Chronic Conditions Manual 2nd edition 2020

Prevention and Management of Chronic Conditions in Rural and Remote Australia

CAPE YORK HEALTH COUNCIL ii Copyright [email protected] 4870 PO Box 7193, , Rural and Remote Clinical Support Unit Comments and contributions to this editionare welcome. Please write oremail to: Comments and feedback and Apunipima Cape York Health Council 2020 © State of Queensland (Queensland Health), theRoyal Flying Doctor Service (Queensland Section) ISBN: 978-1-876560-09-6 Australia 2ndedition 2020 Chronic Conditions Manual: Prevention andManagement ofChronic Conditions inRural andRemote Copyright | Chronic Conditions Manual 2nd edition| Copyright email: [email protected], phone (07) 3708 5069 Director-General and System Strategy Division, Queensland Health Senior Policy Officer (Intellectual Health Innovation,Property), Investment and Research Office ofthe For copyright permissions beyond thescope of this licence contact: https://creativecommons.org/licenses/by-nc-sa/4.0/ view acopy of this licence visit: distribute any derivative work only under thesame licence and you comply with thelicence terms. To the Royal Flying Doctor Service (Queensland Section) and Apunipima Cape York Health Council, you non-commercial purposes, as longas you attribute the State of Queensland (Queensland Health) and International licence (CC BY-NC-SA 4.0). You are free to copy, communicate and adapt thework for This document is licensed under aCreative Commons Attribution Non-Commercial Share Alike 4.0 Copying and reproduction https://www.health.qld.gov.au/rrcsu uncontrolled. Users are responsible for accessing themost recent controlled electronic version at: downloaded it is nolongeracontrolled copy. The A5print and any downloaded versions are The electronic version is theonly controlled version of theChronic Conditions Manual and once Controlled and uncontrolled copies and Cape Hospital and Health Service, Cairns in Rural andRemoteAustralia 2nd edition2020. The Rural and Remote Clinical Support Unit, Torres Health Council (2020) Chronic Conditions Manual: Prevention andManagement ofChronic Conditions Queensland Health, Royal Flying Doctor Service (Queensland Section) and Apunipima Cape York Suggested citation contents iii

1 5 7 7 3 3 ii ii 2 9 9 9 vi vi iii xv 31 57 v 16 73 6 7 8 32 58 6 42 38 94 26 8 x viii v 111 11 116 101 154 147 12 1 1 142 148 128 106 x Contents

Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic |

al appearance al king cessation king and nutrition and ance Care Planning Care ance ial-emotional well-being (child) well-being ial-emotional aging our patients aging our rition (child)

th information ant reflexes ant ysical activity ysical xual and reproductive health reproductive and xual vironment lcohol, tobacco and other drugs (child) other drugs and tobacco lcohol, lcohol, tobacco and other drugs (adult) other drugs and tobacco lcohol, lcohol reduction lcohol linical measurements (child) measurements linical A Bir (child) elimination and Continence (child) hearing and Ears (child) vision and Eyes (child) health Oral Soc (child) Skin considerations Special Section 3. Adv Birth history mother’s C milestones Developmental Inf Nut (child) activity Physical Body measurements (child) measurements Body En Gener A Adult health checks health Adult Child health checks health Child Foreword Unit Support Clinical Remote and Rural Acknowledgements Disclaimer manual this use to How acronyms and Abbreviations Section 1. modifications Lifestyle Copyright Eng A Ph Smo Section 2. Diet Se Contents iv contents | Chronic Conditions Manual 2nd edition| Contents E C Management of diagnosed conditions Section 4. Social-emotional well-being (adult) Reproductive health Physical activity (adult) Pathology (adult) Oral health (adult) Nutrition (adult) Functional capacity and safety Family and domestic violence Eyes and vision (adult) Cognition and recall Clinical measurements (adult) Body measurements (adult) Sk Coronary heart disease Palliative care Overweight and obesity (children) Overweight and obesity (adults) Osteoporosis Osteoarthritis Hypertension Hep Heart failure Dyslipidaemia Developmental delay inchildren Depression Dental caries and periodontal disease Dementi Chronic kidney disease Bronchiectasis As As An Poor growth in children P Di Chronic obstructive pulmonary disease Atrial fibrillation ars and hearing (adult) ersistent pain ontinence and elimination (adult) abetes thma (children 1to 12 years) thma (adults and children over 12) in (adults) xiety disorders atitis B a

206 4 380 228 220 448 264 2 20 2 305 39 423 4 168 166 18 347 372 1 32 18 401 2 47 1 219 335 357 2 2 16 44 414 18 15 1 313 1 2 60 96 92 92 78 32 76 72 55 14 41 11 9 9 2 4 3 3 3 5 5 1 contents v

