cclhd policies, procedures, guidelines...pr2010_281 cytotoxic medications via an ommaya reservoir -...

Central Coast Local Health District – Policies, Procedures, Guidelines as at 10/08/18 1

Central Coast Local Health District Policies, Procedures, Guidelines Current Listing as at 10 August 2018 – Copies available upon request

GE2011_034 Abbreviations, Acronyms and Symbols - Commonly Used and Accepted at CCLHD

PR2016_005 Abciximab (Reopro) Intravenous management and/or administration of for cardiology patients

PR2010_040 Aboriginal Mental Health Consultation Liaison Team

PR2013_015 Absconding / Missing Patient - Unauthorised Leave

PR2010_063 Activated Clotting Time (ACT) Reading Using Hemochron 401

PR2011_046 Acute Care Team (ACT) Referral and Discharge/Transfer - Mental Health

PR2013_020 Acute Renal Failure from Multiple Myeloma Cast Nephropathy using extended hours dialysis and Theralite Membrane - treatment of

PR2017_103 Acute Stroke Units - Standards for Nursing Staff Working Within Acute Stroke Units (ASU) at Gosford and Wyong - CCLHD

PR2017_102 Acute Stroke Units - Standards for Registered Nurses Working In-charge of Gosford and Wyong Wards that incorporate the Acute Stroke Units (ASU) at CCLHD

PR2012_041 Adhesive Skin Traction and Thomas Splint (straight leg fixed skin traction) - application of - CCLHD

GE2011_039 Admission Criteria / Guidelines Wyong Rehabilitation Ward - CCLHD

GE2012_005 Admission Guidelines Continuing Care Unit Long Jetty

GE2012_004 Admission Guidelines Transitional Care Unit Long Jetty

GE2012_008 Admission Guidelines Transitional Care Unit Woy Woy

GE2012_007 Admission Guidelines Woy Woy General

GE2014_010 Admission Non-medical of Children - CCLHD

PR2018_016 Admissions from the Emergency Department - Gosford and Wyong - INTERIM

PR2015_020 Advance Care Directives and Advance Care Plans: use of pre-existing documents during hospital presentations

PR2013_018 Ages & Stages - 3rd Ed (ASQ-3) Questionnaire and Ages & Stages Social Emotional - 2 Ed (ASQ:SE-2) Questionnaire - administration of

PR2009_294 Alcohol Based Skin Preparations - safe use in operating suites

GE2017_001 Alcohol Withdrawal in Inpatient Settings

PR2017_058 Amiodarone - Intravenous Administration in Adults

PR2013_032 Anaesthetic Nurse Management of a Patient receiving Local Anaesthesia for a Surgical Procedure Performed in the Operating Theatres, in the Absence of an Anaesthetist

PR2009_070 Anal Digital Stimulation for Adults

GE2016_009 Anaphylaxis and Hypersensitivity Management in Adults - Satellite Haemodialysis (Long Jetty, Lakehaven and Gosford Satellite) Renal Services

PR2014_007 Animal Assisted Activity in CCLHD

PR2011_030 Anticoagulant Free Intermittent Haemodialysis using the Fresenius 5008S Machine - CCLHN

PR2017_008 Antihypertensive Treatment Post-Stroke (Adult)

PR2015_003 Antimicrobial Stewardship - CCLHD

PR2012_049 APAC (Acute Post-Acute Care) - Referral, Admission and Transfer of Care

GE2016_010 APAC Respiratory Service - referral to

PR2015_030 APINCH Medication Management in the Community Setting

PR2007_008 APO-goII Portable Infusion Pump for Delivery of Apormorphine to Patients with Parkinson's Disease

PR2012_008 Approval of Communication Media in Mental Health Facilities

PR2011_019 Area Financial Services Debtors Bad Debt Write Off - CCLHN

PR2009_080 Arterial Catheter Insertion - Management and Removal

PR2010_141 Arterio-Venous (AV) Fistula and/or Graft including pre/post operative care & management - CCH

PR2007_031 Arteriovenous Fistula and Arteriovenous Graft Cannulation

PR2014_042 Aseptic Technique

PR2014_003 Aseptic Technique - Surgical Hand Antisepsis, (Scrubbing) Gowning and Gloving

PR2016_062 Aspirin Suppositories by per rectum (PR) administration following acute ischaemic stroke in CCLHD Acute Care Hospitals

PR2010_156 Assessment and Treatment of Persons Identified as Extreme and/or High Risk of Harm to Others - MH

PR2011_036 Atrium Express Mini Dry Seal Chest Drain - Inpatient & Community Management for the Adult patient

PR2009_143 Autologous Blood Transfusion (ABT) Bellovac Drain Management

PR2011_084 Automated Peritoneal Dialysis (APD) using the 'Baxter-HomeChoice System' - for in-patients at Gosford Hospital

PR2018_005 Automatic Contrast Injector in Coronary Angiography - Nursing Roles

PR2009_194 Axiom Sump Drain Management - CCLHD

PR2016_061 Bariatric Patient - Management of Work Health & Safety (WHS) Issues



PR2010_306 Basic Life Support Training - Care of Equipment used for

PR2014_050 Bathing Demonstration and Cord Care

GE2015_001 Beach chair position for surgery - patient management

PR2014_012 Bedrails - Use of for Adult Inpatients

PR2009_352 Bellovac and Exudrain Management and Removal - CCLHD

PR2011_050 Bladder Irrigation (Continuous)

PR2009_230 Bladder irrigation (Manual)

PR2009_197 Bladder Scanning (non-real time) - Adult

PR2012_004 Bleach Baths in the Management of Staphylococcus Aureus Infection of Atopic Dermatitis (ECZEMA)

PR2009_074 Blood - Managing Adverse Events Related to Transfusion

PR2013_024 Blood - Massive Transfusion Protocol

PO2013_002 Blood - Patient Blood Management

PR2010_091 Blood Glucose and Blood Ketone Monitoring with Abbott Optium Exceed Meter

PR2009_077 Blood Products - administration of

PO2006_011 Blood Specimen - Safe Collection

PO2009_004 Blood Storage Refrigeration

Pr2009_078 Blood: Intravenous Immunoglobulins - administration of

PR2010_069 Booking Patients for Non Elective Surgery in Operating Suites

GE2009_045 Bowel Management for the Patient in ICU/HDU

GE2011_041 Breast Cancer Post Surgery - Patient's Clinical Guideline - APAC

PR2014_049 Breast Milk - Management, Storage, Transportation and Dispensing of Expressed Breast Milk (EBM)

PR2010_264 Breast Seroma - Drainage of - APAC

PR2014_057 Breast Supplementer for Breastfeeding Babies Needing Additional Milk

PR2014_009 Breastfeeding in the Workplace - Promoting, Protecting and Supporting

PR2009_101 Bronchoscopy Procedure in ICU - Central Coast LHD

PR2009_007 Bronschoscopy - Pre and Post Care of the Adult Patient

PR2012_039 Bucks Traction Application and Care - CCLHD

PO2016_001 Business Continuity Management - CCLHD Policy

PR2012_040 Byant's (Gallows) Traction (Bilateral Vertical Lower Lim Traction) - Application and care of - Paediatrics

PR2013_052 CADD-Legacy Infusion Pump for the Delivery of Enteral Duodopa to Patients with Parkinson's Disease

PR2009_146 Caesarean Sections - Skin to Skin Contact & Breastfeeding in Gosford Operating Theatres

PR2009_145 Caesarean Sections: Numerical Coding Criteria for Non Elective

GE2009_099 Calcium Gluconate (IV) Administration and Monitoring

GE2017_002 Cannabis Withdrawal in Inpatient Settings

PR2008_002 Cardiac Angiography and Percutaneous Coronary Intervention (PCI) - Patient Preparation

PR2009_342 Cardiac Angiography or Percutaneous Coronary Intervention - Clinical Management - CCH

PR2008_072 Cardiac Angiography or Percutaneous Coronary Intervention - Femoral Sheath Removal (including Vascular Closure Device care)

PR2015_016 Cardiac Escort and Transfer

PR2009_046 Cardiac Monitoring - Telemetry and hardwire Cardiac Monitoring

PR2009_401 Cardiac Pacing - External

PR2016_051 Cardiology Bed Management

PR2009_038 Cardioversion Elective

PR2010_057 Care Coordination Team (CCT) Referral and Assessment

PR2010_056 Care Coordination Team Discharge/Transfer of Care

PO2010_006 Cash Handling Police & Procedures Manual (incl Petty Cash) Area Financial Services - NSCCAHS

PR2015_007 Casual Nursing Pool - Transfer of Permanent Nursing Staff to the CCLHD Casual Nursing Pool

PR2015_035 Catheter Maintenance Irrigation (Community)

PR2013_023 Catheterisation - Indwelling Urinary - Community Based

PR2009_195 Catheterisation - Indwelling Urinary - Hospital Based (Adult)

PR2013_034 Catheterisation - Intermittent (In-Out) Urinary Catheterisation Hospital Based - Adult

PR2010_165 Central Venous Access Device (CVAD) Management for Tunnelled and Non-Tunnelled Lines for Haemodialysis including Needleless Access Device (TEGOs)

PR2008_011 Central Venous Access Devices (CVAD) - Paediatric



PR2009_161 Central Venous Catheters (VCV) - insertion, Monitoring, Management and Removal in Adult Patients

