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DOCUMENT ID DOCUMENT TITLE NBMT-POLY010096 Motor Vehicle Policy NBMT-POLY010767 Liability Claims Policy and Procedures NBMT-POLY010769 Miscellaneous Claims Policy and Procedures NBMT-POLY011214 Care and Handling of Specimens NBMT-POLY100021 Electronic Rostering System and Sign Off NBMT-POLY100137 Medical Imaging Network - Electronic Notification of Significant Findings-SWAHS NBMT-POLY100238 Volunteer Policy SWAHS NBMT-POLY100306 Strategic Procurement: Installation of Alarms and Security Systems-swahs NBMT-POLY100651 Peripheral Intravenous Cannula Insertion and Management NBMT-POLY100655 Medication Administration Policy for Nurses and Midwives NBMT-POLY100656 Secondary Employment NBMT-POLY100704 Records Management NBMT-POLY100714 Mobile Rehabilitation Team (MRT) Operational Policy NBMT-POLY100752 Managing Annual Leave NBMT-POLY100785 Handling Cytotoxic Drugs and Related Waste NBMT-POLY100805 Calcium: Treatment of Hypocalcemia, Hypercalcaemia and Electrolyte Supplementation NBMT-POLY100807 A Protocol for Potassium - Treatment of Hypokalaemia and Hyperkalaemia NBMT-POLY100808 Magnesium: Treatment of Hypomagnesaemia, Hypermagnesaemia and Electrolyte Supplementation NBMT-POLY100825 Reportable Incident Brief (RIB) NBMT-POLY100849 Consumer Representative Engagement NBMT-POLY100850 Safe Introduction of New/Altered Interventional Procedures, Technologies or Treatments into Clinical Practice NBMT-POLY100852 Anti-Fungal Prophylaxis in Patients on Peritoneal Dialysis NBMT-POLY100870 Hybrid Medical Record NBMT-POLY100871 Administrative Management of Admitted Patients NBMT-POLY100879 Media Policy NBMT-POLY100915 Somerset Cottage Early Childhood Education and Care Information and Record Keeping NBMT-POLY100964 Workers Compensation and Injury Management NBMT-POLY100978 Dress Code and Uniform Policy NBMT-POLY100985 Hazardous Manual Tasks NBMT-POLY100987 Work Health and Safety NBMT-POLY100991 Recruitment and Appointment of Junior Medical Staff NBMT-POLY100994 NBMLHD Flexible Work Practices NBMT-POLY101117 Somerset Cottage Education and Care Medical Conditions NBMT-POLY101119 Somerset Cottage Education and Care Medication NBMT-POLY101127 Antimicrobial Formulary Restrictions NBMT-POLY101149 Events Policy POLICIES AND PROCEDURES Current Listing as at 4 September 2020 - Copies Available on Request

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Page 1: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

DOCUMENT ID DOCUMENT TITLENBMT-POLY010096 Motor Vehicle Policy

NBMT-POLY010767 Liability Claims Policy and Procedures

NBMT-POLY010769 Miscellaneous Claims Policy and Procedures

NBMT-POLY011214 Care and Handling of Specimens

NBMT-POLY100021 Electronic Rostering System and Sign Off

NBMT-POLY100137 Medical Imaging Network - Electronic Notification of Significant Findings-SWAHS

NBMT-POLY100238 Volunteer Policy SWAHS

NBMT-POLY100306 Strategic Procurement: Installation of Alarms and Security Systems-swahs

NBMT-POLY100651 Peripheral Intravenous Cannula Insertion and Management

NBMT-POLY100655 Medication Administration Policy for Nurses and Midwives

NBMT-POLY100656 Secondary Employment

NBMT-POLY100704 Records Management

NBMT-POLY100714 Mobile Rehabilitation Team (MRT) Operational Policy

NBMT-POLY100752 Managing Annual Leave

NBMT-POLY100785 Handling Cytotoxic Drugs and Related Waste

NBMT-POLY100805 Calcium: Treatment of Hypocalcemia, Hypercalcaemia and Electrolyte Supplementation

NBMT-POLY100807 A Protocol for Potassium - Treatment of Hypokalaemia and Hyperkalaemia

NBMT-POLY100808 Magnesium: Treatment of Hypomagnesaemia, Hypermagnesaemia and Electrolyte

Supplementation

NBMT-POLY100825 Reportable Incident Brief (RIB)

NBMT-POLY100849 Consumer Representative Engagement

NBMT-POLY100850 Safe Introduction of New/Altered Interventional Procedures, Technologies or

Treatments into Clinical Practice

NBMT-POLY100852 Anti-Fungal Prophylaxis in Patients on Peritoneal Dialysis

NBMT-POLY100870 Hybrid Medical Record

NBMT-POLY100871 Administrative Management of Admitted Patients

NBMT-POLY100879 Media Policy

NBMT-POLY100915 Somerset Cottage Early Childhood Education and Care Information and Record Keeping

NBMT-POLY100964 Workers Compensation and Injury Management

NBMT-POLY100978 Dress Code and Uniform Policy

NBMT-POLY100985 Hazardous Manual Tasks

NBMT-POLY100987 Work Health and Safety

NBMT-POLY100991 Recruitment and Appointment of Junior Medical Staff

NBMT-POLY100994 NBMLHD Flexible Work Practices

NBMT-POLY101117 Somerset Cottage Education and Care Medical Conditions

NBMT-POLY101119 Somerset Cottage Education and Care Medication

NBMT-POLY101127 Antimicrobial Formulary Restrictions

NBMT-POLY101149 Events Policy

POLICIES AND PROCEDURESCurrent Listing as at 4 September 2020 - Copies Available on Request

Page 2: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-POLY101155 NSW Health Code of Conduct