5 13 27 93 20 5 535 5 507 524 536 522 4 48 5 508 Contents

Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic

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x stralian cardiovascular disease risk charts risk disease cardiovascular stralian hild safety reporting safety hild C tool assessment risk 2 diabetes type The Australian HAS-BLED Au CHA2DS2-VASc warfarin of use Safe Index Appendices Rheumatic heart disease heart Rheumatic Stroke and transient ischaemic attack ischaemic transient and Stroke 5. Section Inde vi Foreword and Management ofChronic Conditions inRural andRemoteAustralia 2ndedition 2020 Queensland and Australia by presenting to you theChronic Conditions Manual: Prevention It is our privilege to continue to support therural and remote health workforce of and thescope of theclinician's practice constitute ageneral guideto be followed, subject to thecontext inwhich they are used The guidelines and health checks are not definitive statements orprocedures; rather, they more chronic conditions manage and optimise theirhealth, well-being and quality of life while living with oneor recommendations soclinicians can promote patient health literacy to proactively plan, The tools and guidelines are supported by evidenced lifestyle behaviour to stem thegrowing trend of acquiring preventable conditions throughout aperson's life from theChronic birth, Conditions Manual gives clinicians aplatform for early intervention With tools to check thehealth status of individuals at designated and evidenced intervals journey to ahealthier life conditions inaclear, consistent and evidenced manner is a vital partof thepatient's access to concise nationally accepted management guidelines to address chronic literature and best practice frameworks, with use by clinicians as acore aim.Having This collection of guidelines has beendeveloped using contemporary, evidenced for and manage them documents provide acomprehensive collection of practical guidelines to clinically screen State and national strategies have beendevised to address these trends, but few the fabric of thenation, straining national health infrastructure and valuable resources all health care expenditure, leaving anindelible socioeconomic and personal impact on conditions will account for 80%of our nation’s ill health and represent more than 70% of estimated that if current trends continue over thenext two decades, theburden of chronic and thefiscal and social burden of chronic conditions is widely known andIt reported. is Chronic conditions make thelargest contribution to premature death inwestern societies affect themost vulnerable inour society over timewith littlechance of cure orspontaneous resolution, these conditions often or disability dueto multiple and mostly preventable risk factors. Occurring insidiously Chronic conditions are characterised by prolonged illness causing functional impairment Foreword | Chronic Conditions Manual 2nd edition| Forward Queensland Health Dr John WakefieldDr Director-General Chief Executive Officer ApunipimaCape York Noeleen Mulley Health Council Royal Flying Doctor Service Head Medical Consultant (Queensland Section) Dr Katie Clift Rural and remote clinical support unit vii

Rural and Remote Clinical Support Unit Support Clinical Remote and Rural Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic |

workforce initiatives to address the diverse clinical requirements of rural, remote and regional health health regional and remote rural, of requirements clinical the diverse address to initiatives The RRCSU takes pride in the work invested in, and the standards maintained by, these these by, maintained the standards in, and invested pride in the work takes The RRCSU contemporary and evidenced care within a comprehensive primary health care framework care health primary a comprehensive within care evidenced and contemporary pre-recruitment through to ongoing professional development. It supports staff to provide to provide staff supports It development. ongoing professional to through pre-recruitment with continued education and training. This flexibly-delivered program is applicable from from applicable is program flexibly-delivered This training. and education continued with The freely accessible PARROT program supports clinicians in rural and remote locations locations remote and in rural clinicians supports program PARROT accessible The freely collaborative health framework health collaborative by administering and supplying medications within a within medications supplying and administering by 1996 Regulation Poisons) Health (Drugs and and (Drugs the Health under practice in advanced engage to professionals health Queensland, the PCCM provides the authority for nationally endorsed rural and remote remote and rural endorsed nationally for the authority provides the PCCM Queensland, professionals who may be working in isolation from immediate medical support. In medical immediate from in isolation be working who may professionals supports its use. It provides evidence-based clinical care protocols for health health for protocols care clinical evidence-based provides It use. its supports professionals in jurisdictions across Australia where legislation and accredited training training accredited and legislation where Australia across in jurisdictions professionals professionals practising in rural, remote and regional Queensland, and is used by health health by used is and Queensland, regional and remote rural, in practising professionals The PCCM is the principal acute clinical reference and policy document for health health for document policy and reference clinical acute the principal is The PCCM (PARROT) program (PARROT) Training and and Remote Orientation Rural Access Pathways to the Pathways and (PCCM) Manual Care Clinical the Primary (CCM), Manual Conditions Chronic the Chronic include practitioners regional and remote rural, for tools of suite The linked and Apunipima Cape York Health Council Health York Cape Apunipima and service providers in rural and remote health care, including the Royal Flying Doctor Service Service Doctor Flying the Royal including care, health remote and in rural providers service contemporary reference tools and education platforms in partnership with principal principal with in partnership platforms education and tools reference contemporary support tools for Queensland Health's rural and remote workforce. The unit develops develops unit The workforce. remote and rural Health's Queensland for tools support The Rural and Remote Clinical Support Unit (RRCSU) provides quality evidenced clinical clinical evidenced quality provides (RRCSU) Unit Support Clinical Remote and The Rural Rural and Remote Clinical Support Unit Support Clinical Remote and Rural viii Acknowledgements • • • • • • • • • • • • • • • • Editorial Committee • Editor expert input and contributions. unit would also like to acknowledge thefollowing people and organisations for their Section) for theirsubstantial support inthecontinued development of this manual. The Apunipima Cape York Health Council and theRoyal Flying Doctor Service (Queensland The Rural and Remote Clinical Support Unit would like to particularly acknowledge the Acknowledgements | Chronic Conditions Manual 2nd edition| Acknowledgements • Section 1.specialist content review • • • • Queensland Health Health Service Secretariat/Coordinator, Torres and Cape Hospital and Health Service and Remote Clinical Support Unit, Torres and Cape Hospital and Health Service Health and Apunipima MedicalHealth Services Chair Torres and Cape Hospital and Health Service Judy Jann Dr L Dr Lar C C Healthand Service V Soni Shon Se and Support, Torres and Cape Hospital and Health Service P M Service Jo Janet Dr Dr L Dr Jac Dr A Dr Aar Debor Mareeba Hospital, Cairns and Hinterland Hospital and Health Service Andy Se almay Fisher, Public Health Officer, Communicable Diseases, Torres and Cape Hospital aula Thomason, Health Informatics Officer, Primary Health Care Information Systems laudia Regan-Knights, A/Health Promotion Officer, Health QueenslandSupport harlotte Morrison, Public Health Nutritionist, Preventative Health Branch, ary King,Nurseary Educator, Rural and Remote Orientation and Training (PARROT), Rural sslyn Tully, Manager Health Worker Services, Torres and Cape Hospital and Health an Booth,Nurse Manager Clinical Manuals, Rural and Remote Clinical Support Unit, an Booth,Nurse Manager Clinical Manuals, Rural and Remote Clinical Support Unit, Yvonne Doveren, Senior Medical Officer, Royal Flying Doctor Service, Cairns ea Merone, Public Health Registrar, Chronic Condition Manual research, Queensland ucy Harris, Clinical Psychologist, Centre for Parent and Child LondonSupport, lister Keyser, Medical Policy Queensland Director North Primary Health Network, Nean, Manager, Health and Well-being Preventative Unit, Health Brisbane, Unit, y Goris, Senior Nutritionist/Dietitian, Preventative Health Brisbane, Unit, a Small, Nurse Practitioner Chronic and Primary Care, South West Hospital and Harris, Antimicrobial Stewardship Pharmacist Lotus GlenCorrectional Centre / Struber, Chronic Conditions Manager, Apunipima Cape York Health Council a Lynch, Nurse Practitioner, Apunipima Cape York Health Council ki Mein,Director Medical Services Executive, Corporate Support, Wuchopperen a Bishop, Director Research and Projects, Royal Flying Doctor Service, ACT ah Grant, on Hollins, Senior Lecturer, James Cook University

