH switchboard. 

  Transfer of children and adolescents requiring emergency surgery and or the 
resources of a Major Trauma Service will follow the transfer protocols detailed on 
page 21-23 of this directive and in accordance with The Transfer Process   Urgent 
Surgery and Surgical Assessment in SA Health Services Policy Directive  









 
 

 

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  Emergency surgery for adolescents aged 16 years and over presenting with new 
non- paediatric specific conditions, excluding malignancy should be considered for 
treatment by an adult surgeon and anaesthetist in an adult facility, in accordance 
with the Children and Adolescents in Adult Health Services Policy Guideline and in 
alignment with the receiving hospitals clinical services capability 

  South Australian Ambulance Service (SAAS) will transport children and 
adolescents aged under 16 to the most appropriate health service with paediatric 
capability and adolescents aged 16 years and over to the most appropriate local 
adult health service as per the SAAS  

  In the case of an adolescent aged 16 years and over that self-presents to the 
WCH and requires emergency surgery, this can be performed locally with 
consideration of potential to be transferred to an adult service post-operatively  

  Clinical deterioration of a patient will be managed appropriately in alignment with 
the patient s needs and the capacity of the hospital. It should be considered if the 
patient requires an up-transfer to a higher level of care. 

 
  




 
 

 

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Figure 1. Paediatric Emergency Surgery Pathway children aged &lt;16 yrs. 

Child or adolescent aged under 16 presents at  SA Health hospital:

Senior doctor or surgical review confirming surgical care required 

Level 6 
Paediatric 
Hospital

Treat at WCH:
  Admit patient direct to hospital 

under the appropriate surgical team 
unless otherwise indicated

  Provide clinical treatment required
  Ensure a child safe environment
  Continue to actively monitor for 

deterioration 

Hospital
with 
Level 3, 4 
or 5
Paediatric
Facilities

Patient requires surgical involvement that 
is met by local capability 

Patient requires surgical involvement 
that can not be met by local capability  

Surgical review locally

Discuss with the WCH on-call service

Acute or complex co-morbidity requiring 
higher service level of care

Paediatric anaesthetic requirements 
requiring higher level of care

Treat Locally:
  Admit patient to hospital and provide 

required treatment
  Ensure a child safe environment
  Continue to actively monitor for 

deterioration 
  If patient deteriorates and requires a 

higher level of care contact the WCH 
on-call service for out-reach services.

Refer to WCH service:
  Local medical review by senior 

doctor or surgeon to approve patient 
is medically stable to activate 
transfer

  Transfer to be approved by WCH on-
call service.

  Patient transfer to be organised by 
appropriate means and/or priority.

  Continue to actively monitor patient 
for deterioration.

  If patient deteriorates and requires a 
higher level of care contact the WCH 
on-call service for out-reach services.

NO

NO

YES

YES

Where Patient transfer is indicated due to a need for up transfer to a higher level service, transfer to a Major 
Trauma Service or transfer between an adult and a paediatric service, observe patient transfer protocols and 

transfer pathway on page 20-23 of this Directive.



 
 

 

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Figure 2. Paediatric Emergency Surgery Pathway adolescents aged 16-18 yrs. 
 
 

Adolescent aged 16-18 years presents at an SA Health Emergency Department:

Senior doctor or surgical review confirming surgical care required

Pre existing paediatric 
condition identified that 

is already under 
management at a 

hospital with paediatric 
services

New &amp; non-paediatric 
specific condition 

(excluding malignancy)

Treatment by an adult 
surgeon and anaesthetist 

in an adult facility

New paediatric specific 
condition

Malignancy

Liaise with usual place 
of treatment regarding  

transfer

Treatment at closest 
hospital with 

appropriate paediatric 
capability

 

Treatment at WCHN

Where Patient transfer is indicated due to a need for up transfer to a higher level service, transfer to a Major 
Trauma Service or transfer between an adult and a paediatric service observe patient transfer protocols and 

Transfer Pathway on page 20-23 of this Directive.