NBMT-POLY101161 Recruitment and Appointment of Postgraduate Fellows Remunerated Under Award

Conditions

NBMT-POLY101163 Medical Appointments Framework

NBMT-POLY101211 Bullying - Prevention and Management of Workplace Bullying in NSW Health

NBMT-POLY101229 Somerset Cottage Early Childhood Education and Care Relationships with Children

NBMT-POLY101232 Clinical Supervision - Allied Health

NBMT-POLY101299 Somerset Cottage Early Childhood Education and Care Enrolled Child Incidents, Trauma

& Injury Including Serious and Potentially Fatal Incidents

NBMT-POLY101332 Statewide Standing Orders for the Supply or Administration of Medication for Public

Health Response

NBMT-POLY101354 Database Backup (for Locally Managed and Implemented Databases)

NBMT-POLY101409 Pastoral Care

NBMT-POLY101416 Human Immunodeficiency Virus (HIV): Antiretroviral Post-Exposure Prophylaxis

NBMT-POLY101435 Somerset Cottage Early Childhood Education and Care Acceptance and Refusal of

Authorisations

NBMT-POLY101628 Guardianship and Financial Management within Aged Care Wards at Nepean Hospital

NBMT-POLY101637 Somerset Cottage Early Childhood Education and Care Water Safety

NBMT-POLY101640 Patient Handling (No Lift)

NBMT-POLY101647 Somerset Cottage Early Childhood Education and Care Sun Protection

NBMT-POLY101652 Wireless LAN Access and Security

NBMT-POLY101662 Photography and Video Recording by Patients and their Families

NBMT-POLY101663 Access Arrangements to the Children's Ward Across NBMLHD by Companies/Individuals

who are Donating Raised Funds/Gifts

NBMT-POLY101673 Emergency Department Nurse Initiated X-rays for Isolated Limb Injuries

NBMT-POLY101953 Grading, Regrading and Reclassification

NBMT-POLY102003 Somerset Cottage Early Childhood Education and Care - Delivery of Children to and Safe

Collection of Children

NBMT-POLY102010 The Dispensing and Administration of Intravenous Vincristine - Classified as a High Risk

Medication

NBMT-POLY102013 Fraud and Corruption Strategy

NBMT-POLY102107 NBMLHD Employee Reward and Recognition Program

NBMT-POLY102108 Performance Development and Management

NBMT-POLY102125 Management of Non-Work Related Injuries or Health Conditions

NBMT-POLY102136 Somerset Cottage Early Childhood Education and Care Governance

NBMT-POLY102138 Somerset Cottage Management of Infectious Diseases and Immunisation

NBMT-POLY102149 Somerset Cottage Early Childhood Education and Care Information and Communication

Technology

NBMT-POLY102178 Somerset Cottage Early Childhood Education and Care Nutrition

NBMT-POLY102292 Safeguarding Adults at Risk from Abuse

NBMT-POLY102314 Consumer and Community Participation Framework

NBMT-POLY102352 Criteria for Surgery and General Anaesthesia at BMDAMH and Springwood Hospitals

NBMT-POLY102377 Clinical Item Management (includes clinical equipment)

NBMT-POLY102378 Corporate Items Management

NBMT-POLY102382 Normal Vaginal Birth

Page 3: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-POLY102455 Radiographer's Practice

NBMT-POLY102468 Admission Criteria and Transfer - Blue Mountains District ANZAC Memorial Hospital and

Springwood Hospital

NBMT-POLY102471 Career Break Scheme for Nurses and Midwives

NBMT-POLY102542 Separation of Employment

NBMT-POLY102543 NBMLHD Recognition of Service Awards - All Staff

NBMT-POLY102576 Somerset Cottage Food Safety Plan

NBMT-POLY102577 Somerset Cottage Early Childhood Education and Care Sleep, Rest and Relaxation

NBMT-POLY102578 Somerset Cottage Early Childhood Education and Care Educational Program and Practice

NBMT-POLY102579 Somerset Cottage Early Childhood Education and Care Management and Storage of

Chemicals

NBMT-POLY102585 Paediatric Hospital in the Home (HITH)

NBMT-POLY102588 Somerset Cottage Early Childhood Education and Care Fee

NBMT-POLY102590 Somerset Cottage Early Childhood Education and Care Clothing and Comfort

NBMT-POLY102591 Somerset Cottage Early Childhood Education and Care Access, Enrolment and

Orientation

NBMT-POLY102602 Somerset Cottage Early Childhood Education and Care Environmental Sustainability

NBMT-POLY102650 Formulary Management

NBMT-POLY102796 Nepean Adult Hospital in the Home (HITH)

NBMT-POLY102805 ICT Access Control

NBMT-PROC010159 Weapons in SWAHS Facilities

NBMT-PROC010594 Management of Missed Doses of Buprenorphine or Buprenorphine/Naloxone in

NBMLHD Opioid Treatment Program Clinics

NBMT-PROC010601 Management of Missed Doses of Methadone

NBMT-PROC010931 Rehabilitation Medicine Inpatient Referral and Transfer Procedure

NBMT-PROC100004 Acute Management of Croup in Paediatric Patients

NBMT-PROC100008 Nurse Initiated Oral Paracetamol For Paediatric Patients

NBMT-PROC100013 Clinical Coding Procedure

NBMT-PROC100024 Hospital management of Paediatric Patients with Multiple Disabilities

NBMT-PROC100025 Procedure - Processing Subpoenas for Health Care Records

NBMT-PROC100026 Application for Access to Health Care Records by Patients or Clients

NBMT-PROC100029 Management of Women with a Delay in the Onset of Lactation and/or a Low Milk Supply