Nu rse Practitioner Diabetes, West North Hospital and Health Service Acknowledgements ix

Acknowledgements Acknowledgements Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic | Anna Renwick, Senior Social Worker, Weipa Health Service, Torres and Cape Hospital Hospital Cape and Torres Service, Health Weipa Worker, Social Senior Renwick, Anna and Service Health Health Children's for Centre Services, Food and Dietetics Dietitian, Rogany, Ayala Service Health and Hospital Queensland Health Children's Research, Australia of Foundation Continence Manager, Education Robinson, Bronwyn Service, Health Mental Indigenous and Remote Rural Manager Operations Price, Colleen and Hospital Hinterland and Cairns Service, other Drugs and Alcohol Health Mental Service Health Health York Cape Apunipima Nurse/Midwife, Health Child Kneen, Registered Darlene Council Quality Paediatric Queensland Officer, Project Coordinator/Prinicipal Cruice, Diane Brisbane Council, Adjunct Group, Service Wellbeing and Health Paediatrics, of Director White, Dr Andrew University Cook James Dentistry, and Medicine of College Professor Associate Officer, Dental Chief of the Office Services, Health Oral Director Osborne, Dr Peter of School Senior Fellow, Adjunct and Health Queensland Division, Excellence Clinical Queensland of University Dentistry, Centre Sub Network, Development Child Officer Project Principal Christensen, Hannah Brisbane Research, Health Children's for Brisbane Psychiatrist, Chief of the Office Martin, Janet Director, Unit, Brisbane Health Preventative Senior Nutritionist/Dietitian, Goris, Janny Health York Cape Apunipima Nurse/Midwife, Health Child Registered Barrett, Jennifer Council Service, Health Weipa Team, Health Family Consultant, Nurse Clinical Aspinall, Jenny Service Health and Hospital Cape and Torres Dietetics Rehabilitation), and Care (Ambulatory Leader Clinical Dietitian, Bell, Kristie Service Health and Hospital Children's Queensland Services, Food and Health Mental Addiction and Service, Access Addiction and Director, Hipper, Linda Service Health and South Hospital Metro Service, Health Family Health, Sexual and Women’s Men’s, Consultant, Nurse Clinical Hall, Lisa Ailie Perich, Clinical Psychologist Secretariat, Mental Health Alcohol and Other Drugs Other Drugs and Alcohol Health Mental Secretariat, Psychologist Clinical Perich, Ailie of the Office Governance, Clinical Officer, Project Principal Network, Clinical State-wide Psychiatrist Chief Queensland Health Queensland Limited Australia Care Palliative Coordinator, Program Gourlay, Kelly Limited Australia Care Palliative Coordinator, Program Storen, Rebecca and Brisbane Royal Dietetics, and Nutrition Manager Program Barnes, Rhiannon Service Health and North Hospital Metro Hospital, Womens Unit, Health Family Health, Women's and Men's Consultant, Nurse Clinical Ellis, Kristen Service Health and Hospital Cape and Torres Health Family Health, Women's and Men's Worker, Health Advance Pearson, Melora Service Health and Hospital Cape and Torres Unit, and Torres Unit, Health Family Health, Women's and Men's Co-ordinator, Leamy, Joanne Service Health and Hospital Cape • • • • • • • • • • • • • • • • • • • • • • • review content Section 2. specialist x Acknowledgements • • • • • • • • • • • • • • • • • • Section 3.specialist content review • • • • • | Chronic Conditions Manual 2nd edition| Acknowledgements Professor Hugh Taylor, President, theInternational Council of Ophthalmology, Matthew Brown, Director, Deadly Ears Program Service Linda Hipper, Director, Metro South Addiction Service, Metro South Hospital and Health Care Planning, Brisbane Leanne Clemesha, Clinical Nurse Consultant, Advance Care Planning, Office of Advance and Food Services, Queensland Childrens Hospital and Health Service Kristie Bell, Dietitian, Clinical Leader (Ambulatory Care and Rehabilitation), Dietetics Other Drugs Services, Cairns and Hinterland Hospital and Health Service Karen Philp, Cluster Coordinator, Indigenous, Mental Health and Alcohol Tobacco and Palliative Care, Community Health, Metro South Hospital and Health Service Julie Sutherland, Clinical Nurse Consultant, Counsellor, Advance Care Planning, Janny Goris, Senior Nutritionist/Dietitian, Preventative Health Brisbane Unit, Janet Director, Martin, Office of the Chief Psychiatrist, Brisbane Hospital and Health Service Isobel Moase, Program Manager, End of Life Care, Medical Services, Torres and Cape Eliza Charlett, Manager, National Eating Disorders Collaboration, New South Wales University and Preventive Medicine, School of Public Health and Preventive Medicine, Monash Dr Veronica Collins, Project Officer Andrology Australia, Department of Epidemiology Dentistry, Clinical Excellence Division, Queensland health and Adjunct Senior Fellow, School of Dr Peter Osborne, Director Oral Health Services, Office of the Chief Dental Officer, Health Service Mental Health Alcohol and otherDrugs Service, Cairns and Hinterland Hospital and Colleen Price, Operations Manager Rural Remote and Indigenous Mental Health Service, Charlotte Morrison, Public Health Nutritionist, Preventative Health Branch, Brisbane Bronwyn Robinson, Education Manager, Continence Foundation of Australia Healthcare Improvement Unit Allison Lovell, Project Manager, Care at End of Life, Clinical Excellence Queensland, Chief Psychiatrist State-wide Clinical Network, Principal Project Officer, Clinical Governance, Office ofthe Ailie Perich, Clinical Psychologist Secretariat, Mental Health Alcohol and OtherDrugs Dr Tara Douglas, Paediatric Registrar, Apunipima Cape York Health Council Melbourne School of Population and Global Health, University of Melbourne Melbourne Laureate Professor and Harold Mitchell Chair of Indigenous Eye Health, Professor Hugh Taylor, President, theInternational Council of Ophthalmology, Aboriginal and Torres Strait Islander Ear Health Program Matthew Brown, Director, Deadly Ears Program, Queensland Health’s Statewide and Remote Clinical Support Unit, Torres and Cape Hospital and Health Service Mary King,Nurse Educator, Rural and Remote Orientation and Training (PARROT), Rural and Cape Hospital and Health Service Mary Hindmarsh, Registered Nurse, Family Health Team, Weipa Health Service, Torres Unit, Torres and Cape Hospital and Health Service Acknowledgements xi