 
 

 

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Paediatric Elective Surgery Pathway 
The Paediatric Elective Surgery Pathway detailed in Figure 3. below, integrates the 
following principles to enable timely, consistent clinical decision making and treatment for 
planned child and adolescent presentations: 
  Children and adolescents will be referred to the most appropriate hospital. 

Considerations will include; postcode of residence, age, complexity of surgical 
requirements, patient s co-morbidities and the patients/parents and carers 
preferences. 

  Each LHN will undertake the Management of Paediatric Elective Surgery Referrals 
Pathway (Figure 3.) for all incoming referrals prior to accepting and adding the 
patient to the LHN wait list. 

  A specifically named and/or addressed paediatric referral should follow the same 
path as a generic referral; 

  Paediatric surgery referrals will align with the SA Clinical Services Capability 
Framework Surgery   Children s module and the capabilities of the receiving 
hospital. 

  A Paediatric surgery referral cannot be accepted at a location that does not 
provide the service. 

  When a Paediatric surgery referral is unable to be accepted by an LHN, the 
receiving LHN will advise the referring GP that the referral has not been accepted, 
provide reasons for decision and advise that the referral should be forwarded to an 
LHN that provides the service. 

  When surgery is required at a hospital that is not the patient s local hospital, being 
the closest hospital for the patient s home postcode, outpatient follow up where 
possible, will be coordinated at the local hospital. 

 
  



 
 

 

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Figure 3. Paediatric Elective Surgery Pathway 
 
  

  

PRIMARY
HEALTH
CARE
PROVIDER

SA HEALTH
HOSPITAL

YES NO

Assessment indicates potential surgical problem

Referrer sends referral to appropriate LHN considering age and home address and pre-existing conditions under 
treatment

Patient is aged 0 - &lt;16 Patient is aged 16 - 18

Pre-existing condition 
currently under 

treatment at a paediatric 
hospital

New diagnosis or surgical 
issue and not currently 

receiving treatment at a 
paediatric hospital

Referral sent to 
outpatients department 
of patients nearest adult 

hospital

LHN Outpatients Unit receives paediatric surgery referral.
Does the required service align with the receiving LHN hospitals service level capability?

YES NO

Active management of waitlist

Referral sent to outpatients department of patients nearest hospital with 
paediatric services

    

            

    

Referral accepted and 
added to LHN outpatients 

waitl ist

GP informed that referral 
has not been accepted 

and should be referred to 
a hospital with 

appropriate capability.



 
 

 

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Patient Transfers  
SA Health is committed to providing quality care as close to home as possible, however 
this is not always feasible. There may be some circumstances where patients are required 
to be transferred to another SA Health service to ensure the best possible care is provided 
by clinicians and services that are suitably trained and experienced in the clinical care 
required. 
 
Up-transfer 
An up-transfer is when a patient is required to be transferred from the originating hospital 
to an alternative SA Health site that is usually a higher level service, to receive the 
required care. The Transfer Process   Urgent Surgery and Surgical Assessment in SA 
Health Services Policy Directive establishes a streamlined, consistent process for the 
transfer of patients between LHNs where urgent surgery or surgical assessment is 
required which cannot be provided at the originating hospital. The aim is to ensure 
effective and efficient management of patient transfers, centred on meeting the clinical 
needs of the patient and the provision of quality care. 
 
Where a referring medical clinician contacts a surgical consultant at the proposed 
receiving hospital and the surgical consultant confirms the transfer is clinically required, 
the transfer is approved and the patient is accepted by the surgical consultant. A surgical 
consultant will respond to the initial contact from the referring medical clinician regarding 
the urgent transfer request as soon as possible and within a maximum timeframe of 40 
minutes. 
 
The referring medical clinician is responsible for ensuring the patient transfer is 
operationalised via local processes which will include notifying the patient and their 
family/carer about the transfer, and booking patient transport. Patient transport can be 
booked through SAAS via Triple Zero (000), through ambulance attendance queue for low 
acuity bookings such as Inter Hospital Transfers (1800 881 700) or online via the 
Electronic Booking System for users with access to SA Health HAD platform.  
 