NBMT-PROC100030 Issuing of Sickness Certificates by Physiotherapists

NBMT-PROC100034 Complementary feeding of a breastfeeding infant up to six months of age

NBMT-PROC100036 Infant Feeding: Maintenance of Lactation and Management of Common Breastfeeding

ChallengesNBMT-PROC100038 Product Recalls, Safety Alerts and Notices

NBMT-PROC100041 Infant Feeding: Feeding More than One Infant

NBMT-PROC100042 Infant Feeding: Supporting Parents Breastfeeding their Premature or Sick Infant

NBMT-PROC100047 Medical Assessment and Care of Sexual Assault Complainants who Present to the ED

NBMT-PROC100049 Paediatric Lumbar Puncture

NBMT-PROC100050 Intraosseous Access in Paediatric Patients Using the EZ-IO

NBMT-PROC100051 Preparation of Inpatient Infants and Children for CT Scan (Under sedation)

NBMT-PROC100052 Management of Sudden Unexpected Death in Infancy (SUDI)

NBMT-PROC100053 Surveillance of the Newborn following Instrumental Delivery

NBMT-PROC100054 Immunisation: Neonatal

Page 4: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC100055 Peripheral Intravenous Cannula in the Neonate: Insertion, Management and Removal of

NBMT-PROC100060 Nurse/Midwife Practitioner Authorisation

NBMT-PROC100061 Gentamicin Administration in Paediatrics

NBMT-PROC100062 Management of IV Therapy and Cannula Care in Paediatrics

NBMT-PROC100071 Organ and Tissue Donation after Death Confirmed by Irreversible Cessation of the

Circulation of Blood in the Person's Body (DCD) (For the purpose of transplantation into

the body of a living person and or for research or other scientific purposes)

NBMT-PROC100078 Cleaning and Reprocessing of Reusable Infant Feeding Equipment

NBMT-PROC100080 Nepean Imaging Department: Intravenous Administration of Contrast Media in CT

NBMT-PROC100083 Nurse Initiated Lignocaine/Prilocaine (EMLA) For Paediatric Patients

NBMT-PROC100170 Lithgow Hospital Sterilising Department Traceability System - SWAHS

NBMT-PROC100179 Procedure on Approved Abbreviations for Use in the Health Care Record - SWAHS

NBMT-PROC100195 Pre-Discharge X-Rays and Discharge Pending X-Rays-SWAHS

NBMT-PROC100222 Lost and Found Property- SWAHS

NBMT-PROC100312 Safe Handling of Glutaraldehyde - SWAHS

NBMT-PROC100332 Allocation arrangements for SWAHS vehicles - SWAHS

NBMT-PROC100376 Tube Care - Gastrostomy/Jejunostomy Replacement

NBMT-PROC100378 Nasogastric Tube Insertion/Removal: Adults

NBMT-PROC100383 Management of Health Care Records

NBMT-PROC100427 Managing Malignant Hyperthermia SWAHS

NBMT-PROC100454 Crown and Bridge and Indirect Restorative Treatment

NBMT-PROC100456 Oral Health: Treatment Planning of Removable Dentures

NBMT-PROC100457 Oral Health: Endodontic Treatment - Selection Criteria

NBMT-PROC100458 Oral Health: Management of Patients Presenting with Head Lice

NBMT-PROC100477 Paracetamol Overdose in Children

NBMT-PROC100508 Testing Duress Alarms in SWAHS Facilities - SWAHS

NBMT-PROC100515 Rights of Private Practice - Allied Health Professionals in SWAHS Facilities - SWAHS

NBMT-PROC100526 Shunt Patency Study in Nuclear Medicine

NBMT-PROC100567 Therapeutic Venesection

NBMT-PROC100590 Procedure for Breath-Hold Carboxyhaemoglobin Measurement - Nepean RFL - SWAHS

NBMT-PROC100612 Approach to the patient with suspected Toxic Epidermal Necrolysis (TEN) Stevens

Johnson Syndrome - SWAHS

NBMT-PROC100614 National Recommendations for User-applied Labelling of Injectable Medicines, Fluids

and Lines

NBMT-PROC100640 Management of Medical Gases (portable cylinders) within SWAHS Facilities Procedure -

SWAHS

NBMT-PROC100650 Keeping Babies Safe During Skin-to-Skin Contact

NBMT-PROC100654 Access to and Release of Patient/Client Health Information

NBMT-PROC100657 Nursing Procedure for Administration of Oral Medications to Paediatric Patients while

Fasting

NBMT-PROC100658 Nurse Initiated Amethocaine Gel 4% (Local AnGel®) for Paediatric Patients

NBMT-PROC100661 Water testing for Chlorine, Chloramine in Haemodialysis Units

NBMT-PROC100664 Hypoglycaemia in Paediatric Patient with Diabetes Mellitus

NBMT-PROC100665 Nursing and Midwifery Clinical Handover and Internal Patient Transfer and Escort

NBMT-PROC100666 Water Monitoring and Management of Legionella across NBMLHD

NBMT-PROC100667 Non-Specialist Locum Medical Officers - Engagement and Management

Page 5: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC100668 Release of Clinical Notes to Insurance Companies and Solicitors

NBMT-PROC100710 Management of Registration Currency of Nurses and Midwives

NBMT-PROC100713 Same Gender Accommodation

NBMT-PROC100723 Neonatal Partial Exchange Transfusion

NBMT-PROC100724 Kangaroo Care for Neonates

NBMT-PROC100726 Neonatal Apnoea

NBMT-PROC100728 Syntocinon Induction of Labour

NBMT-PROC100729 Career Medical Officers Continuing Medical Education and Professional Development

Leave

NBMT-PROC100730 Presentation of Pregnant Women to the Emergency Department at Lithgow Health