PR2017_100 Cervical Collars - Management of Long Term Cervical Collars in Adults in CLCHD In-patient Areas

PR2014_004 Cervical Collars - Short Term Immobilisation - application of

PR2014_005 Cervical Collars for Long Term Immobilisation - initial application of Philadelphia Collar

PR2017_084 Cervical Collars for Long Term Immobilisation - initial application and fitting of Miami J Collar

PR2013_040 CHARM Cytotoxic Ordering - INTERIM

PR2009_246 Chemical Pleurodesis - Assisting the Medical Officer to perform

PR2015_029 Chest Pain - management of

PR2010_083 Chickenpox (Varicella) - Infection Prevention and Control Management of the Patient in Acute Care Settings

GE2013_002 Children's Ward, Gosford Hospital - admission to

PR2011_062 Chloral Hydrate (Paediatric) as a Paediatric Sedation for EEG - use

PR2009_407 Cleaning Infectious Areas - Environmental Services

PR2012_043 Clinical Aggression Response - Hospital Patients (Gosford and Wyong Hospitals)

GE2013_001 Clinical Aggression Response Teams - Adult Sedation Guidelines

PR2014_043 Clinical Equipment and Medical Device Management

PO2013_004 Clinical Handover

PO2017_001 Clinical Handover - Medical Officer - CCLHD

GE2017_006 Clinical Handover - Medical Officer - Leader Guide

PR2017_031 Clinical Handover - Medical Officers - Nightly (2200) - Gosford and Wyong Hospitals

PR2017_030 Clinical Handover - Medical Officers - Weekday Afternoons (1600) - Wyong Hospital

PR2017_029 Clinical Handover - Medical Officers - Weekday Mornings (0800) - Gosford and Wyong Hospitals

PR2017_032 Clinical Handover - Medical Officers - Weekend Mornings (0800) - Gosford and Wyong Hospitals

PR2011_042 Clinical Products: Clinical Product or Equipment Evaluation

PR2011_041 Clinical Products: Clinical Product Quality Issues - management of

GE2010_026 Closed Femoral Shaft Fractures in Children - Management of Isolated

PR2010_265 Clostridium Difficile - Infection Prevention and Control Management in 'In-patient' Settings

GE2009_046 Communicable Diseases / Transmissible Micro-Organisms - A Reference Guide

PR2010_301 Community Specialist Mental Health Services for Older People (SMHSOP) Service Criteria

PR2009_052 Community Treatment Orders - Mental Health

PR2013_006 Company Representatives - Conditions of Entry into Clinical Areas

PR2009_192 Compression - Graduated Compression Stockings (GCS) and Trhomboembolitic Deterrent Stocking (TEDS) Application

PR2009_148 Compression Devices - use for the prevention of Venous Thrombi Embolism (VTE)

GE2016_004 Compression Therapy for Venous and Mixed Aetiology Leg Ulcers

PR2017_081 Compression Wraps - Application of Circaid Juxtalite Compression Wraps for Treatment of Mixed and Venous Leg Ulcers - Inpatient and Community

PO2007_048 Computer Use Email, Internet, Intranet - CCLHD

PR2007_032 Connection of a Patient to Fresenius 4008S/H Haemodialysis Machine - CCH

GE2009_034 Constipation Management (uncomplicated) in Adults

PR2014_059 Consumer and Community Representatives Reimbursement

PR2011_010 Consumer Use of Mobile Telephones within Mental Health Inpatient Units

PR2009_356 Consumer/Patient Flow and Bed Management - Mental Health

PR2017_025 Contingent Worker Procedure

PR2009_068 Continuous Ambulatory Peitoneal Dialysis (CAPD) - initiation of first

PR2008_025 Continuous Ambulatory Peritoneal Dialysis (CAPD) - management for Baxter and Fresenius Systems

PR2010_126 Continuous Subcutaneous Infusion Using a NIKI T34 Syringe Driver in CCLHD

GE2009_043 Contrast-Induced Nephropathy (CIN) Prevention of

PR2018_009 Coronary Angiogram / Left Heart Catheterisation - Circulating (Scout) Nurse Role

PR2015_034 Coronary Angiogram / Left Heart Catheterisation - Haemodynamic Monitoring Nurse Role using the Siemens Sensis Haemodynamic System

PR2009_032 Coronary Angiogram Left Heart Catheterisation - Instrument Nurse Role

PR2011_027 Coronary Angiography/Percutaneous Coronary Intervention (PCI) - Day Only/Return to Wyong Hospital

PR2009_093 Correct patient, Correct Procedure and Correct Site

PO2011_001 Credentialing and Defining Scope of Practice - CCLHD

PR2010_002 CYPMH - Management of Adolescents Admitted to Mental Health Inpatient Units



PR2010_003 CYPMH - Referral Criteria for Youth Mental Health (YMH)

PR2010_009 CYPMH - Young People Early Psychosis Intervention Service (YPPI) Referral Criteria

GE2011_052 Cytotoxic Drugs and Related Waste Management - CCLHD

PR2011_053 Cytotoxic Medication (Oral) - administration of

PR2010_285 Cytotoxic Medication Extravasation - Management of

PR2010_279 Cytotoxic Medications Intrathecal via Lumbar Puncture - administration of

PR2010_280 Cytotoxic Medications Intravenous via Infusion or Bolus - Administration of - Adult/Adolescent

PR2010_286 Cytotoxic Medications Subcutaneous or Intramuscular - Administration of - Adult/Adolescent

PR2010_284 Cytotoxic Medications via an Ambulatory Infusion Pump - CADD Legacy 1 - Administration of - Adult/Adolescent

PR2010_281 Cytotoxic Medications via an Ommaya Reservoir - administration of

PR2010_283 Cytotoxic Medications via Bladder Instillation within Cancer Services - Administration of - Adult/Adolescent

PR2010_282 Cytotoxic Spill - management of

PR2018_018 Day Only Surgical / Endoscopy Procedure Patients - Medical Team Escalation for Unexpected Post Procedure Admissions

PR2008_042 Death of a Consumer/Patient within a Mental Health Inpatient Unit - management and reporting

PR2011_044 Death of a Patient in CCLHD Hospitals

PR2009_150 Death of a Patient in CCLHD Operating Suite

GE2011_053 Delirium Management in Older People - Clinical Practice Guideline

GE2009_055 Diabetes Mellitus (Type 1) in Children - Guidelines for Inpatient Care including children in the Paediatric Assessment Unit and the Emergency Departments

GE2014_009 Diabetic Foot Assessment Guidelines

GE2009_054 Diabetic Ketoacidosis in Children and Adolescents - clinical guidelines for the management of

GE2009_065 Discharge Medication Supply - CCH

PR2012_036 Dobutamine - Intravenous (Adult)

PR2008_049 Dobutamine Stress Echocardiogram CCLHD

PR2011_077 Documentation in the Health Care Record by Nurses & Midwives

PR2008_024 Doppler Ultrasound to obtain Ankle Brachial Pressure Index (ABPI)

GE2011_027 Drain Care and Management of Complications

PO2014_002 Dress Code for CCLHD Employees

PR2009_287 Drug Samples & Starter Packs - MH/D&A

PR2009_154 Drugs - Intravenous (IV) opioid medications - administering bolus doses in PARU (recovery room)

GE2014_002 Duodopa - Admission Pathway for the Trial of Duodopa Intestinal Gel for the patient with Parkinson's Disease

PR2014_056 Dural Puncture and Intrathecal Catheter - Immediate Management in Birthing Suite

GE2013_004 Ear, Nose and Throat: Post Operative Management and Care (Paediatric)

PR2013_043 Early Pregnancy Assessment Service (EPAS): referral to and initial assessment

PR2011_026 Electrical Equipment/Appliances at Work - Management of Non-Clinical - CCLHN

PR2016_045 Electrocardiograph (ECG): Standard and Non-standard 12 Lead

PR2018_007 Electroconvulsive Therapy (ECT) - roles of the administering and treating psychiatric teams in the assessment and management of

PR2010_317 Electrophysiological Studies (EPS) - patient preparation and transfer

PR2018_021 eMeds medication Carts - for inpatient units utilising Herman Miller Medication Cart Brand CT620

PR2018_001 eMeds Transfer Procedure

PR2010_154 Emergency Department Mental Health Team Clinical Handover

PR2013_047 Emergency Response System (Clinical): Alterations to Calling Criteria on Standard Adult Observation Charts / Standard Paediatric Observation Charts

PR2017_104 Emergency Response System (Clinical): Clinical Review, Paediatric Emergency and Rapid Response Processes for Paediatric Patients - Gosford Hospital (excluding Emergency Department)

PR2017_105 Emergency Response System (Clinical): Clinical Review, Paediatric Emergency and Rapid Response Processes for Paediatric Patients - Wyong Paediatric Assessment Unit (PAU)

PR2013_046 Emergency Response System (Clinical): for Birthing Suite and Maternity Ward (Adult and Newborn) - Gosford Hospital

PR2014_033 Emergency Response System (Clinical): for Wyong Midwifery Birthing Service (Maternal and Neonatal Patients) - Wyong Hospital

GE2010_103 Emergency Response System (Clinical): Gosford Hospital - Children's Ward - Paediatric Flowchart

PR2014_036 Emergency Response System (Clinical): Neonates in Special Care Nursery (SCN)