Acknowledgements Acknowledgements Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic | eston-Thomas, Public Health Medical Officer Sexual Health, Tropical Public Public Tropical Health, Sexual Officer Medical Health Public eston-Thomas, a McLean, Staff Specialist endocrine, Cairns Hospital Cairns endocrine, Specialist Staff a McLean, Health and Hospital Coast Sunshine Care, Palliative Trainee Advanced a Morgan, a Robinson, Education Manager, Continence Foundation of Australia of Foundation Continence Manager, Education a Robinson, hard Baer, Renal and Nephrology Specialist, Mater Medical Centre and Clinical Clinical and Centre Medical Mater Specialist, Nephrology and Renal Baer, hard son Yates, Paediatric Endocrinologist, General Paediatrician, Medical Director Medical Paediatrician, General Endocrinologist, Paediatric Yates, son aurav Puri, Senior Staff Specialist Endocrine and Diabetes, Cairns Hospital , Chair , Hospital Cairns Diabetes, and Endocrine Specialist Staff Senior Puri, aurav eter Osborne, Director Oral Health Services, Office of the Chief Dental Officer, Dental Chief of the Office Services, Health Oral Director Osborne, eter eter Donovan, Director Clinical Pharmacology, Senior Staff Specialist Internal Internal Specialist Staff Senior Pharmacology, Clinical Director Donovan, eter unwarjit Sangla, Director Endocrinology Hospital and Health Service Health and Hospital Townsville Endocrinology Director Sangla, unwarjit eanne Brown, Nephrology Nurse Practitioner, Cape York Kidney Care Program, Torres Torres Program, Care Kidney York Cape Practitioner, Nurse Nephrology Brown, eanne Scott McKenzie, Staff Specialist, Cardiologist, Advanced Heart Failure and Cardiac Cardiac and Failure Heart Advanced Cardiologist, Specialist, Staff McKenzie, Scott ana Mosca, Senior Nurse Advisor, RHDAustralia, Northern Territory Northern RHDAustralia, Advisor, Senior Nurse Mosca, ana ofessor Alison Mudge, Senior Staff Physician, Internal Medicine and Aged Care, Royal Royal Care, Aged and Medicine Internal Physician, Staff Senior Mudge, Alison ofessor lie Perich, Clinical Psychologist Secretariat, Mental Health Alcohol and Other Drugs Other Drugs and Alcohol Health Mental Secretariat, Psychologist Clinical lie Perich, avid Ruzicka, Nurse Practitioner, Palliative Care Service, Sunshine Coast Hospital and and Hospital Coast Sunshine Service, Care Palliative Practitioner, Nurse Ruzicka, avid llison Lovell, Project Manager, Care at End of Life, Clinical Excellence Queensland, Excellence Clinical Life, of End at Care Manager, Project Lovell, llison Health Children's for Centre Services, Food and Dietetics Dietitian, Rogany, yala arla Scuderi, Pharmacist Advanced, Kidney Health Service, Metro North Hospital and and North Hospital Metro Service, Health Kidney Advanced, Pharmacist Scuderi, arla Brisbane Branch, Health Preventative Nutritionist, Health Public Morrison, harlotte ebecca Taylor, Clinical Nurse Consultant, End of Life Care Program Manager, Clinical Clinical Manager, Program Care Life of End Consultant, Nurse Clinical Taylor, ebecca olleen Price, Operations Manager Rural Remote and Indigenous Mental Health Service, Health Mental Indigenous and Remote Rural Manager Operations Price, olleen Dr Dr P of School Senior Fellow, Adjunct and health Queensland Division, Excellence Clinical Queensland of University Dentistry, Dr Ric Network Clinical Renal State-wide the of Chair Dr P Dr K Dr L Service Health and Hospital Cape and Metro Hospital, Women’s and Brisbane Royal Endocrinologist, Care, Aged and Medicine Service Health and North Hospital Statewide Diabetes Clinical Network Clinical Diabetes Statewide Dr Ja Service Health and Hospital Townsville Wellbeing, and Health Dr Annie Pr Service Health and Hospital Hinterland and Cairns Cairns, Services Health Dr G Dr Ann Dr Ann Service