Service

NBMT-PROC100742 Patient Risk Assessment and Home Visiting Policy for Home Dialysis Nurses in Western

Renal Service

NBMT-PROC100745 Nepean Emergency Admission

NBMT-PROC100749 Carer Identification

NBMT-PROC100753 Sick Leave Management

NBMT-PROC100754 Pressure Injury Prevention, Identification and Management

NBMT-PROC100759 Neonatal Resuscitators: Set up and Use of Laerdel Manual Neonatal Resuscitator

NBMT-PROC100761 Learning and Development Leave

NBMT-PROC100770 Case Management of patients in the Opioid Treatment

NBMT-PROC100771 Management of Victims of Assault who have Suffered Strangulation

NBMT-PROC100775 Methadone, Buprenorphine and Buprenorphine - Naloxone Dosing for In-patients

NBMT-PROC100776 Primary Care and Community Health Safety and Security

NBMT-PROC100779 Continuous Ambulatory Peritoneal Dialysis (CAPD) Exchange - Fresenius Stay Safe

Balance System

NBMT-PROC100780 Continuous Ambulatory Peritoneal Dialysis (CAPD) Exchange - Baxter Freeline Solo Twin-

Bag System

NBMT-PROC100788 Clinical Emergency Response System: Blue Mountains ANZAC Memorial Hospital

Recognition and Management of the Deteriorating Patient and Management of REACH

NBMT-PROC100789 Neonatal Resuscitators: Set up and use of NeopuffTM Infant T-piece Resuscitator (Fisher

& Paykel®)

NBMT-PROC100790 Safe Use of Paracetamol

NBMT-PROC100794 Early Detection and Management of Airway Compromise after Anterior Neck Surgery

NBMT-PROC100795 Morphine Administration during Labour

NBMT-PROC100799 Transfer of Opioid Treatment Patients to Community Pharmacies where Patients are

Prescribed for by NBMLHD Opioid Treatment Program Prescribers

NBMT-PROC100800 Renal Perfusion Scan (DTPA)

NBMT-PROC100801 Harm Minimisation for Infants Postpartum

NBMT-PROC100802 12 Lead Electrocardiograph ECG

NBMT-PROC100803 Management of Neonatal Pneumothorax

NBMT-PROC100804 Paediatric / Adolescent: Education of Long Term Patients at Nepean Hospital

NBMT-PROC100810 Blood Glucose Testing Procedure Using Using Nova Stat Strip Express Meter

NBMT-PROC100813 Management of Complaints or Concerns about Clinicians

NBMT-PROC100814 TAM - Raising an Online Request for Work / Repair (Biomedical & Maintenance)

NBMT-PROC100816 Resuscitation of the Newborn

NBMT-PROC100819 Nepean Hospital Medical Imaging/Nuclear Medicine: Bone Scan

Page 6: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC100820 Renal Scan (DTPA/MAG3) With/Without Lasix

NBMT-PROC100821 Cerebral Angiography - Medical Imaging Department

NBMT-PROC100822 Thyroid Scan/Uptake Study - Nepean Imaging/Nuclear Medicine

NBMT-PROC100823 Renal Cortical Scan (DSMA) Nuclear Medicine Department

NBMT-PROC100824 Nerve Root Block - Nepean Imaging

NBMT-PROC100826 Insertion of a Nephrostomy Catheter in the Medical Imaging Department

NBMT-PROC100827 Drainage Insertion under CT Guidance

NBMT-PROC100828 Nepean Hospital Imaging/Nuclear Medicine Myocardial Perfusion Scan

NBMT-PROC100829 Medical Imaging: Insertion of a Chest Port

NBMT-PROC100830 Gastrointestinal Bleeding Scan

NBMT-PROC100831 Lymphoscintigraphy Scan in the Nuclear Medicine Department

NBMT-PROC100832 Gastric Emptying Scan in the Nuclear Medicine Department

NBMT-PROC100833 Hepatobiliary Scan in the Nuclear Medicine Department

NBMT-PROC100834 Blood Culture Collection - Adults

NBMT-PROC100835 Barium Meal Procedure in the Medical imaging Department

NBMT-PROC100836 Barium Swallow in the Medical Imaging Department

NBMT-PROC100838 Embolisation - Nepean Medical Imaging Department

NBMT-PROC100839 Liver Biopsy under Ultrasound Guidance

NBMT-PROC100840 Transjugular Liver Biopsy - Nepean Medical Imaging DepartmentBiopsy

NBMT-PROC100841 Myelogram

NBMT-PROC100842 CT Enterography

NBMT-PROC100844 CT Guided Fine Needle Aspiration of Lung

NBMT-PROC100845 Vascath Insertion

NBMT-PROC100846 Percutaneous Transhepatic Cholangiogram - Nepean Medical Imaging Department

NBMT-PROC100848 Open Disclosure

NBMT-PROC100851 Peritoneal Dialysis Peritonitis: Acute 48 Hours Treatment Regime

NBMT-PROC100853 Peritoneal Dialysis Related Peritonitis: Follow up Treatment Regime

NBMT-PROC100854 Iron Infusion for Chronic Kidney Disease (CKD) Patients

NBMT-PROC100855 "Failure to Attend" and "Unable to be Contacted" - Primary Care and Community Health

NBMT-PROC100858 Management of Naso-Pharyngoscopes - Nepean Cancer Care Centre

NBMT-PROC100859 Insulin/Glucose Infusion - Nursing Management in Adults

NBMT-PROC100860 Sepsis in a Neonate (Early & Late onset sepsis) Diagnosis and Management

