Paediatric Clinical Practice Guidelines Audit Project


To assess compliance with the guidelines and assist local health districts to further improve the care of children in emergency departments.


Empower generalist NSW hospitals, which see the majority of children presenting to an emergency department, with tools and resources to deliver the highest quality care, regardless of location.


Several hundred medical records in each Local Health District (LHD) were reviewed to assess compliance with the guidelines and variation from best practice. In excess of 1,600 medical records across NSW were reviewed as part of the audit. Semi-structured interviews were held across the state with a mix of LHD/Hospital executive, medical officers and nursing representatives from a mix of seniority levels within the LHD and Emergency Department to obtain an idea about what has happened to the guidelines since their introduction and concepts for future directions.

The findings support the paediatric clinical practice guidelines program as a key quality and safety initiative for children’s health in NSW.

While twelve paediatric clinical practice guidelines exist, only seven of the guidelines have an audit tool available to check if recommended practices are being followed. Over the next 12 – 24 months, the CEC will develop the remaining five audit tools so that a full suite of audit tools for the clinical practice guidelines will be available. A process to develop an audit tool to accompany the release of a new guideline has already been implemented.


During 2012/13 the “snapshot“ audit data has been analysed. A report based on the audit results for compliance with seven of the guidelines will form the basis for recommendations to further improve paediatric clinical practice across NSW.


The “snapshot” audit is a partnership between the CEC:

  • NSW Kids and Families
  • NSW Ministry of Health
  • three Child Health Networks 

A key element of implementation of the guidelines is the development of local partnerships with clinicians, particularly the Paediatric Clinical Nurse Consultants, and facilities within the LHDs.

NSW Kids and Families is taking the lead on implementing all actions identified. Partners and timeframes have also been presented. NSW Kids and Families intends to provide a status update every 12 months.

Final report

The final report is currently awaiting final approvals for publication.

Key Dates

Pilot Sites

Implementation Sites


Further Details


Sarah Patterson
Paediatric Safety and Quality Coordinator
02 9269 5553

Dr Sarah Dalton
Clinical Director (CLP,CPI & BTF)
02 9269 5504

Page Top | Added: 6 November 2013 | Last modified: 9 April 2015

Sarah Patterson
Paediatric Safety and Quality Coordinator
02 9269 5553