GE2010_100 Emergency Response System (Clinical): Paediatric Flowchart - Gosford Emergency Department

GE2010_108 Emergency Response System (Clinical): Wyong Hospital Paediatric Assessment Unit - Paediatric Flowchart

PR2016_069 Emergency Response System for Medical Emergencies in Non-inpatient Areas (Gosford, Wyong and Woy Woy Hospitals; Long Jetty health Care Centre; Community Health Centres

PR2016_014 Emergency Response System: Clinical Review Process for Adult - In-patient Long Jetty health Centre

PR2016_002 Emergency Response System: Clinical Review Process for Adult In-Patient - Woy Woy Hospital

PR2015_024 Emergency Response System: Clinical Review process for adult inpatients - Gosford and Wyong Hospitals

PR2016_029 Emergency Response System: Clinical Review Process for Adults (16 years and over) - Community Health Services

PR2016_017 Emergency Response System: Rapid Response Process for Adult - In-Patient Long Jetty Health Centre

PR2016_001 Emergency Response System: Rapid Response Process for Adult In-Patient - Woy Woy Hospital

PR2015_021 Emergency Response System: Rapid Response Process for Adults - Gosford and Wyong Hospitals

PR2016_030 Emergency Response System: Rapid Response Process for Adults (16 years and older) - Community Health Services

PO2018_001 eMR - Downtime Policy

PO2011_002 eMR - Electronic Recording of Risks and Alerts - CCLHN

PR2018_002 eMR Downtime Procedure

GE2012_016 End of Life - medication recommendations for symptom management in Adults

PR2009_102 End Tidal Co2 Monitoring

PR2009_071 Enema Administration for Adults: Evacuant or Retention CCLHD

PR2014_032 Enoxaparin in Treatment of Acute ST Elevation MI (STEMI)

PR2017_069 Enteral Tube Feeding - management of adult patients

PR2016_008 Entonox - use for adult procedural pain in ward areas

PR2016_028 Epidural Infusions (Continuous) - care and management of

PR2009_157 Epirubicin Administration in Operating Theatres and Postoperative Patient Care

PO2012_002 Equipment Management Policy

PR2009_345 Equipment, Fixed - Maintenance Operations

PR2009_344 Equipment, Portable - Maintenance Operations

PR2016_046 Exercise Stress Test

PR2017_018 Exercise Stress Testing (EST) - Clinical Suitability of Emergency and Acute Admitted Patients

PR2009_299 External Service Providers, Engagement/Management/Evaluation - NSCCAHS

PR2009_103 Extubation of ICU Patient with an Endotracheal Tube

PR2009_104 Eye Care for the Intubated and Ventilated Patient

PR2015_028 Eye Shields - Insertion, Cleaning and Storage of Internal Eye Shields for Superficial (SCT) Radiotherapy

PR2011_081 Faecal management System, Flexi Seal

PR2009_073 Faeces - Manual Removal of - for Adult Patients

PR2014_013 Falls Prevention and Management - ADULTS

PO2008_001 Falls Prevention and Management - CCLHD

PR2014_015 Falls Prevention and Management - MATERNITY and NEONATAL

PR2014_016 Falls Prevention and Management - Paediatrics

GE2013_013 Falls Prevention and Management for Community Service Providers in CCLHD

GE2014_012 Falls Prevention: Fall Alarms - appropriate use for adult patients as an additional falls risk management strategy

GE2011_038 Falls Risk and Non Slip Socks - appropriate use for patients as an additional falls risk management strategy

PR2014_014 Falls Risk Management - MENTAL HEALTH and DRUG & ALCOHOL

PR2017_075 Fascia Iliaca Block (Nurse Initiated) - Gosford Emergency Department

GE2016_002 Fasting Guideline for Adult Patients who Require Fasting prior to General Anaesthesia or Sedation

PR2016_057 Fever, Sugar, Swallow (FeSS) Protocols for Acute Stroke Management in CCLHD Acute Care Hospitals

PR2012_046 Financial Delegations - approval and maintenance

PR2009_127 Fire Alarm Isolation & De-Isolation Procedure for all Facilities - CCLHD

PR2009_128 Fire Safety, Training Requirements

PR2009_129 Fire Table Top Exercises

PR2014_010 Firearms - Possession of - Notification & Managing Risk to Other Persons - Mental Health

PO2010_010 Fixed Assets Policy and Procedures

PR2014_006 Flecainide Challenge

PR2010_020 Fleet Vehicles - Accident/Breakdown/Repair

PR2010_021 Fleet Vehicles - Management of



PR2010_014 Fleet Vehicles - Non CCLHD Use of when on Official Business

PR2010_023 Fleet Vehicles - Private Use of Official

PR2010_019 Fleet Vehicles - Records Requirements

PR2010_018 Fleet Vehicles - Selection & Changeover of Vehicles

PR2010_017 Fleet Vehicles - Servicing Procedure

PR2010_016 Fleet Vehicles - Traffic & Parking Regulations/Overnight Use & Garaging

PR2010_015 Fleet Vehicles - Use & Responsibility for Drivers

PR2008_030 Forensic - Community Mental Health Service regarding Forensic Patients and/or High Risk Civilian Patients - Mental Health Referrals

PR2009_158 Forensic Evidence - management in operating suites

PR2009_243 Forensic Patients - Management of Conditionally Released within CCLHD Community Mental Health Facilities

PR2016_018 Fractional Flow Reserve (Pressure Wire) - Nursing Roles

PO2015_003 Fraud and Corruption Control Policy

PR2011_049 Fresenius reverse osmosis machine - "AquaUNO" - Cleaning & Maintenance (Citrosteril, Dialox & filter change - CCLHN

PR2011_056 Fundraising and Donations Management

PR2011_080 Ganciclovir - administration of

PR2013_017 Gastrostomy - nursing management of the adult patient in CCLHD

GE2011_025 Genital Herpes: Pregnancy & Intrapartum Care & Management

PO2007_047 Global Email Management

GE2009_047 Glyceryl Trinitrate (GTN) Intravenous - CCLHD

GE2015_009 Gosford Cancer Day Unit - transfer of patients to Unit for Bone Marrow Biopsy

GE2009_012 Gosford Coronary Care Unit (CCU, Medical 3 Telemetry / Cardiac Monitored Beds - admission to

PR2010_308 Gosford Hospital Mortuary - Admission & Discharge of Bodies - CCH

PR2011_002 Grading Procedure - CCLHD

PR2016_032 Haemodialysis - administration of a fluid bolus during intermittent haemodialysis

PR2011_040 Haemodialysis - Photometer Chlorine Testing, Hard/Soft Water Testing, Colony Forming Units and Endotoxins - water testing for

PR2018_003 Haemodialysis Medication Management/eMeds

PR2009_036 Haemodialysis Prep of Patient for & Admin of Patient Meds - CCH

PR2009_205 Hand Hygiene - Performance of

GE2009_057 Hand Hygiene and Hand Care

PR2009_399 Hazardous Chemicals and Dangerous Goods - Maintenance Operations

PO2008_028 Hazardous Manual Task Policy

PR2017_011 Head of Department (HOD) Appointment Process and Key Accountabilities

PR2018_011 Health Literacy - development and approval of resource content for consumer use

PR2017_004 Health Records - Destruction of Imaged Hard Copy Health Records stored in eMR

PR2015_039 Health Service Manager (HSM) - Salary Progression

PR2009_346 Heights, Working At - Maintenance Operations

PR2015_015 Helicopter Landing Site (HLS) Operation and Medical Retrieval Procedure - Gosford and Wyong Hospital

GE2010_125 Heparin Infusion - Acute coronary Syndrome - CCLHD

GE2013_007 Heparin Infusion - Venous or Arterial Thromboembolism (including Pulmonary Embolism, Deep Vein Thrombosis & Atrial Fibrillation)

PR2010_295 Heparin Infusion & Loading Dose for Intermittent Haemodialysis using Fresenius 5008S Machine - CCH

PR2016_007 Hickman Catheter Management in Adults

GE2009_085 High Falls Risk Patients in Tub/Water Chair Management - CCH

PR2013_038 High Flow Humidified Nasal Cannula Oxygen in Paediatrics (Emergency and Children's Ward)

GE2015_002 Hip Fracture Pain Management for Adult Patients

PR2012_038 Hip Spica Care - care of the child with - CLCHD

PR2016_006 HIV Post-Exposure Prophylaxis (PEP) following Non-Occupational Exposure to HIV

PR2018_006 HIV, Hepatitis B and Hepatitis C - Management of CCLHD Employees Potentially Exposed to

PR2016_033 Holter Monitor Management

GE2011_037 Home Visiting Health & Safety Guideline - CCLHD

GE2012_010 Hospital Play Program - guidelines of practice



PR2007_026 Hospital Property Claim Procedure - CCLHD

PR2009_347 Hot Works Permit Procedure - Maintenance Operations

PR2009_005 Humidification (Airway) - Adults

PR2016_040 Humidified High Flow Nasal Prongs Oxygen (HHFNPO) for Adults - General Wards and Respiratory Service Utilising the AIRVO 2

PR2011_058 Humidified High Flow Oxygen Therapy - Nasal or Tracheal Interface: Coronary Care, Gosford M4 and ICU

PR2016_048 HYDROmorphone - prescribing, storage, ordering, supply, administration and monitoring procedure