Di Pr Service Health and North Hospital Metro Hospital, Women's Brisbane D Service Health Health Service Health C C and Hospital Hinterland and Cairns Service, other Drugs and Alcohol Health Mental Service Health Belind C A Health Unit, Queensland Improvement Healthcare A Service Health and Hospital Queensland Health Children's Research, Ai of the Office Governance, Clinical Officer, Project Principal Network, Clinical State-wide Psychiatrist Chief R Melbourne Laureate Professor and Harold Mitchell Chair of Indigenous Eye Health, Health, Eye Indigenous of Chair Mitchell Harold and Professor Laureate Melbourne Melbourne of University Health, Global and Population of School Melbourne Service Health and North Hospital Metro Implementation, Service Operations • • • • • • • • • • • • • • • • • • • • • • review content specialist Section 4. xii Acknowledgements • • • • • • • • • • • • • • • • • • • • • • • | Chronic Conditions Manual 2nd edition| Acknowledgements Sio Sar Brisbane Sar Sandr Service Program, Royal Brisbane and Womens Hospital, Metro Hospital North and Health Sahr Rhi Improvement Clinical Unit, Excellence Division, Department of Health R and Women’sHospital Pr Townsville Hospital and Health Service M West Hospital and Health Service Li Service Lind Care Planning, Brisbane L K and Food Services, Queensland Childrens Hospital and Health Service Kri Palliative Care, Community Health, Metro Hospital North and Health Service Ju Coast Hospital and Health Service Judith M Healthand Service Research and Education, Royal Brisbane and Womens Hospital, MetroHospital North Jo Jann Janet Iso Health Service (Queensland), Tropical Public Health Services, Cairns and Hinterland Hospital and Erin Ho Moreton Hospital and Health Service Dr Metro Hospital North and Health Service Dr Transplant Unit, The Prince Charles Hospital, Metro Hospital North and Health Service Coast Hospital and Health Services Womens Hospital, MetroHospital North and Health Service Hospital and Health Service eanne Clemesha, Clinical Nurse Consultant, Advance Care Planning, Office of Advance ylie McKenna, A/Manger Rheumatic Heart Disease Program, Queensland achael Olorenshaw, State-wide Renal Clinical Network Coordinator, Healthcare sa Wells, Clinical Nurse Consultant Chronic Disease, Primary Health Care Team, Central atthew Bryant, Director,atthew Bryant, Queensland North Persistent Pain Management Service, hn Haberecht, Director of Learning and Development, Centre for Palliative Care lie Sutherland, Clinical Nurse Consultant, Counsellor Advance Care Planning, ofessor Kesh Baboolal, Executive Director Internal Medicine Services, Royal Brisbane stie Bell, Dietitian, Clinical Leader (Ambulatory Care and Rehabilitation), Dietetics Sree Krishna Venuthurupalli, Consultant Nephrologist, Nephrology Services, West Shaun Pandy, Geriatrician, Internal Medicine Services, The Prince Charles Hospital, bel Moase, Program Manager, End of Life Care, Medical Services, Torres and Cape annon Barnes, Program Manager Nutrition and Dietetics, Royal Brisbane and bhan Brophy, Chief Executive Officer, National Asthma Council Australia, Victoria ah Mathers, Senior Medication Safety Officer, Medication Services Queensland, a Noonan, Technical Advisor, RHDAustralia, Northern Territory a Hipper, Director, Metro South Addiction Service, Metro South Hospital and Health y Goris, Senior Nutritionist/Dietitian, Preventative Health Brisbane Unit, a Ashley, Senior Pharmacist, Queensland State-wide Antimicrobial Stewardship Martin, Director, Martin, Office of the Chief Psychiatrist, Brisbane a Lawrence, Clinical Renal Nurse, Diagnostic and Subspecialty Services, Gold well, A/Manager, Rheumatic Heart Disease Register and Control Program urrells, Respiratory Clinical Nurse Consultant, Chronic Disease Programs, Gold Acknowledgements xiii