NBMT-PROC100862 Paediatric Urinary Catheterisation

NBMT-PROC100864 Central Venous Access Devices (CVAD) Procedures in Paediatrics

NBMT-PROC100865 Employing from Allied Health Short Term Staff Pool

NBMT-PROC100872 NBMLHD Executive - Escalation Process and Expectations

NBMT-PROC100882 Chicken Pox Exposure (Varicella Zoster Virus (VZV)) in Pregnancy

NBMT-PROC100883 Allied Health Clinical Handover - Acute and Sub-acute Care

NBMT-PROC100887 Clinical Emergency Response System - Lithgow Hospital : Recognition and Management

of the Deteriorating Patient

NBMT-PROC100888 Exchange Transfusion in the Neonate at Nepean NICU

NBMT-PROC100890 Urinary Catheterisation in the Neonate

NBMT-PROC100891 Thermoregulation for the Neonate - Small Baby

NBMT-PROC100892 Nurse Initiated Supplemental Oxygen Therapy in Paediatric Patients on the Paediatric

Ward

NBMT-PROC100945 Umbilical Venous Catheter Insertion in Neonates

Page 7: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC100947 Home Dosing of Patients - Opioid Treatment Program

NBMT-PROC100948 Management of Cyanotic Episodes in Neonates

NBMT-PROC100952 Gate Pass for Inpatients Under the Care of Nepean Cancer Services

NBMT-PROC100954 Removal of Intra-Aortic Balloon Catheter

NBMT-PROC100957 External Pacing

NBMT-PROC100959 ACT (Hemochron Response) as a Guide to Arterial Sheath Removal

NBMT-PROC100961 Digital Compression for Removal of Femoral Arterial Sheath

NBMT-PROC100962 Electrical Cardioversion at Nepean Hosiptal

NBMT-PROC100972 Management of Administrative Records

NBMT-PROC100974 Fem-o-Stop Application and Management

NBMT-PROC100975 Day-Only Pacemaker Insertion in the Cardiac Catheter Laboratory at Nepean Hospital

NBMT-PROC100984 Clozapine Initiation

NBMT-PROC100986 Clinical Handover

NBMT-PROC100988 Routine Probiotics for Preterm Neonates at Nepean Hospital Intensive Unit

NBMT-PROC100997 Care of the Patient Pre and Post Electrophysiological Study (EPS)

NBMT-PROC101000 Cardiac Procedure for MET during Transfer of Patients between Nepean Private Hospital

and the Cardiac Cath Lab at Nepean

NBMT-PROC101005 Use of Microwave Moist Heat Pack for a Patient with Cancer requiring Peripheral

Intravenous Cannulation (PIVC)

NBMT-PROC101007 i.PM Patient Registration Procedure

NBMT-PROC101008 Administration of High Flow Nasal Cannula Oxygen and the Acute Management of

Bronchiolitis in Paediatric Patients

NBMT-PROC101021 Management of Malignant Ascites Using the Pleurx Drainage System

NBMT-PROC101022 Management of Topical Negative Pressure Therapy

NBMT-PROC101025 NAS - Neonatal Abstinence Syndrome: Diagnosis and Management

NBMT-PROC101026 Paracentesis for the Management of Ascites

NBMT-PROC101029 Medical Imaging: Interventional Bookings for Angiography, Fluoroscopy, Ultrasound and

CT

NBMT-PROC101031 Vascular Stent with or without Angioplasty – Nepean Medical Imaging Department

NBMT-PROC101032 Peripheral Angiography - Nepean Medical Imaging Department

NBMT-PROC101033 Administration of Blood and Blood Components - Management of Transfused Patients

NBMT-PROC101036 Nepean Imaging - Cardiac CT

NBMT-PROC101037 Medical Imaging - Correct Patient, Correct Procedure and Correct Site

NBMT-PROC101038 Tube Feeding in Neonates: Gastric and Transpyloric

NBMT-PROC101039 CPAP: Continuous Positive Airway Pressure via Drager™ Ventilation

NBMT-PROC101040 CPAP/BiPAP : Non Invasive Nasal Ventilation Using the Viasys Infant Flow® SiPAPTM

Machine

NBMT-PROC101044 Vomiting Neonates - Management

NBMT-PROC101045 Ostomy Care: Infant Practice

NBMT-PROC101046 Pulse Oximetry Screening for Congenital Heart Defects in Newborn Infants

NBMT-PROC101048 Nepean Outreach Service Community Staff Safety and Security

NBMT-PROC101049 Management of Subcutaneous Medications in Palliative Care: Intermittent Injections

and Continuous Subcutaneous Infusion via BD Saf-T Intima, NIKI T34 TM and NIPRO

SurefuserTM+ Devices

NBMT-PROC101050 Neonatal Hypoglycaemia Management

NBMT-PROC101051 Nappy Rash and Epidermal Stripping in Neonates

Page 8: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101052 Transcutaneous Monitoring (TCM) in the Neonate

NBMT-PROC101053 Inpatient Telephone Enquiries - Release of Information

NBMT-PROC101057 Newborn Discharge Baby Checks

NBMT-PROC101059 Humidified High Flow Nasal Cannula Oxygen using Fisher & Paykel Delivery System

(Neonatal)

NBMT-PROC101060 Weight Management in Pregnancy

NBMT-PROC101061 Insertion of Central Venous Catheter and Post Insertion Care for Neonates

NBMT-PROC101063 Nursing Care of Adult Vascular Access Devices including: Central Venous Catheter,

Hickmans and Portacaths

NBMT-PROC101076 Neonatal Capillary Sampling

NBMT-PROC101077 Management of Preterm Premature Rupture of Membranes (PPROM)