GE2010_127 Hyperkalaemia in Adults - Management & Treatment

PR2014_017 Hypoglycaemia: Recognition and Treatment for Adults with Diabetes

GE2017_012 Hyponatraemia - Pharmaceutical Management

PR2017_007 Hypothermia (inadvertent) - prevention and management in the adult perioperative patient

GE2014_013 Implantable Cardioverter Defibrillators: Deactivation as Part of End of Life Management

GE2010_128 Implantable Pacemaker Devices Selection Criteria

PR2007_024 Incremental Dosing of Parenteral Schedule 8 and 4D Drugs for Adult Inpatients - Medications

PO2008_031 Individual Patient Special Policy

PR2011_082 Indwelling Pleural Catheter (IPC) PleurX - Inpatient and Community - Management of the Adult Patient

GE2018_002 Infection Control Application in the Home Environment - Wound and Product Management - Community

GE2014_005 Infection Prevention & Control During Construction, Renovation and Maintenance

GE2009_070 Infection Prevention & Control in the Operating Suites

GE2014_007 Infection Prevention and Control in the ICU & HDU

GE2009_058 Infection Prevention and Control Precautions (Standard and Additional) - when to use

GE2009_037 Infections - outbreak management (CCLHD)

PR2009_325 Influenza (including Seasonal and Pandemic Strains) - Infection Prevention and Control Management of the Patient in Acute Care Settings

PR2018_015 Information Security Management System (ISMS) Procedure

PR2013_005 Inhalation Medication Delivery in Adult Patients - Metered Dose Inhaler (MDI)

PR2013_004 Inhalation Medication Delivery in Adult Patients - Nebulisers

PR2009_006 Inhaled Medication Nebulised Antibiotics

PR2008_069 Injury Management and Workers compensation - CCLHD

PR2017_070 Insulin - Intravenous Infusion Management - Adult. INTERIM (pending DTC approval)

PR2009_200 Insulin Infusions in Children and Adolescents - management of

PR2010_089 Insulin Pen use in Mental Health Drug & Alcohol Facilities: Safe Sharps Handling

PR2012_024 Insulin Pump Paediatric Procedure for Inpatients

PR2008_068 Intercostal Catheter (ICC), Adult and Underwater Seal Drain (UWDS) Nursing Management - CCLHD

PO2009_019 Inter-Facility Patient Transfer - NSCCAHS

PO2013_001 Internal Control Policy

PR2009_119 Intra-abdominal Pressure Monitoring

PR2011_055 Intra-Aortic Balloon Pump - Insertion & Management - CCLHD

PR2008_050 Intranasal Fentanyl Administration for Paediatric Patients - CCLHD

PR2010_267 Intranet - publishing and content management

PR2017_005 Intra-osseous Access for Adults

PR2016_004 Intrathecal or Epidural Opioids (Single Dose) management for the first 24 hours

GE2007_006 Intravenous Antibiotic Infusions - Continuous - Acute/Post Acute-Care (APAC)

GE2010_068 Intravenous Antibiotics in Acute Post-Acute Care (APAC) - administration of

PR2018_012 Intravenous Antiemetic Administration for Children

PR2013_030 Intravenous Fluid Therapy: Nursing Management of Paediatric Patients Receiving Intravenous Fluid Therapy

PR2011_060 Intravenous Iron Sucrose Administration during Intermittent Haemodialysis using the Fresenious 5008S Machine

GE2009_077 Intravenous Medication Administration for Adults by Nurses and Midwives within CCLHD

GE2009_023 Intravesical BCG in Adults - Guidelines for Use - CCH

PR2017_083 Intravesical Medication Instillation (non-cytotoxic) - Community

PR2009_118 Intubation (Oral/Nasal Endotracheal) for adult patient in patient in ICU/HDU and Emergency

PO2015_001 Investment Management Policy for CCLHD

PR2013_037 Iron - Intravenous Replacement Therapy

GE2013_011 ISBAR Framework for Clinical Communication



PR2009_348 Isolation of Services - Maintenance Operations

PR2015_018 Joint Outreach Burns Service (JOBS) Clinic - Wyong Paediatric Assessment Unit

PR2013_042 Junior Medical Officer (JMO) Census Task List: use for ordering of routine tasks and Clinical Reviews

PR2013_029 Junior Medical Staff - Administration of Un-rostered Overtime and Call-back (Recall)

PR2010_085 Ketamine Infusion - Instructions for Set Up and Management for Adult Patients (Acute Pain Service)

PR2012_016 Labelling of Injectable Medicines, Fluid and Lines

GE2010_006 Lactation - Suppression of

PR2017_006 Lactation Aids - Finger Feeding (Neonates)

PO2014_004 Laser Safety in Operating Theatres

GE2008_013 Leg Ulcer Management

PR2009_130 Liability Claims - Management of potential or Actual

PR2009_090 Lifepak 1000 Biphasic Automated External Defibrillator

PR2012_031 Lignocaine (Lidocaine) infusion for Cardiac Arrhythmia

PR2009_222 Lignocaine Infusion - Intravenous Administration for Management of Headache

PR2012_053 Liquid Medicines by Routes other than Injection - Safe Administration

PO2011_003 Loading Dock Access

PR2013_001 Local Anaesthetic - continuous infusion via a disposable elastomeric pump

PR2016_027 Local Anaesthetic Infusions - Instructions for Set Up and Management of the Yellow CADD-Solis Pump

PR2014_037 Low Frequency Ultrasonic Wound Debridement (LFUWD) using the Sonoca 185

PR2011_054 Lumbar Puncture (Adult) - Nursing Care During and After Lumbar Puncture

PR2015_009 Lymphoedema Alerts for Inpatients

GE2009_075 Magnesium for Treatment of Hypomagnesaemia - CCH

PR2016_041 Magnesium Sulphate (Intravenous) in the Treatment of Severe Acute Asthma in Children and Adolescents

PR2006_021 Management of patient under the Mental Health Act 2007 (NSW) who are admitted to a general hospital ward – MH

PR2017_056 Maternity - Acupressure use in the Perinatal Period

PR2016_011 Maternity - Administration of Rh (D) Immunoglobulin (Anti-D)

PR2017_062 Maternity - Admission and Care of the Healthy Full Term Baby in the Postnatal Ward

PR2016_024 Maternity - Admission/Transfer to Gosford Maternity Ward

GE2012_001 Maternity - Anemia in Pregnancy: Diagnosis and Management

GE2009_123 Maternity - Ano-Rectal Dysfunction in the Postnatal Period

PR2012_018 Maternity - Antenatal Fetal Heart Rate Monitoring

GE2014_015 Maternity - Antepartum Haemorrhage (APH) - Recognition and Management

PR2017_059 Maternity - Aromatherapy use During Labour

PR2014_055 Maternity - Artificail Rupture of Membranes for Augmentation of Labour

PR2017_072 Maternity - Baby Born Before Arrival

PR2012_029 Maternity - Bariatric (Obesity) Management

PR2013_036 Maternity - Bimanual Compression of the Uterus and Uterine Artery Stretch Postpartum Haemorrhage

GE2010_009 Maternity - Bladder Care - Birthing Suite and Postnatal Ward

PR2016_025 Maternity - Body Mass Index (BMI): Assessment and Management

PR2017_086 Maternity - Breast Expression and Storing Colostrum Antenatal for use in the Newborn Period

GE2009_056 Maternity - Breastfeeding in Maternity Services - Principles for Protecting, Promoting and Supporting

GE2013_014 Maternity - Care in Normal Labour and Birth

PR2017_090 Maternity - Care of a Woman Admitted in Early Labour

PR2010_013 Maternity - Cervical Ripening using the Multi-Balloon (Atad) Catheter

GE2011_046 Maternity - Cholestasis - diagnosis and management

PR2016_052 Maternity - Collection of Cord Blood for pH Sampling

PR2017_077 Maternity - Cord Prolapse - recognition and management of

PR2011_038 Maternity - Cup Feeding (Expressed Breast Milk)

PR2017_013 Maternity - Declining Blood / Blood Products

GE2015_003 Maternity - Direct Admission of 36 Week Gestation Infant to the Maternity Ward

GE2011_045 Maternity - Discharge of Mother and Baby Postnatally

PR2017_098 Maternity - Donor Human Breastmilk (DHM) Use

PR2014_061 Maternity - Electric Breast Pump - use of

PR2017_074 Maternity - Emergency Lower Segment Caesarean Section (ELSCS) - preparation for and care of immediately



following procedure

PR2017_057 Maternity - Episiotomy

PR2017_019 Maternity - External Cephalic Version (ECV)

PR2015_026 Maternity - Fetal Blood Sampling for Lactate Analysis using the Nova Statstrip Xpress Lactate Meter

PR2014_054 Maternity - Fetal Fibronectin and Actim Partus Testing

PR2017_014 Maternity - Fetal Scalp Electrode (FSE)

PR2010_088 Maternity - First Hospital Antenatal Visit (Booking-in Visit)

GE2011_049 Maternity - General Patients (Outliers) in Gosford Maternity Ward: Transfer

PR2014_025 Maternity - Gestational Diabetes Mellitus (GDM) - Screening and Management

PR2017_055 Maternity - Hand Expression of Breast Milk

PR2017_091 Maternity - Hepatitis B Surface Antigen (HBsAg) Positive Mothers - Antenatal Care and Management