A request for a SAAS MedSTAR retrieval team or further assessment can be done by 
telephoning 13STAR (select option 6) and requesting an  urgent booking for surgical 
transfer/assessment. A Nurse Retrieval Coordinator (NRC) will return the referring 
medical clinician s call as soon as possible and within a maximum timeframe of 40 
minutes. 
 
The receiving hospital is responsible for operationalising its response for a patient 
accepted for transfer by a Surgical Consultant via local processes, including addressing 
the following: 
  Securing a bed for the patient;   
  Notifying the referring medical clinician of patient acceptance and transfer 

approval; and 
  Facilitating clinical handover between the referring medical clinical and accepting 

Surgical Consultant. 
 

Patients deemed as clinically requiring a transfer are not to be refused transfer based on 
the bed state of the receiving hospital. The originating hospital and the receiving hospital 
in partnership with SAAS will negotiate the timing of the patient transfer that is appropriate 
for the urgency and the patient s clinical condition. It is the responsibility of the receiving 
hospital to manage its beds to accommodate the accepted patient.  





 
 

 

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Any issues in relation to bed availability and the acceptance of the patient are to be 
escalated to the receiving hospital Chief Operating Officer (in hours) and the Executive 
On-Call (out of hours). Figure 4 
 
Down-transfer 
A down-transfer is when a patient has had surgical care at a higher level service and is 
now being transferred to a lower level service closer to their home for post-operative 
and/or rehabilitation care. 
 
A down-transfer can only happen when the following has occurred: 
  Confirmation that the receiving hospital has the appropriate post-operative and/or 

rehabilitation services required for the patient s care; 
  Nursing staff to discuss with the patient and family/carer about the discharge 

summaries and expectations at the receiving hospital; 
  Medical and/or Dental staff to contact the receiving hospital s medical practitioner 

who has agreed to admit the patient to continue the clinical care to provide a 
comprehensive clinical handover of the patient; 

  Allied Health staff to detail interventions and recommendations for ongoing 
management in the appropriate discharge documentation for the receiving 
hospital; 

  All arrangements, discharge summaries and recommended management plans to 
be documented in the patient s medical records and transported to the receiving 
hospital with the patient; 

  Transfer to be booked with SAAS using standard procedures; 
  Clinical pharmacist to liaise directly with the receiving hospital regarding discharge 

medication requirements. 
  On the day of transfer the receiving hospital should be contacted to re-confirm bed 

availability within an environment that is in alignment with child safe requirements; 
and 

  Once the patient has left the ward the dispatching hospital should contact the 
receiving hospital to advise the patient is now on route with an estimated time of 
arrival. 

 
The aim is to ensure effective and efficient management of patient transfers, centered on 
meeting the clinical needs of the patient and the provision of quality care while maintaining 
the safety of the child or adolescent. 
 
Transfer - Trauma  
The South Australian Trauma System paediatric Trauma Team Activation Criteria provide 
the following additional recommendations regarding patients requiring secondary transfer 
and or the resources of a Major Trauma Service: 
  Patients who have had their 16th birthday (?16 years) should be referred and 

transferred to the Adult Major Trauma Services (Royal Adelaide Hospital or 
Flinders  Medical Centre) 

  Patients who are under 16 years of age (&lt;16 yrs.) should be referred and 
transferred to the Paediatric Major Trauma Service (Women s and Children s 
Hospital). 




 
 

 

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Figure 4: The SA Health Transfer Process   Urgent Surgery and Surgical Assessment in 
SA Health Services Policy Directive provides the following pathway to guide decisions 
regarding transfer: 





 
 

 

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Statewide Paediatric Surgical Support Services 
 
On-call Support 
The WCH as the Level 6 service in South Australia will provide an on-call support service 
to all SA Health services as an escalation mechanism to enable timely decision making 
where there is uncertainty about the most appropriate course of action to manage a 
patient s condition. On-call support does not replace any transfer protocols that are 
required to be followed. On-call support is available for discussion in complex cases 
where a more specialist paediatric clinical opinion is required. Where on-call support is 
provided, care of the patient remains the responsibility of the health service and clinical 
team where the patient is located. 
 
The WCH on-call support service will be available 24 hours a day, 7 days a week. It 
should be noted that for some specialities this is in the form of a state wide roster. 
 