NBMT-PROC101078 Recognition of a Sick Baby or Child in the Emergency Department

NBMT-PROC101080 Fetal Fibronectin (fFN) - A Screening Test for Preterm Labour

NBMT-PROC101081 Managing External Organisations Usage of Community Health Facilities

NBMT-PROC101084 Administration of the Edinburgh Depression Scale (EDS/EPDS) Conducted in the

Antenatal and Postnatal Period (and considerations for referrals with a positive response

for Question 10)

NBMT-PROC101116 Management of Tuberculosis

NBMT-PROC101118 Somerset Cottage Education and Care Management of Fever

NBMT-PROC101126 Release of Patient/Client Information for Ongoing Care by Health Information and

Records Services, and Community Health Centres

NBMT-PROC101133 Bathing a baby - up to 3 months

NBMT-PROC101138 Nepean Imaging/Nuclear Medicine Cerebral Perfusion (Diamox) Scan

NBMT-PROC101139 Speculum Examination in Obstetrics

NBMT-PROC101145 Administration of Intranasal Fentanyl for Paediatric Patients

NBMT-PROC101146 Initiation and Management of Non-Invasive Ventilation (NIV)

NBMT-PROC101147 Urinary Procedures and Collection of Adequate Urine Specimens in Infants and Children

NBMT-PROC101148 Medical Imaging - Reporting of Medical Images Performed in Error

NBMT-PROC101151 Diabetic Ketoacidosis - DKA - Medical and Nursing Management in the Adult

NBMT-PROC101159 Renal Cyst Aspiration and Sclerotherapy-Medical Imaging

NBMT-PROC101164 Booking of Elective Caesarean Sections

NBMT-PROC101166 Prevention of Falls and Harm from Falls in Adult Inpatients

NBMT-PROC101185 Water Immersion for Labour and Birth

NBMT-PROC101199 Drug & Alcohol: Duress Alarm Response - Woodlands Clinic, BMDAMH

NBMT-PROC101200 Duress Alarm Response - Lithgow Opioid Program (OTP) Clinic

NBMT-PROC101201 Duress Alarm - Gateway Opioid Treatment Program (OTP) Clinic

NBMT-PROC101202 Duress Alarm Response - Centre for Addiction Medicine, Nepean

NBMT-PROC101203 Management of Patients that Vomit after Receiving a Methadone, Buprenorphine or

Buprenorphine/Naloxone Dose in NBMLHD Opioid Treatment Program Clinics

NBMT-PROC101210 Appointment of Medical Observers and Medical Visitors

NBMT-PROC101212 Pathology Specimen Labelling - Acceptance, Rejection and Cancellation

NBMT-PROC101214 QARS Developing an Audit, Governance and Monitoring

NBMT-PROC101223 Passy Muir Speaking Valve for NON-VENTILATED Tracheotomised Patients: Including

Humidification NBMT-PROC101226 Use of Nitrous Oxide (N2O) in Paediatrics

NBMT-PROC101228 Management of the Deteriorating Child Requiring a Higher Level of Care

NBMT-PROC101233 TOP 5/This is ME Strategies to Support Care and Communication

Page 9: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101241 Information and Referral to the Involuntary Drug and Alcohol Treatment Program (NSW

Drug and Alcohol Treatment Act 2007)

NBMT-PROC101242 Intravenous to Oral Antibiotic Step-Down Guide

NBMT-PROC101243 Management of Skin Tears

NBMT-PROC101244 Accessing and Storing of Schedule 8 Drug Keys at Nepean Hospital

NBMT-PROC101274 Muscle Relaxed Neonate - Nursing Care of

NBMT-PROC101276 Ongoing Management of the Surgical Patient when Surgeon is Offsite at Lithgow

NBMT-PROC101277 Humidified High Flow Nasal Cannula Oxygen Therapy for Adult Patients

NBMT-PROC101278 Cooling: Induced Systemic Hypothermia for the Treatment of Neonatal Hypoxic

Ischaemic Encephalopathy (HIE)

NBMT-PROC101279 Active Follow-Up and Opportunistic Immunisation of Children and Adolescents in the

Hospital Setting

NBMT-PROC101280 3-Lead Electrocardiograph (ECG) Monitoring in Paediatrics and Neonates

NBMT-PROC101282 Management of Shoulder Dystocia

NBMT-PROC101283 Renal Dialysis Unit: Nursing Management of Complications related to Haemodialysis:-Air

Embolism; Dialyzer Reaction and Anaphalaxis

NBMT-PROC101284 Oral Health: QARS Clinical Care Audit

NBMT-PROC101285 QARS: Oral Health Care Record Completeness Audit

NBMT-PROC101286 Developing a Telehealth Outpatient Clinic/Ambulatory Care Service

NBMT-PROC101287 Mifepristone and Misoprostol for Second Trimester Induction of Labour

NBMT-PROC101288 Work Health and Safety Incident and Hazard Reporting

NBMT-PROC101289 QARS Monthly Work Health Safety and Environmental Inspection Audit

NBMT-PROC101300 Management of Incorrect Dose (Overdose) of Methadone Administered in NBMLHD

Opioid Treatment Program Clinics

NBMT-PROC101302 Work Health and Safety for Construction Work and Construction Contractors

NBMT-PROC101307 eQATE Environmental Cleaning Audit

NBMT-PROC101311 Proximity to Facilities for Oncall Medical Staff

NBMT-PROC101319 Safe Start - From the Antenatal Period to 2 Weeks Postpartum

NBMT-PROC101325 Appointment of Nursing and Midwifery Observers

NBMT-PROC101327 Prevention of Contrast Induced Nephropathy

NBMT-PROC101329 Management of External Service Providers

NBMT-PROC101333 Pharmaceutical Company Representatives

NBMT-PROC101335 Conventional Ventilation of the Neonate via Drager Babylog 8000plus