PR2017_028 Maternity - Hydralazine (Apresoline) Bolus and Infusion

GE2017_014 Maternity - Hyperemesis Gravidarum (HG) and Nausea and Vomiting in Pregnancy (NVP) Management

GE2010_021 Maternity - Hypertension in the Postnatal Period - management of

PR2016_010 Maternity - Indications for Ordering and/or Referral for Ultrasound in Pregnancy

PR2017_073 Maternity - Infant Feeding with an Infant Formula

PR2017_061 Maternity - Infant Formula - preparation, storage and cleaning of equipment

PR2014_053 Maternity - Inspection of Placenta, Membranes and Cord

PR2013_045 Maternity - Intrapartum Fetal Heart Rate Monitoring

PR2017_101 Maternity - Lactation Aids - Nipple Shield Use

PR2017_106 Maternity - Latex Sensitivity / Allergy - management of

PR2017_042 Maternity - Magnesium Sulfate Infusion

GE2016_006 Maternity - Management for Women with Human Immunodeficiency Virus (HIV) - pregnancy, intrapartum and postnatal care

PR2017_082 Maternity - Management of Preterm Labour

PR2016_003 Maternity - Management of Stillbirth and Neonatal Death

PR2017_076 Maternity - Mastitis and/or Breast Abscess Management

PR2007_027 Maternity - Maternal Group B Streptococcus (GBS) Screening and Prophylaxis

PR2017_089 Maternity - Membrane Sweep for Low-Risk Antenatal Woman > 38 Weeks Gestation to Prevent Postdates Pregnancy

PR2014_052 Maternity - Nitrous Oxide (N2O+O2) use Intrapartum

PR2014_020 Maternity - Non-Viable Fetus Between 15 and up to 20 Weeks Gestation - Management and Disposal of

PR2016_053 Maternity - Opioid Dependent Women - Continuum of Care

PR2017_017 Maternity - Perineal and Genital Tract Trauma Assessment and Repair

GE2009_128 Maternity - Perineal Care in the Postnatal Period

PR2017_071 Maternity - Planned Homebirth Transfer to Hospital

PR2017_088 Maternity - Prelabour Rupture of Membranes (PROM) at term gestation (>37 weeks)

GE2014_016 Maternity - Shoulder Dystocia - Recognition and Management

PR2014_034 Maternity - Sterile Water Injections for Relief of Low Back Pain in Labour

PR2015_025 Maternity - Supporting Women in their Next Birth After Caesarean Section (NBAC)

PR2016_059 Maternity - Telephone Consultation

PR2015_011 Maternity - Termination of Pregnancy (greater than 14 weeks gestation) using Mifepristone and/or Misoprostol

GE2009_129 Maternity - Third and Fourth Degree Perineal Tears (Obstetric Anal Sphincter Injury) Management Guideline

PR2017_087 Maternity - Thrombocytopenia in Pregnancy, Referral and Management

GE2011_042 Maternity - Transfer of Obstetric Patient from Gosford (Level5) Hospital to a Level 6 Hospital

PR2017_079 Maternity - Transfer of the Deceased Neonate/Fetus to and from the Mortuary

GE2011_044 Maternity - Trauma in Pregnancy Guidelines

GE2014_017 Maternity - Unbooked Presentations to Birthing Suite

PR2017_060 Maternity - Urine Testing in Pregnancy - Urinalysis and Midstream Urine (MSU)

PR2016_031 Maternity - Use of Hot Packs

PR2013_028 Maternity - Uterine Balloon (BAKRI) for Postpartum Haemorrhage

PR2017_078 Maternity - Uterine Hyperstimulation Management

PR2015_038 Maternity - Vaginal Examination

PR2013_027 Maternity - Varicella Zoster Virus (VZV) or Chickenpox in Pregnancy

PR2013_026 Maternity - Water Immersion use During Labour and Birth



GE2016_001 Maternity - Weighing and Management of neonates with Greater than 10% Weight Loss from Birth Weight

PR2015_036 Maternity Services - Antenatal Pertussis (dTpa) Vaccination

PR2018_019 Maternity Services - Dinoprostone (Prostaglandin E2 - PGE2) Cervidil and Prostin for Pre-Labour Cervical Ripening

PR2017_097 Maternity Services (only) - Epidural Infusion - Use in Labour

PR2014_024 Maternity Services: Emergency Response System (Clinical): Midwife Clinics in Hospital Community Centres

GE2013_012 Maternity Services: Venous Thromboembolism (VTE) Risk Assessment & Prophylaxis Prescribing Guide: Pregnancy & Postnatal Period

GE2014_001 Maternity: Breech Presentation - Antenatal and Intrapartum Assessment and Management

PR2014_046 Maternity: Fetal Growth Deviation - detection and management for suspected Fetal Growth Restriction (IUGR)

GE2014_011 Maternity: Hepatitis C Virus (HCV) - Screening and Management During Pregnancy, Birthing and Postnatal Period

PR2014_044 Maternity: Management of Women with Diabetes During the Intrapartum and Post Natal Period (including operative birth)

PR2010_268 Maternity: Postdates Management of Women Assessed as Normal Risk

PR2014_026 Maternity: Stabilisation and Transfer of Women from Wyong Midwifery Birthing Service (WMBS)

PO2015_002 Medical Observership

PR2016_049 Medication Management - Complementary and Alternative Medicines

PR2016_050 Medication Management - Obtaining 'Not Available' Medication

PR2017_043 Medication management - Subcutaneous Breakthrough Medications for Palliative Care Patients in Community Settings

PR2015_004 Medications to Infants and Children Administration - CCLHD

PR2009_081 Meningococcal Disease (bacterial) - Infection Prevention and Control Management of the Patient in Acute Care Settings

PR2009_286 Mental Health - Admission to Acute Mental Health Inpatient Units

PR2017_010 Mental Health - Assertive Outreach Team Discharge/Transfer of Care (Adult)

PR2017_009 Mental Health - Assertive Outreach Team Referral and Assessment (Adult)

PR2008_041 Mental Health - Authorised Patient Leave from Mental Health Inpatient Units

PR2011_066 Mental Health - Behaviour Assessment Intervention Service (BASIS) Referral Pathway and Service Criteris

GE2012_009 Mental Health - Care Zoning Clinical Practice Guidelines

GE2010_115 Mental Health - Clozapine Treatment - Prescribing and Monitoring Requirements prior to, during commencement and throughout ongoing therapy

PR2018_014 Mental Health - Discharge from the Youth Mental Health Team / Young People's First Episode Psychosis Intervention (YPPI) Team

PR2010_166 Mental health - Duress alarm System and Response within Mental health inpatient Facilities

PR2010_313 Mental Health - Emergency Services Access to Clinical Information from mental Health Services During high Risk Situations

GE2011_054 Mental Health - Heat Wave Preparation and Actions for Mental Health Consumers

PR2006_005 Mental Health - Identification of Consumers within Mental Health Services

PR2011_045 Mental Health - New Referrals and Failure to Attend Planned Appointments - Minimum Follow Up Requirements

PR2017_026 Mental Health - Olanzapine Pamoate Long-Acting Injection (LAI) - administration

PR2010_038 Mental health - Patient Valuables and Belongings - Mental Health Inpatient Units

GE2007_004 Mental Health - Pharmacological Management of Acute Behavioural Disturbance in Adults within Mental Health Inpatient Units

GE2017_005 Mental Health - Psychiatric Emergency Care Centre (transfer to)

PR2007_030 Mental Health - Resolution of Conflicting Approaches to Clinical Care in High Risk Situations in Mental Health

PR2009_397 Mental Health - Specialist Mental Health Services for Older People (SMHSOP) Miri Miri Acute Inpatients Unit - admission/referral

PR2009_398 Mental Health - Specialist Mental Health Services for Older People (SMHSOP) Miri Miri Acute Inpatient Unit - transfer of care/discharge

PR2011_009 Mental Health - Specialist Mental Health Services for Older Persons - Discharge of Mental Health Consumers/Patients into Residential Aged Care Facilities - CCLHD

PR2008_039 Mental Health - Transfer of Care from Adult Mental Health Inpatient Facilities

GE2010_121 Mental Health - Triaging/Managing Care of the Pregnant Mental Health Inpatient

PR2008_040 Mental Health - Unauthorised Leave form Mental Health Inpatient Units

PR2010_155 Mental Health - Use of Courtyard Areas within Mental Health Inpatient Facilities

PR2011_012 Mental Health - Yakalla Social and Recreation Program - Assessment and Ongoing Management

PR2011_024 Mental Health Acute Care Team - Clinical Pathway for Transitional Care of Consumers Discharged from Mental



Health Inpatient Facilities

PR2013_022 Mental Health Clinical Documentation

PR2009_290 Mental Health Clinical Review

GE2013_010 Mental Health Illness/Disorder - assessment and management of patients presenting to the Emergency Department with a

PO2006_029 Mental Health On Call Responsibilities for Psychiatry Registrars, Career Medical Officers (CMOs) and Consultants

PR2010_108 Mental Health Review Tribunal Correspondence, Complaint and Concern Management - Mental Health

PR2010_073 Mental Health Service - Clinical Pathways for People Who May Be Suicidal

PR2008_007 Mental Health: Accredited Persons under the Mental Health Act 2007 (NSW)