Acknowledgements Acknowledgements Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic | Clinical Access and Redesign Unit Redesign and Access Clinical Network Clinical Cardiac Statewide Network Clinical Youth and Child Statewide Queensland Network Clinical Dementia Statewide Network Clinical Diabetes Statewide Network Clinical Medicine General Statewide Network Clinical Renal Statewide Network Clinical Respiratory Statewide Network Clinical Stroke Statewide Network Neonatal and Maternity Statewide Elizabeth Perks, Clinical Pharmacist, Torres and Cape Hospital and Health Service Health and Hospital Cape and Torres Pharmacist, Clinical Perks, Elizabeth Service Health and Hospital Cape and Torres Pharmacist, Outreach Dockray, Janelle Andy Harris, Antimicrobial Stewardship Pharmacist, Lotus Glen Correctional Centre and and Centre Glen Correctional Lotus Pharmacist, Stewardship Antimicrobial Harris, Andy Hospital Mareeba Kathy Cook, Clinical Nurse Consultant, Maternal and Child Health Program, Torres and and Torres Program, Health Child and Maternal Consultant, Nurse Clinical Cook, Kathy Service Health and Hospital Cape Torres Service, Health Weipa Team, Health Family Nurse, Registered Mary Hindmarsh, Service Health and Hospital Cape and and Torres Service, ATODS and Health Mental Weipa Psychologist, , Batianoff Natasha Service Health and Hospital Cape Family Health, Sexual Women’s and Men’s Consultant, Nurse Clinical Harbour, Tracy Service Health and Hospital Cape and Torres Unit, Health Jenny Aspinall, Clinical Nurse Consultant, Family Health Team, Weipa Health Service, Service, Health Weipa Team, Health Family Consultant, Nurse Clinical Aspinall, Jenny Service Health and Hospital Cape and Torres Julie Hall, Social Worker, Child Protection Liaison Officer/Early Intervention Parenting Parenting Intervention Officer/Early Liaison Protection Child Worker, Social Hall, Julie Service Health and Hospital Cape and Torres Unit, Health Family Clinician, Branch, Legislation and Policy Strategic Policy, Strategic A/Manager, McDonald, Sharon Health of Department Division, Planning and Policy Strategy, Unit,Protection Child Cairns Officer, Liaison Protection Worker/Child Social Hale, Tracey Service Health and Hospital Hinterland and Cairns Elizabeth (Libby) Cavanagh, Child Protection Liaison Officer, Maternal and Child Health, Health, Child and Maternal Officer, Liaison Protection Child Cavanagh, (Libby) Elizabeth Service Health and Hospital Cape and Torres Yogi Sagar, Senior Pharmacist, Cairns Hospital, Cairns and Hinterland Hospital and and Hospital Hinterland and Cairns Hospital, Cairns Pharmacist, Senior Sagar, Yogi Service Health Suzanne Russell, Project Officer, Advance Care Planning, Central West Hospital and and Hospital West Central Planning, Care Advance Officer, Project Russell, Suzanne Service Health • • • • • • • • • • and programs: and continued support of all the Project Coordinators and members of the following networks networks the following of members and Coordinators the Project all of support continued The Rural and Remote Clinical Support Unit would like to acknowledge and thank the thank and acknowledge to like would Unit Support Clinical Remote and The Rural • Programs and Networks Clinical Statewide Health Queensland • • • • • review content Pharmaceutical • • • • forms Check Health State-wide • • Section 5. specialist content review content specialist Section 5. • • xiv Acknowledgements • • • • • • • • • • • • • • National bodies and review panels • • • • • • al Health Alcohol and OtherDrugs Branch • • • | Chronic Conditions Manual 2nd edition| Acknowledgements • • • • thanks Special Cape Hospital and Health Service Torres and Cape Hospital and Health Service Central West Hospital and Health Service Queensland, Healthcare Improvement Unit Improvement Unit Hospital and Health Service Healthcare Improvement Unit Network and State-wide Diabetes Clinical Network, Clinical Excellence Queensland, St St St Ment Health Service C T Mic Healthand Service Liz Li K Jamie P Emm Dr Br Service, Children’s Health Queensland Hospital and Health Service, Brisbane C Queensland, Healthcare Improvement Unit Anne C Jame RHD Nation C Nation C Nation Rheu St De O C azz Harding, Administration Officer, Rural and Remote Clinical Unit,Support Torres and ylie Kidby, State-wide Cardiac Clinical Network Coordinator, Clinical Excellence entre for Parent and Child Support (London) ontinence Australia entre for Palliative Care Research and Education harlene Vogler, Cultural Practice Program Coordinator, Torres and Cape Hospital and aitlyn Fletcher, Senior Pharmacist Immunisation, Queensland Specialist Immunisation ffice of the Chief Dental Officer sa Wells, Clinical Nurse Consultant, Chronic Disease, Primary Health Care Team, atewide Rural and Remote Clinical Network atewide Older Person’s Health Clinical Network atewide Child Protection Clinical Partnership atewide Persistent Pain Management Clinical Network adly Ears Program Wheatley, Diabetes Nurse Educator, Cooktown Hospital, Torres and Cape Hospital helle Guilliatt, Business Support Officer, Rural and Remote Clinical Unit, Support Australia ent Knack, Principal Project Officer, State-wide Maternity and Neonatal Clinical a Broe, Graphic Design, Rural and Remote Clinical Support Unit, Torres and Cape s Cook University matic Heart Disease (RHD)Program Queensland al Eating Disorder Collaboration al Heart Foundation al Asthma Council ameron, State-wide Renal Clinical Network Coordinator, Clinical Excellence age, Principal Project officer, Clinical Excellence Queensland, Healthcare Disclaimer xv luding essary essary eference elevant elevant an r Disclaimer of or in r s l (inc nec a ing Doctor ing Doctor al s a Fly onstitute clinical clinical onstitute sing out sing ari to verifyto or negligence) for any any for or negligence) not c f alth Council alth Council The information is is The information He . Health, the Royal the Royal Health, Flying ice in relation to the the to in relation ice alth, the Royal alth, the Royal o use the information or the information o use Service (Queensland Section) (Queensland Service o this publication by by publication o this t e advised e advised He or int alth Council alth Council ar adv He York ape York judgment land land eaders eaders ing Doct ublication must be sought must ublication r p Fly The information does does The information York ape York Queens unipima C unipima Specialist h. Specialist y e responsible for making their own their own making for e responsible b opriate uc Ap ar ein and s Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic ation. | eplace clinical clinical eplace her appr orm distributed by Queensland by Queensland distributed not r eaders eaders pon as pon as r s alth,the Royal alth,the Royal u at He esented esented linically linically and inf se of or reliance on or inability on or inability or reliance se of th doe c u alth Council be liable (including liability liability (including be liable alth Council pr land land He and Manual is Manual s be relied not be relied Queens York ape York ovided in this publication, or incorporated or incorporated publication, in this ovided hall hall ation, direct, indirect, punitive, special or consequential) what so ever so ever what or consequential) special punitive, ation, direct, indirect, hould hould the matters of the matters pr Condition lely on the basis on the basis lely s s ainst or made upon or incurred or incurred upon made or ainst so ag limit