NBMT-PROC101336 Management of Late Preterm Babies in Post natal Ward

NBMT-PROC101337 Patient Identification in the Administration of Medication to Patients Engaged in the

NBMLHD Opioid Treatment Program

NBMT-PROC101338 Management of Methadone, Buprenorphine and Buprenorphine/Naloxone Dose

Diversion by Patients Engaged in the Opioid Treatment Program

NBMT-PROC101339 Drug and Alcohol: QARS - Patient Identification in the Administration of Medication to

Patients Engaged in the Opioid Treatment Program

NBMT-PROC101342 Petty Cash and Petty Cash Floats

NBMT-PROC101349 Allied Health Honorary Appointments

NBMT-PROC101350 Safer Sleeping Practices for Babies within the NBMLHD Maternity Services

NBMT-PROC101351 QARS Drug & Alcohol Clinical Documentation Audit

NBMT-PROC101358 Mental Health: Restraint and Mechanical Restraint

Page 10: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101359 Involuntary Discharge from the Nepean Blue Mountains LHD Opioid Treatment Program

NBMT-PROC101365 Management of Patients with Bariatric Needs

NBMT-PROC101367 Oral Health: Management of Patients with a Multi Resistant Organism (MRO) in a Dental

Setting

NBMT-PROC101368 Oral Health: Indications of Preformed Metal Crowns (PMC)

NBMT-PROC101369 Oral Health: Indications for Space Maintainers

NBMT-PROC101370 Oral Health: Use of Dental Imaging

NBMT-PROC101371 Oral Health: Prevention of Endocarditis Following Dental Treatment

NBMT-PROC101373 Organ and Tissue Donation After Death - Confirmed by Irreversible Cessation of all

Function of a Persons Brain (DBD) (For the Purpose of Transplantation into the Body of a

Living Person and/or for Research or Other Scientific Purposes)

NBMT-PROC101379 COVID-19: Home Visiting and Community Outreach for D&A Psychosocial Interventions

within the Drug and Alcohol Service

NBMT-PROC101381 Rostering Best Practice

NBMT-PROC101385 Oral Health: Management of Dental Postoperative Complications

NBMT-PROC101386 Processing Requests for Health Care Records for the Coroner

NBMT-PROC101390 Prescription and Management of Immunoglobulins

NBMT-PROC101391 Methotrexate - Safe Use Of Oral Methotrexate For Non-Oncology, Non-Haematology

Indications

NBMT-PROC101394 Admission to Mental Health Inpatient Care

NBMT-PROC101396 QARS Audit, Falls Prevention and Management of Falls (inpatient)

NBMT-PROC101397 Clean Linen Supply Delivery Roll on Roll off System - Nepean Hospital Linen Services

NBMT-PROC101398 Venous Thromboembolism (VTE) Risk Assessment Tool

NBMT-PROC101400 QARS: Babies - Sleeping Practices

NBMT-PROC101403 QARS: Pharmacist only S8 and S4D Register Audit

NBMT-PROC101413 QARS Patient/Client Privacy Awareness Audit

NBMT-PROC101418 Provision of Health Services to Patients from Corrective Services NSW

NBMT-PROC101419 Basic Life Support: Recognition and Management of the Deteriorating Patient

NBMT-PROC101420 Clinical Emergency Response System Nepean Hospital - Recognition & Management of

the Deteriorating Patient

NBMT-PROC101424 QARS: Administration of Blood and Blood Products Intravenous Immunoglobulins

Developing an Audit, Governance and Monitoring

NBMT-PROC101426 Removal of Temporary (Non-Tunnelled/Uncuffed) Vascular Catheter Used for

Haemodialysis by a Registered Nurse

NBMT-PROC101427 Finger Cots - Use in Neonatal Units

NBMT-PROC101430 Adverse Reaction Reporting

NBMT-PROC101433 Mental Health: Cleaning Services to Mental Health Inpatient Units at Nepean Campus

NBMT-PROC101434 Mental Health: Catering Services and Meal Deliveries to Inpatient Mental Health Units at

Nepean Hospital

NBMT-PROC101436 Completion of Summary of Injuries

NBMT-PROC101437 Paediatric Falls Prevention

NBMT-PROC101438 Credentialing for Insertion of Adult Peripheral Intravenous Cannula (PIVC)

NBMT-PROC101439 Ketamine Analgesic Infusions in Adult Patients (>16 years)

NBMT-PROC101440 Analgesic Transdermal 'Patch' Medications: Prescribing and Administration

NBMT-PROC101441 Patient Controlled Analgesia (Intravenously)

Page 11: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101442 Continuous Epidural Analgesia

NBMT-PROC101443 Mental Health: Searching People and their Property

NBMT-PROC101444 Nomination of Designated Officers and Designated Specialists

NBMT-PROC101447 Recognition and Management of Patients who are Clinically Deteriorating

NBMT-PROC101451 High Risk Medicines Management

NBMT-PROC101454 Mental Health: Bereavement

NBMT-PROC101456 Management of Nursing Staff who are Pregnant, Breast feeding or Planning Pregnancy

NBMT-PROC101468 Medical Clinical Handover: After Hours Junior Medical Staff Nepean Hospital

NBMT-PROC101472 Clinical Documentation in the Health Care Record

NBMT-PROC101487 Very Low Energy Diet (VLED) for Inpatients

NBMT-PROC101488 Use of Personal Electronic Devices

NBMT-PROC101489 Nurse Initiated Pathology Collection for Multi Resistant Organisms (MRO) Screening

NBMT-PROC101490 Admission and Transfer of Patients on Peritoneal and Haemodialysis in Non-Tertiary