PR2009_337 Mental Health: Children 0-17 Visiting Mental Health Inpatient Units

PR2009_245 Mental Health: Consumer Participation Procedure

PR2009_244 Mental Health: Family and Carer Participation Procedure

PR2008_004 Mental Health: General Practitioners / Private Health Care Providers Liaison with Mental Health Services

PR2006_012 Mental Health: Searching of Patients and their Belongings in Mental Health Units

PR2010_263 Methoxyflurane via Penthrox Inhaler for procedural pain management during bone marrow biopsy in Cancer Care/M2 - CCH

PR2012_035 Metoprolol - Intravenous (HEART RATE CONTROL) - Adults

PR2010_253 Midazolam Infusion for Seizure Management in Children and Adolescents

PR2014_008 Midwifery Antenatal Care: women requiring obstetric/medical consultation and referral (code B)

PR2017_002 Midwifery Postpartum (Infant) Care - Requiring Paediatric Medical Consultation and Referral (Code B)

PR2017_001 Midwifery Postpartum Care (Maternal) - Woman Requiring Obstetric Medical Consultation and Referral (Code B)

GE2009_036 Mobile Communications Devices (including Mobile Phones) - allocation and use

PR2009_326 Mobile Phones - Payment for Non-Work Use of Mobile Phones

PR2016_047 Mobile Technology: Bring Your Own Device (BYOD)

PO2007_042 Mortality Review Policy - CCLHD

PR2015_002 Motor Vehicle Procedure - CCLHD

PR2009_234 MRAB - Infection Prevention and Control Management of the Patient in Acute Care Settings

PR2010_068 MRSA - Collection of Screening Swabs - CCLHD

PR2009_235 MRSA - Infection Prevention and Control Management of the patient in the Acute Care Settings

GE2010_024 MRSA - Screening, the Decolonisation Process and Clearance

PR2009_040 Myocardial Perfusion (Sesta Mibi) Scans

PR2014_011 Nasal Sprays, Nasal Drops, Nasal Douches and Nasal Toilet Administration

PR2010_107 Nasogastric/Orogastric Tube Insertion and Management in Adult Patients

PR2009_009 Nasopharyngeal Airway - Nursing insertion, management and suctioning in adult patients

PR2009_282 Nasopharyngeal Aspiration in Infants and Children - CCLHD

PR2012_026 Negative Pressure Wound Therapy Dressing

PR2017_066 Neonatal - Administration of Oral/Intramuscular Medications in Special Care Nursery (SCN)

PR2016_063 Neonatal - Administration of Vitamin K (Konakion MM)

PR2015_005 Neonatal - Admission to the Special Care Nursery (SCN)

PR2016_058 Neonatal - Assessment and Management of neonates at Risk of Early onset Group B Streptococcus (EOGBS) Infection

PR2017_022 Neonatal - Assisting Paediatric Medical Officer with Lumbar Puncture

GE2016_005 Neonatal - Babies Requiring Medical Review Before Going Home

GE2017_007 Neonatal - Birth Before 32 Weeks - increasing the ambient room temperature in operating theatres and Birthing Suite

PR2016_038 Neonatal - Blood Culture Collection

GE2017_013 Neonatal - Care of a Neonate from a Mother who is Hepatitis B Surface Antigen Positive, Hepatitis C PCR Positive or HIV Positive

PR2017_053 Neonatal - Care of a Neonate Post Fall Within Maternity Services

PR2017_016 Neonatal - Care of the Ventilated Neonate in the Special Care Nursery

PR2017_046 Neonatal - Discharge from Special Care Nursery (SCN) of Neonates/Infants Requiring Home Oxygen (o2) Therapy

PR2016_064 Neonatal - Discharge from the Special Care Nursery (SCN)

GE2015_010 Neonatal - Guidelines for Palliative Care and Neonatal Death

PR2017_096 Neonatal - Hypothermia - Prevention, Identification and Management in Wyong Birthing Service, Gosford Birthing Suite, Neonatal Ward, Special Care Nursery, Operating Theatres and Post Anaesthetic Care Unit

PR2017_065 Neonatal - Immunisations, Neonatal Immunisations



PR2016_026 Neonatal - Insertion and Confirmation of Placement of Nasogastric and Orogastric Tubes

PR2017_050 Neonatal - Intraosseous Infusions (IO) in Special Care Nursery (Non-Battery Powered EZIO Devices)

PR2017_063 Neonatal - Intravenous (IV) Cannulation of Neonates / Infants by Nurses/Midwives

PR2017_034 Neonatal - intravenous Therapy via Peripheral Cannula

PR2017_047 Neonatal - ISTAT Blood Gas Analyser

PR2016_016 Neonatal - Jaundice Exchange Transfusion

PR2017_051 Neonatal - Low Flow Nasal Cannula in Special Care Nursery (SCN)

PR2018_008 Neonatal - Nasal Continuous Positive Airway Pressure (nCPAP) in Special Care Nursery (SCN)

GE2018_001 Neonatal - Neonatal Abstinence Syndrome - management of - CCLHD

PR2016_044 Neonatal - Newborn Bloodspot Screening Test (NBST)

PR2017_044 Neonatal - Newborn Pulse Oximetry Screening

GE2016_011 Neonatal - Non-invasive Blood Pressure Monitoring

PR2017_048 Neonatal - Observations in the Newborn Period

PR2017_045 Neonatal - Oxygen Therapy - Headbox / Crib O2

PR2017_049 Neonatal - Physical Examination

PR2016_066 Neonatal - Plaster and Circulation Observations

PR2017_064 Neonatal - Pneumothorax - Chest Drain Insertion and Clinical Care

PR2016_015 Neonatal - Respiratory Monitoring MR10 (Graseby Respiration Monitor)

PR2017_020 Neonatal - Screening for Retinopathy of Prematurity (ROP)

PR2017_067 Neonatal - Subgaleal Haemorrhage (SGH) Identification and Management

PR2016_043 Neonatal - Therapeutic Cooling

PR2016_060 Neonatal - Transfer of the Neonate to the Magnetic Resonance Imaging Suite (MRI)

GE2017_010 Neonatal - Transfer to a Neonatal Intensive Care Unit (NICU) from the Special Care Nursery (SCN)

PR2017_033 Neonatal - Treatment of Jaundice by Phototherapy

PR2018_004 Neonatal - Umbilical Arterial Catheter (UAC) - Insertion and Line Management

PR2017_068 Neonatal - Umbilical Venous Catheter (UVC) - insertion and line management

PR2017_023 Neonatal - Urine Collection

PR2017_052 Neonatal - Venepuncture of Neonates/Infants by Nurses/Midwives

PR2016_056 Neonatal - Weighing and Measuring Neonates in the Special Care Nursery (SCN)

PR2017_012 Neonatal - Well Baby Examinations (Blue Book Checks) Attended by Midwives/Neonatal Nurses Prior to the Neonate Going Home

PR2014_060 Neonatal Hypoglycaemia: Prevention, Identification of, Screening, Assessment and Management

PR2016_013 Neonatal Resuscitation

PR2015_006 Neonatal: Heated Humidified High Flow Nasal Cannula

PR2012_011 Nephrostomy Tube Insertion

PR2012_012 Nephrostomy Tube Irrigation and Care of (community)

PR2012_013 Nephrostomy Tube Removal

GE2017_009 Neutropenia Febrile and Non-Febrile - Management of Adults

PR2013_044 Nicotine Replacement Therapy (NRT) for pregnant and postnatal women (Quit for New Life - Q4NL) - Nurse/Midwife Initiated

PR2009_385 Nitrous Oxide Administration for Paediatric Patients

PR2011_028 Noise Management & Protection of Hearing at Work

PR2009_017 Non-Invasive Ventilations (NIV) - Adults

PR2013_031 Notification of Significant Positive Radiographic Findings

GE2007_016 Nurse Initiated Medication - Adult Patients

PR2010_143 Nursing and Midwifery Practice: Credentialing and Defining the Scope of Clinical Practice

PR2012_052 Nursing and Midwifery Staffing - Managing Unplanned Shortfalls

PR2014_058 Nursing Interventions for Acute Ischaemic Stroke Patients receiving Intravenous Thrombolyisis (tPA)

GE2010_012 Nutrition Care Guideline - Roles and Responsibilities of Nurses & Midwives

PR2016_036 Obstetrics & Gynaecology (O&G) - Credentialing of O&G Registrars Commencing at CCLHD

GE2009_084 Octreotide Acetate via IV Infusion - Guidelines for Administration - CCH

PR2008_044 On-Call Executive Arrangements - Mental Health

PR2011_039 Operation & Management of Portable Fresenius reverse Osmosis Machine - "AquaUNO" for use with Fresenius 5008S for intermittent Haemodialysis - CCLHN



GE2015_007 Opioid Conversion and Opioid Switching Guideline

GE2017_003 Opioid Withdrawal in Inpatient Settings

PR2009_221 Oral Care

PR2009_109 Oral Care for the Patient in ICU/HUD-CCLHD

PR2014_041 Oral Ondansetron - Single Dose in the Management of Acute Gastroenteritis in Children

PR2017_039 Organ and Tissue Donation after Brain Death

PR2017_038 Organ and Tissue Donation after Circulatory Death

PR2013_003 Out of Pocket Expenses

PR2016_055 Out-of-Home-Care Primary health Screen 2A (OOHC PHS 2A) - Child and Family Health Nurses completing for children 0-5 who are on the Out-of-Home-Care Health Pathway Program (OOHC-HPP)