Service (Queensland Section) and and Section) (Queensland or Service

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Chronic The Chronic Disclaimer xvi How to use this manual The contents of theChronic Conditions Manual is broken into five(5) sections How to use this manual | Chronic Conditions Manual 2nd edition| How to use this manual condition 2. Diagnosis–briefly outlines elements taken into consideration when diagnosing the 1. Whatis –provides a brief background and explanation of thecondition bearing ageif appropriate, and theneed for urgent referral The introductory box–highlights highrisk groups, consideration for women of child- following: chronic conditions inAustralia. These guides follow thesame format and include the condition inacommunity setting.It provides 26separate guides for themost common This sectionis intended for all clinicians whowork directly with patients with achronic Management of diagnosed conditions Section 4. conditions recommendations for routine checks of people over 15 years of chronic ageto identify As pertheChild health check sectionexcept this sectionprovides best-practice Adult health check Section 3. manual Lifestyle modification and Management of diagnosed conditions sections of the Health check sections focus onhealth promotion and are complemented by boththe identified questioning and clinical procedures, and recommends referral if concerns are It provides asystematic guidefor health performing check assessments via direct 15 years of chronic ageto identify conditions T Child health check Section 2. lifestyle behaviours This • • • • • • clinical practice. These are: This Lifestyle modifications Section 1. sectionprovideshis best-practice recommendations for routine checks fromto birth Smoking cessation Sexual and reproductive health Physical activity Diet and nutrition Alcohol reduction Engaging our patients information can becopied and disseminated to patients to support healthy sectioncontains best-practice healthy lifestyle information that aims to support How to use this manual xvii

