Controlled Document
Doc-ID: HEALTHINTRA-1703-154
Areas applicable: Registered nurses, Registered Midwives, Enrolled Nurses (Medication qualification), Medical officers, Pharmacists and Managers in NT Public Hospitals
Policy Statement
The development, approval and use of all Scheduled Substance Treatment Protocols (SSTP) in Northern
Territory public hospitals will follow a standardised process.
Policy Purpose
To ensure all SSTP(s) in use across the network are developed in accordance with the Northern Territory
Poisons and Dangerous Drugs Act (PADDA) using a sound governance process.
Definitions
Scheduled Substance Treatment Protocols (SSTP) - Section 90 of the Northern Territory PADDA outlines that the Chief Health Officer (CHO) may approve an SSTP, commonly known as a “standing order”, for use in any place approved in writing by the CHO. This includes a hospital, a ward or department.
SSTPs authorise registered nurses and/or medication enrolled nurses to administer or supply medication in specified situations without a prior patient-specific prescription. A health practitioner following a Scheduled
Substance Treatment Protocol cannot vary from its conditions. If the circumstances do not match the criteria specified in the Protocol, then a patient-specific prescription is required in order to administer medication.
SSTPs may be suitable for the following:

Schedule 3, schedule 4, restricted schedule 4 or schedule 8 medications

Unscheduled and schedule 2 medications administered via intravenous route or considered to have a higher medication safety risk
Further information regarding nurse initiated (unscheduled or schedule 2) medications is being drafted and will be published on the document control system when available.
Responsibilities
Nursing:

Ensure participating staff complete the specified accreditation requirements as outlined in the respective SSTP(s) before administering medication(s).

Nurses must ensure that they have appropriate knowledge and skills prior to using an SSTP.
Medical:

The Unit Head (Medical Officer) is accountable for the development and overview of SSTPs being used in their area.

The Unit Head must ensure that appropriate consideration is given to the impact of the SSTP on safety and quality issues.

Ensure appropriate consultation has occurred and is detailed on a Document Consultation Record located on the document control system

The Unit Head must submit the NT Drug and Therapeutics Committee (NTD&TC) approved SSTP to the Branch Head who will then forward to the CHO for final approval using the template provided.
Title: PGC Template to Create Clinical Procedures & Guidelines
TRIM: | Version: 7.0 | Approved Date:21/12/2012 | Last Update: 19/02/2013 | Review Date: 21/12/2014
Page 1 of 3
Printed: 17/04/2020 11:36:00 AM - Printed copies are for reference only.
For the latest version, refer to the Policy Guideline Centre on the Department’s Intranet.
Department of Health is a Smoke Free Workplace

DEPARTMENT OF HEALTH
Controlled Document
Doc – ID: HEALTHINTRA-1703-154

Where appropriate, medical officers must perform the review of patients in a timely manner following administration of a medication via an SSTP.
Unit Managers:

Ensure appropriate evaluation and monitoring occurs on an annual basis.

Ward/Unit based SSTP registers which enable the recording of all approved SSTP(s)

Ward/Unit level registers of Registered Nurses (RNs) who have been assessed and accredited
(where required) for the administration of a particular SSTP
Policies, Procedures and Guidelines Coordinator:

Assist the NTDTC in the coordination of SSTPs,

Requesting the Document Control System Administrator to place SSTP on the document control system once ratified.

Communicate new or revised network SSSTPs to nominated Hospital Policy and Procedure Officers, who are then responsible for communicating them to relevant hospital staff.
NTDTC:

Ensure that all SSTPs which are submitted to the CHO incorporate necessary education and accreditation requirements associated with the administration of the SSTP.
Policy content and Implementation
The development, approval and use of all SSTP(s) in Northern Territory public hospitals will follow the standardised process outlined in appendix 1.
Key Aligned Documents
SSTP template
CHO submission template.
Key Legislation, Acts and Standards
NT Poisons and Dangerous Drugs Act – Section 90
NT Poisons and Dangerous Drugs Regulations
Evaluation / Accountability for Monitoring and Review
Unit Managers, or their delegate, will

undertake an annual audit to ensure: o SSTP(s) have been used appropriately o 100% of SSTP(s) have the approval of the Unit Head (Medical Officer). Unit registers, of staff accredited to undertake SSTP, are accurate and up to date o Accredited staff have participated in agreed assessment and reviews as identified against each SSTP.

Co-ordinate review and resubmission of SSTP(s) prior to scheduled review date.
All SSTP(s) must be reviewed 3 years from original approval.
Author / Contributors
Name Position Service/Program
Bhavini Patel
Sharna Glover
Joanna Keily
Director of Pharmacy
Senior Clinical Pharmacist
Acting Director of Pharmacy
Pharmacy, RDH
Pharmacy, RDH
Pharmacy, RDH
Didier Palmer Director of Emergency Medicine Emergency Department, RDH
Alternative Search Words
Disclaimer for reformatting – format has been changed to accommodate technical requirements. Content has not been altered .
Title: PGC Template to Create Clinical Procedures & Guidelines
TRIM: | Version: 7.0 | Approved Date:21/12/2012 | Last Update: 19/02/2013 | Review Date: 21/12/2014
Page 2 of 3
Printed: 17/04/2020 11:36:00 AM - Printed copies are for reference only.
For the latest version, refer to the Policy Guideline Centre on the Department’s Intranet.
Department of Health is a Smoke Free Workplace

DEPARTMENT OF HEALTH
Controlled Document
Doc – ID: HEALTHINTRA-1703-154
Appendix 1: Policy content and Implementation process
1. Clinical unit identifies medicines that are suitable for administration under an SSTP and gains approval from Unit
Head (Medical Officer)
2. SSTP developed in consultation with relevant staff (e.g. nurse educators, medical specialists, pharmacists) using a standardised template . Give consideration to NT-wide applicability.
3. Annual assessment and accreditation process requirements assessed. If yes, identify learning needs and develop accreditation process.
4. Circulate draft SSTP to appropriate hospital based nursing and midwifery committees for their review
5. Consider feedback and update draft as appropriate
6. Unit Head(s) to co-jointly consider impact of the recommended
SSTP with Director of Medical Services/Divisional Co-Directors.
3a. Liaise with
NTDTC Secretary
7. Final draft of SSTP submitted to the Northern Territory Drugs and
Therapeutics Committee for endorsement
Endorsed
8. Unit Head forwards the approved SSTP to Branch
Head for submission to the CHO for approval as per under section 90 of the NT Poisons and Dangerous
Drugs Act (PADDA) using approved template
Approved
7a. NTDTC will liaise with
Poisons Control
9. Inform eMMa team of CHO approval and
Upload on the document control system
Title: PGC Template to Create Clinical Procedures & Guidelines
TRIM: | Version: 7.0 | Approved Date:21/12/2012 | Last Update: 19/02/2013 | Review Date: 21/12/2014
Page 3 of 3
Printed: 17/04/2020 11:36:00 AM - Printed copies are for reference only.
For the latest version, refer to the Policy Guideline Centre on the Department’s Intranet.
Department of Health is a Smoke Free Workplace