Out-reach Services 
The WCH as the Level 6 service in South Australia will provide a specialist out-reach 
paediatric surgical service that supports clinicians from lower level services in time of 
clinical need. 
 
The out-reach services will be provided when a patient is deemed too unstable to be 
transferred to higher level services. The Level 6 service will be responsible in arranging on 
an ad-hoc basis, the specialist clinician(s) required to attend the lower level facility as 
soon as practicable to provide the clinical care required. In these extreme circumstances 
the Level 6 service will also inform the clinical management plan and direct the care 
required to actively manage the patient to prevent any further deterioration. The Level 6 
service will remain in direct contact with the lower level facility to remotely monitor the 
patient s condition until the out-reach service arrive on site. 
 
The out-reach services will temporarily upgrade the capacity of the lower level facility. For 
further information regarding Credentialing and Scope of practice requirements see pages 
24-25 of this Directive. 
 
Paediatric Surgical Patients with Complex Conditions 
For some complex conditions, there may be a requirement for collaboration between the 
expertise of the sub-specialist adult and paediatric clinicians. Support links, including 
undertaking appropriate Credentialling and Scope of Clinical Practice for adult sub-
specialists to attend and consult upon children in the paediatric environment will be 
established. 
 
SA Health Paediatric Workforce 
SA Health is committed to ensuring the paediatric surgical workforce is suitably registered, 
trained and experienced. 
The allocation and/or rostering of paediatric staff state wide will reflect industrial 
requirements, changing hospital population profiles and the service demand. The 
paediatric surgical workforce will: 
  Respond flexibly to population changes and location of demand; 
  Operate across sites and support after hours care across the state wide system; 
  Integrate specialist services across co-located paediatric and adult services for 

seamless care; and 
  Facilitate efficient and effective use of a generalist workforce to support the 

provisions of paediatric care. 



 
 

 

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The state wide paediatric workforce will be supported to build on the strengths of each 
clinician and each hospital by optimising the up-skilling and training of the state wide 
paediatric surgical workforce. 
 
Credentialling and Scope of Clinical Practice Requirements 
 
Medical and Dental 
Each LHN will be responsible for ensuring that all medical and dental practitioners who 
are providing clinical care to children and adolescents have the appropriate level of 
qualifications, AHPRA registration and paediatric experience and that all are credentialed 
and have a defined Scope of Clinical Practice prior to the provision of any clinical services 
as per the SA Health Credentialling and Defining the Scope of Clinical Practice for 
Medical and Dental Practitioners Policy Directive. 
 
Allied Health 
Each LHN will be responsible for ensuring that all Allied Health Professionals who are 
providing clinical care to children and adolescents adhere to the SA Health Authenticating 
Allied Health Professionals Credentials and Access Appointment Policy Directive. This 
includes having the appropriate level of qualifications, AHPRA registration (where 
required) and paediatric experience and that Credentialling and Scope of Clinical Practice 
processes are completed for all allied health practitioners prior to the provision of clinical 
services. Any visiting AHP under access appointments or other agreed arrangements are 
to have fulfilled the SA Health credentialling requirements prior to seeing any patient 
 
Nursing 
All nurses will work within their scope of practice. Scope of practice is that in which 
nurses/midwives are educated, competent to perform and permitted by law. Nurse s 
scope of practice is influenced by the context in which they practice, the health needs of 
people, the level of competence and confidence of the nurse/midwife and the policy 
requirements of the service provider. 
 
Each LHN will be responsible for ensuring that suitably skilled nursing staff who are 
providing clinical care to children and adolescents have the appropriate registration, 
training and supervision. Credentialling of nurse practitioners and where appropriate 
advanced practice nurses will be in line with the Governance Framework for Advanced 
Scope of Practice Roles and Extended Scope of Practice Roles in SA Health Policy 
Directive. 
 