How to use this manual this use to How Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic | The Health Check Forms Check The Health comprehensive developed has Unit Support Clinical Remote and The Rural align with that forms check health Adult and Child compliant Medicare standardised items check health Medicare claiming for the requirements at: https://www.health.qld.gov. use and download for available freely are forms These au/rrcsu Appendices and assessment risk condition chronic support to tools of a range section contains This making decision or order Online –details the specific elements required to successfully manage the the manage successfully to required elements specific the –details 3. Management care of continuity and engagement patient around strategies including condition considered modalities treatment various on options – provides 4. Medications approved PBS and LAM suggested of a list including condition, the for appropriate medications monitor to clinician the for pathway care a structured –provides care of 5. Cycle management ongoing and follow-up with assist and progress information the relevant listing section reference own its guide has –each 6. References sources to provide resources on-line date to up of examples clinician the –offers Resources 7. is The clinician patients. educating and managing with assist to further information required as resources local additional seek also to encouraged Section 5. xviii abbreviations and acronyms Abbreviations and acronyms | Chronic Conditions Manual 2nd edition| Abbreviations and acronyms CQI CPSP CPAP COPD CNC cm cm cm CKD CHN CHB CHADS₂ CDC CBT CAT CAM CALD BSA BRCA2 BRCA1 BP BMI BMD BGL BBV BAC ASQ APSGN ATODs ARF AODs ALT Alc AFP AF ADLs ACR 3 2 improvement Continuous quality Central post stroke pain pressure Continuous positive airway disease Chronic obstructive pulmonary Clinical nurse consultant centimetre cubed (volume) centimetre squared (area) centimetre Chronic kidney disease Child health nurse Chronic hepatitis B fibrillation stroke risk Questions that assess atrial Centre for Disease Control Cognitive behaviour therapy disease assessment test Chronic obstructive pulmonary Confusion Assessment Method diverse Culturally and linguistically Body surface area onset Genes for breast cancer, early Blood pressure Body mass index Bone mineral density Blood glucose level Bloodborne viruses Blood alcohol concentration Ages and Stages Questionnaire glomerular nephritis Acute post-streptococcal drugs Alcohol, tobacco and other Acute rheumatic fever Alcohol and otherdrugs Analine aminotransferase Alcohol Alpha fetoprotein Atrial fibrillation Activities of daily living Albumin-creatinine ratio GPCOG g GDS GDM GAD FOBT FiT FIFO FCU FAQ FASD ESR EPDS eGFR ED ECV ECG EC Dx DVT DV DPI DM Dietitian DBP dB daPa CVD CVA CT CSOM CSDD CS CR CrCl assessment of cognition General practitioner gram GeriatricDepression Scale Gestational diabetes mellitus General anxiety disorder Faecal occult blood test Faecal immunochemical test Fly infly out First catch urine Questionnaire Functional Activities Fetal alcohol spectrum disorder sedimentationErythrocyte rate Depression Scale Postnatal Edinburgh (estimated) Glomerular filtration rate Erectile dysfunction canalEar volume Electrocardiogram/graph Editorial Committee (during orat diagnosis) Diagnosis Deep veinthrombosis Domestic violence powderDry inhaler Diabetes mellitus Accredited practicing dietitian pressure blood Diastolic Decibel pressure Dekapascal–a measure of Cardiovascular disease Cerebrovascular accident scan Computerised tomography media Chronic suppurative otitis Dementia Cornell Scale for Depression in Caesarian section Controlled release Creatinine clearance abbreviations and acronyms xix

Abbreviations and acronyms and Abbreviations Item numbers that refers to a to refers that numbers Item can revenue which for service be claimed milligram microgram millilitre millimetre millimole Examination State Mini Mental Officer Medical (medicines) release Modified imaging resonance Magnetic men with sex Men who have Medical And Health National Council Research Nanomole Practitioner Nurse delivery vaginal Normal parasites and cysts Ova, glucocorticosteroids Oral test tolerance glucose Oral media Otitis apnoea sleep Obstructive a parent, The biological or provider, carer, primary a child of caregiver Pathways to Access Rural and and Orientation Remote Training Benefits Pharmaceutical Scheme Manual Care Clinical Primary reaction chain Polymerase embolism Pulmonary of Evaluation Parent Status Developmental care health Primary booklet record health Personal book) (baby disease inflammatory Pelvic required As dose metered Pressurised inhaler Post traumatic stress disorder Health Queensland Electronic Health Queensland Service Publishing Medicare Medicare item mg microg mL mm mmol MMSE MO MR MRI MSM NHMRC nmol NP NVD OCP OCS OGTT OM OSA Parent PARROT PBS PCCM PCR PE PEDS PHC PHR PID prn pMDI PTSD QH QHEPS Chronic Conditions Manual 2nd edition | 2nd Manual Conditions Chronic | Question that assess risk of of risk assess that Question with bleeding major atrial in anticoagulation fibrillation Haemoglobin B virus Hepatits carcinoma hepatocellular lipoproteins High-density cholesterol preserved with failure Heart fraction ejection reduced with failure Heart fraction ejection virus immunodeficiency Human papillomavirus Human Hypertension Worker Health history, (MHx–Medical History PMHx–Past history, PHx–Past history) medical Hertz daily of activities Instrumental living corticosteroids Inhaled tolerance glucose Impaired glucose fasting Impaired Intra-muscular psychotherapy Interpersonal units International Kilogram Indigenous Kimberley Assessment Cognitive Litre acting ß₂ agonist Long Medicines Approved of List Health in Queensland (used facilities) lipids density Low receptor Leukotriene antagonist ventricle–ventricular Left and Alcohol Health, Mental other Drugs Scheme Subsidy Aid Medical inhaler dose Metered (heart infarction Myocardial attack) Schedule Medicare Benefits HAS-BLED Hx LAM Hb HBV HCC HDL-C HFPEF HFREF HIV HPV HTN HW Hz IADLs ICS IGT IFG IM IPT IU kg KICA L LABA LDL LTRA LV MHAODs MASS MDI MI MBS xx abbreviations and acronyms | Chronic Conditions Manual 2nd edition| Abbreviations and acronyms +ve -ve = / ≤ ≥ < > WHO Vol VA UTI ULN UEC TIA TG TC SUDI SNHL SIDS STI SOB SBP SABA RUDAS ROM RN RhF RHD RFDS Positive Negative Equals, equal to Per Less than orequal to Greater than orequal to than Less Greater than World Health Organization Volume Visual acuity Urinary tract infection Upper limit of normal Urea, electrolytes, creatinine Transient ischaemic attack Triglyceride Total cholesterol infancy Sudden unexpected death in loss neurologicalSensory hearing Sudden infant death syndrome Sexually transmitted infection Shortness of breath Systolic pressure blood actingß₂agonistShort Assessment Scale Rowland Universal Dementia Range of motion Registered Nurse Rheumatoid factor Rheumatic heart disease Royal Flying Doctor Service