PR2011_022 Outpatient Appointments Conducted by Inpatient Clinicians - Mental Health

GE2014_006 Overnight Transfusion of Haemodynamically stable patients in the Medical Assessment Units (MAU)

PR2009_002 Oxygen Therapy - Management in Adults

PR2012_025 Pacemaker - Cardiac - Temporary Medtronic 5392

PR2016_065 Pacemaker/AICD/Loop Recorder Interrogation

GE2015_006 Pacemakers (PPM) and Implantable Cardiac Defibrillators (ICDs) - Management of for Radiation Oncology Patients

PR2017_092 Paediatric Allergy (including anaphylaxis) - assessment and management in the hospital setting

PR2009_223 Paediatric Ambulatory Care: Peripheral Intravenous Cannula Care for Home or Clinical Treatment

GE2009_030 Paediatric High Observation Unit (HOBS) - Children's Ward, Gosford Hospital - Operational Guidelines

PR2013_025 Paediatric Patients Discharged Home on Oxygen

PR2014_040 Paediatric Preoperative Fasting Management - CCLHD

GE2008_032 Parental Nutrition (PN) - Adult Guidelines

PR2011_057 Parents' Evaluation of Developmental Status (PEDS) Administration of - CCLHD

PR2012_051 Parking Infringement or Appeal

GE2015_004 Patchwork for Health Staff

PR2016_068 Patient and Family Activated Response ('REACH' Model) - Gosford Hospital

GE2010_122 Patient Care Equipment used in Healthcare Settings - cleaning of non-critical

PR2014_002 Patient Controlled Analgesia (PCA) - care of the patient and instructions for the set up and management of the CADD-Solis Infusion Pump

PR2016_019 Patient Controlled Analgesia (PCA), Nurse controlled Analgesia (NCA) and Continuous Opioid Infusions (COI) for Paediatric Patients Weighing Less than 50kg

PR2012_009 Patient Identification

PR2007_036 Patient Identification in Cancer Services and Renal Units at CCLHD

PR2010_066 Patient Safety Handover Checklists - Use in Clinical Handover

PR2015_027 Patient Special - Care and Management

PO2009_017 Patient Transfer from an Intensive Care or High Dependency Unit to an Appropriate Acute Specialty Bed

GE2014_008 Patient Transport - Working in the Uncontrolled Environment

PR2012_045 Patient Transport Clinical Emergency Management

PR2010_024 Patients Medication - Storage & Management - CCH

PR2017_024 PCs and Related Equipment / Software Purchasing Procedure

PR2009_013 Peak Expiratory Flow (PEF) Performance and Monitoring the Adult Patient

GE2013_003 Pelvic Inflammatory Disease (PID) - management of mild to moderate STI-related PID in non-admitted patients

PR2009_196 Penile Sheath - application of

PR2009_120 Percutaneous Dilatational Tracheostomy Procedure in ICU

PR2009_042 Pericardiocentesis (Percutaneous)

PR2015_032 Perineural Infusion of Local Anaesthetic (PILA) - Care and Management of

PR2015_001 Peripheral Intravenous Cannula (PIVC) Insertion, Management and Removal in Adult Patients

GE2008_026 Peripheral Intravenous Cannulas - management of in infants and children

PR2013_013 Peripherally Inserted Central Catheter (PICC) and Midline Catheter Management in Adult Patients

PR2009_383 Peripherally Inserted Central Catheter (PICC) and Midline Catheter Insertion - Adult Patients

PR2009_382 Peripherally Inserted Central Catheter (PICC) Insertion - Paediatric Patients at Gosford Hospital

PR2009_065 Peritoneal Dialysis - Connecting and/or Changing the Extension Set on a Tenckhoff Catheter

PR2009_062 Peritoneal Dialysis - Tenckhoff catheter repair / cut down

PR2009_063 Peritoneal Dialysis Catheter and Exit Site Care - post-operative management of the



PR2010_296 Peritoneal Dialysis patient with Peritonitis and instillation of intraperitoneal (IP) medication - management of

PR2017_054 Peritoneal PleurX Catheter - Inpatient and Community Management of the Adult Patient

PR2009_041 Permanent Pacemaker (PPM) - Management of the Patient Pre and Post Insertion

PR2018_017 Permanent Pacemaker (PPM) Implantation - nursing roles

PR2014_047 Personal Protective Equipment (PPE) - correct donning & doffing for very high risk infectious conditions (INTERIM)

PR2016_039 Personal Protective Equipment (PPE) - selection, use, maintenance and procurement

GE2009_059 Personal Protective Equipment for Infection Risk - appropriate use

PR2009_204 Personal Protective Equipment for Infection Risk - wearing of

PR2009_354 Pertussis (Whooping Cough) - infection Prevention and Control Management of the Patient in Acute Care Settings

PR2017_021 Pharmacological Stress Echocardiogram

PR2009_281 Phenytoin Intravenous: Administration for Management of Status Epilepticus in Adults - CLCHD

GE2011_030 Phosphate Replacement in Adults

PR2009_349 Planned Preventative Maintenance - Maintenance Operations

PR2008_010 Pleural Aspiration and/or Pleural Biopsy - Assistant's Role

PO2005_004 Policy - Mega Policy

PR2014_039 Policy, Procedure and Guideline - Development, Approval and Implementation System - Framework for Central Coast Local Health District

PR2012_047 Port a Cath (Venous) - Management in Adults

PR2009_162 Positioning and Pressure Injury Prevention for Patients in Operating Suites

GE2010_011 Postnatal Assessment and Care

PR2014_051 Postnatal Cold Pack Application

PR2015_023 Postoperative Care of the Adult Surgical Patient

PR2016_054 Post-Splenectomy Vaccination Procedure for CCLHD Adult (>18 years) Patients

PR2013_010 Potassium Administration - Adult Patients within CCLHD

PR2016_042 Potassium Administration - Paediatric Patients within CCLHD

GE2009_092 Pregnancy - Per Vaginal Bleeding & Abdominal Pain in Early Pregnancy

GE2009_091 Pregnancy Care: Women with Type 1 and 2 Diabetes

PR2015_022 Preoperative preparation and clinical handover of the adult surgical patient

PR2015_012 Pressure Injury Prevention and Management - Adult Community

PR2014_048 Pressure Injury Prevention and Management - Adult Inpatient

PR2013_049 Prostacyclin (Epoprostenol) Continuous Nebulisation Therapy

PR2013_050 Provisional Mental Health Disorders - patients presenting to the Emergency Department with: Assessment, Review, Management and Discharge

PR2013_009 Psychiatric Assessments and Referral from General Hospital Wards

GE2017_004 Psychostimulant Withdrawal in Inpatient Settings

GE2011_029 Psychotropic Medications: Recommended Maximum Daily Doses - Mental Health

PR2012_020 Public Interest Disclosure Reporting Procedure

PR2010_239 Radial Artery when used for Coronary Angiography, including the use of the TR Band - management of

PR2017_093 Recognition and Referral of the Unwell Child - Child and Family Health Settings

PR2014_028 Record Destruction

PR2014_027 Records - destruction of records under normal administration practice

PO2014_003 Records Management Policy

PR2014_030 Records: Disposal of Imaged Hard Copy Records Registered in TRIM

PR2014_029 Records: Document Management - Total Records Information Management (TRIM)

PR2017_015 Recovery of the Adult Patient in the Post Anaesthetic Care Unit (PACU) Stage One - Operating Suites

PR2017_085 Recovery of the Paediatric Patient in the Post Anaesthetic Care Unit (PACU) Stage One - Operating Suites

PR2009_072 Rectal Catheter / Flatus Tube Insertion - Adult

PR2016_021 Remifentanil Patient Controlled Analgesia (Intravenous) - use for women in labour only

PR2009_037 Renal Biopsy - Care of patient Pre & Post

PR2018_013 Research - Management of a Complaint about a Research Project

PR2017_099 Research - Management of Clinical and Non Clinical Data

PR2017_040 Research and Clinical Trials - Financial Management

PR2016_022 Research Documentation Developed for External Presentation

PR2016_023 Research Documentation Developed for External Publication



PO2013_005 Residential Aged Care Placement Policy

GE2010_043 Restraint - Procedural Restraint for Paediatric Patients

PR2010_238 Restraint Application and Management - CCLHD

PO2010_004 Restraint Minimisation Policy - CCLHD

GE2010_093 Restraint: Assessment Prior to Use - CCLHD

GE2010_094 Restraints: Alternatives to Use - CCLHD

GE2013_009 Resuscitation Plans (adult and paediatric) initiation, use and storage

PR2008_001 Resuscitation Trolley and Equipment - Adult (excludes ICU, ED and Operating Theatres)

PR2009_033 Right Heart Catheterisation - Nursing Roles

PR2017_027 Ring Pessary Change - for Pelvic Organ Prolapse (POP)

PR2010_065 Risk Management Enterprise-Wide

PO2006_009 Safety Alert and Recall Policy - CCLHD

PR2008_037 Safety and Security of Children in Central Coast Local Health District

PR2017_080 Safework NSW - Reporting of Notifiable Incidents and Responding to Visits or Enquiries