Credentialling for Emergency and Outreach Services 
The Credentialling and Defining the Scope of Clinical Practice for Medical and Dental 
Practitioners Policy Directive states that a Practitioner in an emergency situation, if no 
other Practitioner with suitable credentials is available, is entitled to perform whatever acts 
or procedures are deemed necessary to preserve the health and life of a person 
regardless of the Practitioner s Credentials and Scope of Clinical Practice granted by the 
Credentialling and Scope of Clinical Practice Committee. Emergency care should be 
administered in conjunction with the Medical Board of Australia,  Code of Conduct for 
Doctors in Australia , section 2.5. 
 
Specialist anaesthetists, surgeons and other peri-operative staff required to perform 
outreach services in a situation when a patient is too unstable to be transferred to a higher 
level service, must be credentialled to work within the lower level service and must 
continue to work within their defined scope of clinical practice as per the Credentialling 
and Defining the Scope of Clinical Practice for Medical and Dental Practitioners Policy 














 
 

 

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Directive. All staff must be credentialed to work in the lower level service. Where required, 
temporary credentialling and scope of clinical practice will be granted as per local LHN 
guidelines. 
 
Allied Health Professionals are credentialled to work within their existing scope of practice 
and may provide services in an emergency within their scope of practice. AHP s working 
in a paediatric service should have a scope of practice that includes working with children; 
where they have not provided services for some years clinicians will work within their skill 
set seeking supervision or clinical advice as required. 
 
Any outreaching AHP with extended scope of practice (for the higher level facility) will 
work within their defined extended scope at the lower level facility only if relevant. In the 
context of an outreach service, an AHP at a lower level facility can receive support from 
the on call service of the higher level or employing facility.  
 
Nursing staff may provide services in an emergency within their scope of practice. All 
nursing/midwifery staff will have access to emergency care and resuscitation education 
programs annually completing assessments in adult, child and neonate basic life support 
skills. 
 
Clinical Supervision, Education and Training 
Paediatric services in South Australia will operate on a cooperative basis. Each LHN will 
have the capacity to support education and ongoing professional development programs. 
Each LHN will be responsible for ensuring all clinicians who are providing paediatric care 
are suitably trained with the appropriately level of experience.  
 
The WCHN as the SA Health Level 6 paediatric service can provide mentorship and 
advice when approached, to assist with the provision of training but does not have the 
capacity to provide state wide training for all SA Health clinicians. 
 
5. Implementation and Monitoring 
 
This policy directive will be reviewed by the State-wide Paediatric Surgical Services 
Project Board one year after implementation and three yearly thereafter or as required. 
The Inpatient dashboard currently under development within the Quality, Information and 
Performance (QIP) Hub will support LHNs to monitor implementation and compliance with 
this Policy Directive in real time through the availability of data relating to paediatric 
elective and emergency surgery including patient age, procedure and location of surgery.  
 
6. National Safety and Quality Health Service Standards 

 

 
 

National Standard 
1 
 

Clinical 
Governance 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 

 
 
 

 
 

National 
Standard 3 

 
Preventing &amp; 
Controlling 
Healthcare- 
Associated 
Infection 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Comprehensiv

e Care 
 
 

 
 

National 
Standard 6 

 
Communica

ting for 
Safety 

 
 
 
 

 
 

National 
Standard 7 

 
Blood 

Management 

 
 

National 
Standard 8 

 
Recognising &amp; 
Responding to 

Acute 
Deterioration 

 
 

? ? ? ? ? ? ? ? 



















































 
 

 

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7. Definitions 
 

Paediatric Children and Adolescents  
Aged under 18 years of age at the time of admission 

Neonate An infant in the first 28 days of life 

Infant Aged less than 1 year at the time of admission 

Child Aged 1 year or older and less than 14 years at the time of admission 
Trauma - Aged under 12 years 

Adolescent Aged 14 years or older and less than 18 years at the time of admission 
Trauma - Aged 12 years or older and less than 16 years 

Adult Aged 18 years or older at the time of admission 
Trauma - Aged 16 years and older 

Elective** 
surgery 

Elective surgery is planned surgery that is booked in advance as a result of 
specialist clinical assessment, resulting in placement on an elective surgery waiting 
list 
 

Emergency** 
surgery 

Emergency Surgery is surgery to treat trauma or acute illness subsequent to an 
emergency presentation.  The patient may require immediate surgery or present 
for surgery at a later time following this unplanned presentation. This includes 
when the patient leaves hospital and returns for a subsequent admission, when 
unplanned surgery is required for an already admitted patient or when unplanned 
surgery for a patient already on an elective waiting list due to acute deterioration 
 

Non-specific 
surgery 

Surgery for children and adolescents, aged zero to 18 years at the time of 
admission, that is required to treat or correct any condition, disease, illness, injury, 
trauma or disorder that is not specific to a paediatric condition. Examples of this 
include; acute appendicitis, cholecystitis &amp; torsion of testes. 
 
This can be compared to when an adult with the same condition would also require 
a surgical intervention. 
 
Non-specific surgery can be carried out in a hospital where a safe surgical service 
can be provided by an appropriately trained and credentialled surgical team and a 
child safe environment is available 
 

Paediatric 
surgery 

Surgery for children and adolescents aged zero to 18 years at the time of admission 
that is required to treat or correct any condition specific to childhood including 
congenital conditions, childhood specific diseases, illness or other disorders. 
 
As per the SA Health Clinical Services Capability Framework (CSCF), paediatric 
surgery should be carried out in appropriate level service for the procedure being 
provided and should be undertaken by paediatric surgeons and anaesthetists with 
appropriate experience and/or qualifications in the relevant clinical domain. 
** The definitions used within this Directive differ from the definitions within the ISAAC 
Reference Manual: South Australian Admitted Patient Activity Data Standards document 





 
 

 

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Acronyms 
 

CSCF SA Health s Clinical Service Capability Framework 

ED Emergency Department 

GP General Practitioner 

FMC Flinders Medical Centre 

LHN Local Health Network 

LMH Lyell McEwin Hospital 

PCA Post-conceptional age 

RACS Royal Australasian College of Surgeons 

RAH Royal Adelaide Hospital 

SAAS South Australian Ambulance Service 

SC Surgical Complexity 

SPSSCRG Statewide Paediatric Surgical Service Clinical Reference Group 

WCH Women s and Children s Hospital 

WCHN Women s and Children s Health Network 

AHP Allied Health Professional 

 
  



 
 

 

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8. Associated Policy Directives / Policy Guidelines and Resources 
 
SA Health Paediatric Clinical Practice Guidelines 
South Australian Trauma System Clinical Governance Framework 
SA Health Trauma Model of Care 
South Australian Trauma System paediatric Trauma Team Activation Criteria 
Transition from Paediatric to Adult Healthcare Services Clinical Procedure 
Transfer Process   Urgent Surgery and Surgical Assessment in SA Health Services 
Policy Directive 
Children and Adolescents in Adult Health Services Policy Guideline  
SA Health Clinical Services Capability Framework (CSCF) 
CSCF Module: Emergency Services   Children s 
CSCF Module: Surgical Services   Children s 
Governance Framework for Advanced Scope of Practice Roles and Extended Scope of 
Practice Roles in SA Health Policy Directive. 
Credentialling and Defining the Scope of Clinical Practice for Medical and Dental 
Practitioners Policy Directive  
SA Health Authenticating Allied Health Professionals Credentials and Access 
Appointment Policy Directive 
SA Health Elective Surgery Policy Framework and Associated Procedural Guidelines 
SA Health Consent to Medical Treatment and Healthcare Policy Guideline 
SA Health Policy Directive - Providing assessment and or medical treatment where patient 
consent cannot be obtained 
 
 
 
9. Document Ownership &amp; History 

Approval 
Date Version 

Who approved New /  
Revised Version Reason for Change 

11/10/19  V1.0 Don Frater DCE, System Leadership &amp; Design  Original approved version 

 

Document developed by:  System Design and Planning, System Design and Leadership 
File / Objective No.: eg. 2017/11364  |  A1644826 
Next review due:   31 October 2020  
Policy history: Is this a new Policy Directive (V1)?  Y 
 Does this Policy Directive amend or update an existing Policy 

Directive version?   N 
 If so, which version? 
 Does this Policy Directive replace another Policy Directive with a 

different title?  N 
 If so, which Policy Directive (title)? 
 
ISBN No.:                             978-1-76083-182-0 
 

 
























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