PR2008_070 Salbutamol Infusion - management in children and adolescents

PR2014_045 SAM Sling Pelvic Binder - application of

PR2009_284 Scabies - Application of Topical Scabicide by Nurses in Acute Settings to Treat Affected Patients

PR2009_283 Scabies - Infection Prevention and Control Management in the Acute Care Settings

PR2017_094 'Scoop and Run' - Emergency Patient Transfers Requiring Procedural/Surgical Intervention between Gosford and Wyong hospital

PR2012_021 Section 22 Mental Health Presentations to Gosford Mental Health Centre

PR2013_048 Security of Non Medical Records consumer Information Material

PR2010_226 Security Risk Review, Assessments and Improvements - Security Services

PR2012_023 Sedation (Adult Conscious/Procedural) - Nursing Role

PR2014_023 Self-Catheterisation - Clean Intermittent

PR2009_110 Sengstaken - Blakemore Tube - Insertion and Management of

PR2012_017 Sexually Transmissible Infections - Positive Results Management Pathway

PR2010_084 Shingles (Herpes Zoster) - Infection Prevention and Control Management of the Patient in Acute Care Settings

PR2010_291 Sick Leave Management

PR2009_187 Sitz Bath

GE2008_030 Skin Flap Management Guidelines - NSCCAHS

GE2008_029 Skin Graft Management Guidelines

GE2007_003 Skin Tear Guidelines

PR2011_013 Smoke Free Workplace

PO2010-007 Social Media - using - CCLHD

PO2010_007 Social Media - Using - CCLHD

GE2009_100 Social Work Supervision and Consultation

GE2010_118 Special Purpose and Trust Monies - Guidelines for Recording

PR2010_149 Specialist Mental Health Services for Older People (SMHSOP) Referral Process for Consumers Requiring Acute Admission to Hospital

PR2010_110 Specialist Rehabilitation Clinical Procedure - Mental Health

PR2010_157 Specialling of MH Patients in General Wards & Emergency Department - MHDA

PO2018_002 Specimen Collection (Excluding Blood)

PR2010_052 Spinal Log Roll for Patients requiring Spinal Cord Alignment - NSCCAHS

PR2012_048 Spinal/Vertegral Fractures - Transfer of patients with - Inter-Hospital Emergency & Intensive Care Services

PR2009_014 Spirametry Testing of the Adult Patient

PR2010_273 Staff - employing from Overseas

PR2012_006 Statistical Discharge Mental Health

PR2011_067 Sterilising Services - Care, Handling, Transport & Storage of Medical Devices - CCLHD

PR2011_068 Sterilising Services - Cleaning & Disinfecting of Medical Devices - CCLHD

PR2011_069 Sterilising Services - Inspection, Assembly & Packing of Medical Devices - CCLHD

PR2011_070 Sterilising Services - Sterilisation of Medical Devices - CCLHD

PR2011_071 Sterilising Services - Tracking & Traceability of Medical Devices - CCLHD

PR2017_041 Stoma Appliance change for a urinary Stoma (with or without ureteric stents insitu)



PR2009_226 Stoma Appliance Change for Colostomy or Ileostomy (Faecal Stoma)

GE2016_007 Stoma Management of High Faecal Output (Inpatient)

PR2009_015 Streptokinase Via Intercostal Catheter (ICC) - CCLHD

PR2018_020 Stroke and Transient Ischemic Attack (TIA) Facilitated Admission and Discharge Guide

PR2009_231 Stump Bandaging

GE2009_040 Sub-cutaneous enoxaparin (Clexane) prescribing, administration and monitoring in adults

PR2009_098 Subcutaneous Fluid Administration in Adults - (Hypodermoclysis)

PR2011_031 Sucrose - Nurse Initiated for Procedure Related Pain in Infants

PR2009_001 Suctioning of the Artificial Airway

PR2010_064 Sudden Unexpected Death In Infancy (SUDI) - Management

PR2008_045 Suicide Death in Community Setting - managing a possible - Mental Health

PR2009_069 Suppository Administration for Adults

PR2014_022 Suprapubic Cather Dressing in the Community Setting

PR2013_033 Suprapubic Catheter (SPC) Post Insertion Management and SPC Catheter Change Within Hospital Setting - Adults

PR2014_021 Suprapubic Catheter Change in the Community Setting

PR2012_015 Surgery - Cancellations/Postponements on the Day of Surgery - Operating Suite Patient Management

PR2009_323 Surgical Implants - Intraoperative management

PR2010_247 Surgically Removed Tissue or Explanted items - returning to a patient or next of kin

PR2009_202 Swallowing and Nutritional Management of Patients - CCLHD (Interim)

PR2008_038 Swinging Beds - Identification of Virtual and Maintenance of - CCLHD

GE2015_005 Target Temperature Management post Cardiac Arrest

PO2017_002 Task Assessment and Competency Assessment

PR2010_307 Taxi Travel

PR2010_315 Therapeutic Plasma Exchange Procedure: Spectra Optia Apheresis System

PR2015_017 Tirofiban - Intravenous

PR2017_036 Tocilizumab (ACTEMRA) Infusion for Paediatric Patients

PR2018_010 Tonsillectomy - Paediatric Day Stay

PR2015_010 TOP 5 Procedure

PR2014_035 Topical Anaesthetics in Children

PO2007_003 Topical Antimicrobial Dressing Policy

PR2009_171 Tourniquet (pneumatic) - management in Operating Suites

GE2010_041 Toys and Play Equipment - Cleaning and Disinfection

PR2009_315 Tracheostomy Care & Management in Adults

PR2009_198 Traction Application of - CCH

PR2012_054 Transdermal Medications - Prescribing and Administration in Inpatient Care Settings

PR2010_070 Transfer and Escort of Patients within a Facility

GE2012_012 Transfer of Care Guideline

PR2010_292 Transfer of Critically Ill or Ventilated Patients Within One Facility

PR2009_203 Transfer of Critically Ill Patients Inter-Hospital

GE2017_008 Transit/Discharge Lounge - transfer of patients to

GE2014_003 Transition Bed Guideline

PR2012_044 Transoesophageal Echocardiogram (TOE) in Diagnostic Cardiology CCLHD / Division of Medicine - preparing and scope reprocessing for

PR2016_067 Transoesophageal Echocardiogram (TOE)

PR2009_047 Transoesphageal Echocardiogram

PR2009_117 Transport of Critically Ill, Ventilated or High Dependency Patients to the Magnetic Resonance Imaging (MRI) Suite

PR2009_186 Transport Options for Mental Health Consumers

PR2016_012 Transthoracic Echocardiogram

PR2016_035 Travel - Domestic Travel Procedure

PR2016_034 Travel - Overseas Travel Procedure

PR2009_285 Tuberculosis - Infection Prevention and Control Management of the Infectious Patient in Acute Care Settings

PR2013_014 Uniform for Nurses and Midwives

PR2009_410 Universal Health Home Visiting (UHHV) Child and Family Health Nursing

PR2016_009 Urinary Catheterisation of Children



PR2010_153 Urinary Retention - Management

PR2009_224 Urine Specimen - collection from an ilial conduit

GE2008_031 Use of Natalizumab (Tysabri) in the Ambulatory Care Unit - CCH

PR2016_037 Vacated/Unoccupied Buildings - management of within CCLHD

PR2009_228 Vaginal Medications - Insertion of

PR2009_350 Vaginal Pack Removal

GE2011_005 Vancomycin Dosing and Administration in Adults

GE2012_015 Vasopressor and Inotropic Infusion Management

PR2017_095 Venepuncture and Blood Collection - Adults

PR2015_013 Venesection - Therapeutic within Cancer Services

PR2008_035 Venous Sampling Line - Paediatric

GE2016_003 Venues/Locations, Non CCLHD Owned - Conducting Activities in

PR2010_266 Viral Gastroenteritis - infection Prevention and Control Management of the Patient in Acute Care Settings

PR2011_011 Visitor Access and Entry into Mental Health Inpatient Units

PO2016_002 VMO Meetings, Teaching, Committees - Eligible for Payment

PR2009_236 VRE - Infection Prevention and Control Management of the Patient in Acute Care Settings

GE2009_088 VRE - Screening and Clearance of Patients

GE2017_011 Warfarin Prescribing - Adults - CCLHD

PO2009_010 Waste Management and Resource Recovery Policy - CCLHD

PO2012_001 Weighing of Patients within CCLHD

PR2011_079 Weighted Blankets - use within Mental Health Inpatient Units

PR2006_001 Welcome to Country

PO2008_029 Work Health & Safety Policy

GE2008_034 Wound Assessment

PR2015_037 Wound Cleansing and Irrigation - products and techniques

PO2008_034 Wound Debridement - Hospital and Community

GE2009_039 Wound Management of Malignant Wounds

PR2009_189 Wound Packing - Insertion and Removal

PO2008_040 Wound Photography Consent Policy - CCLHD

PR2016_020 Wound Swab Procedure

PR2007_035 Wounds - Probing of Acute and Chronic Wounds

GE2012_003 Wyong Coronary Care Unit (CCU), Medical 2 Telemetry / Cardiac Monitored Beds - admission to

PR2014_031 X-Ray Access to CCLHD Transitional Care Units (Mobile)

cclhd policies, procedures, guidelines...pr2010_281 cytotoxic medications via an ommaya reservoir -...

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