Facilities

NBMT-PROC101491 Medpass

NBMT-PROC101492 Patient Identification and Alert Bands

NBMT-PROC101493 Managing Early/Unexpected Inpatient Discharges or Transfers - Dietetics

NBMT-PROC101494 Unfractionated Heparin Infusion - Treatment of Venous and Arterial Thrombosis; the

Management of Acute Coronary Syndrome and Anti-coagulation Post Thrombolytic

Therapy

NBMT-PROC101496 Renal Biopsy Under Ultrasound Guidance

NBMT-PROC101498 How to Tattoo Patients Undergoing Radiotherapy at NCCC

NBMT-PROC101499 Medication Reconciliation Adapted from the ACSQHC document "National Medication

Management Plan User Guide"

NBMT-PROC101507 Trial of Void for Women undergoing Gynaecological Surgery and Postnatal Patients

(where indicated)

NBMT-PROC101510 Allied Health Credentialing and Defining Scope of Practice

NBMT-PROC101512 Adult Pain Management in Post Anaesthetic Care Unit

NBMT-PROC101514 Completion of Certificates of Expert Evidence for NSW Police Force

NBMT-PROC101520 Medication Management: Gate Leave

NBMT-PROC101521 Medical Outpatient Department - Nepean Hospital

NBMT-PROC101527 Screening for Malnutrition of Adult Inpatients in NBMLHD Facilities

NBMT-PROC101528 Nutritional Management of Inpatients - Dietetics Services

NBMT-PROC101529 Management of Umbilical Cord Prolapse

NBMT-PROC101530 Coroners Case - Neonatal

NBMT-PROC101531 Clinical Supervision - Central Referral Service

NBMT-PROC101532 Management of Neonates with Surfactant Administration

NBMT-PROC101534 Endotracheal Suctioning of the Neonate

NBMT-PROC101539 Transition of Paediatric Patients With Chronic and Complex Health Issues to Adult Based

Care

NBMT-PROC101627 Mental Health: Seclusion

NBMT-PROC101630 Wayfinding and Signage

NBMT-PROC101631 Eye and Tissue Only Donation following Death

NBMT-PROC101633 Mental Health: Accredited Persons

NBMT-PROC101634 Maintenance and/or Visiting Contractor Staff Accessing the Nepean Hospital Mental

Health Unit/s to Carry out Work

Page 12: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101635 A Protocol for Phosphate: Treatment of Hypophosphataemia and Hyperphosphataemia

NBMT-PROC101639 Management of Chest Pain on Haemodialysis

NBMT-PROC101658 Management of Intradialytic Hypotensive Episodes on Haemodialysis

NBMT-PROC101661 Screening for Retinopathy of Prematurity (ROP) by RetCam™ Examination at Nepean

Hospital

NBMT-PROC101664 Inpatient Modified Diet and Thickened Fluid Provision and Education

NBMT-PROC101666 Adult Postoperative Nausea and Vomiting Treatment

NBMT-PROC101667 Dobutamine Stress Echocardiogram

NBMT-PROC101670 Somerset Cottage Early Childhood Education and Care Environmental Cleaning: Facility

and Equipment

NBMT-PROC101671 Child Care Services Infection Control and Hygiene Procedures - Direct Care

NBMT-PROC101672 Acute Management of Abdominal Pain in Infants and Children

NBMT-PROC101676 Oral Health: Pulpotomy of Deciduous Molars

NBMT-PROC101681 Mental Health: Lithgow Hospital Emergency Department - Model of Care

NBMT-PROC101687 Spirometry

NBMT-PROC101689 Care of Adult Patients with a Tracheostomy

NBMT-PROC101696 Intrapartum Management of a Twin Vaginal Birth, Nepean Hospital Birth Unit

NBMT-PROC101700 Antenatal, Intrapartum and Early Neonatal Management of HIV

NBMT-PROC101701 Continuous Positive Airway Pressure (CPAP) Clinic

NBMT-PROC101703 Preparation, Delivery and Administration of Vivonex®

NBMT-PROC101705 Smoke Free Health Care

NBMT-PROC101706 Mental Health Extraordinary Event Management and Demand Plan for Acute Inpatient

Beds 2015NBMT-PROC101707 Transfer between Community Mental Health Services

NBMT-PROC101708 Octreotide Administration in Adults

NBMT-PROC101709 Processing of Search Warrants for Health Care Records

NBMT-PROC101711 Escalation Process and Expectations of the Mental Health Executive on Call

NBMT-PROC101718 Delivery of Nitrous Oxide to Adult Patients for Procedural Pain Management

NBMT-PROC101719 Continuous Intravenous Opioid Infusions in Adult Patients (>16 years)

NBMT-PROC101720 Anticoagulants: Information for Patients

NBMT-PROC101721 Use of “Angel Cot” Cold Cot following Foetal/Neonatal Death within Nepean Hospital

NBMT-PROC101723 Suppression of Lactation

NBMT-PROC101724 Preparation and Transfer of a Neonate for Procedures and Consultations Outside NICU

(eg Magnetic Resonance Imaging (MRI) & CT Scanning)

NBMT-PROC101725 Corticosteroid and Cyclophosphamide Use in Renal Disease

NBMT-PROC101726 Standard Neonatal Observation Charts (SNOC) Use

NBMT-PROC101730 Mental Health: Children and Adolescents Visiting Inpatient Mental Health Settings

NBMT-PROC101731 Mental Health: Providing a Family Focused Service to Consumers and their Dependent

Children

NBMT-PROC101733 Management of Clients of Nepean Chest Clinic with a Positive Tuberculin Skin Test (TST)

at Routine Screening

NBMT-PROC101734 Management of Clients with Latent Tuberculosis Infection (LTBI) that are referred to the

Nepean Chest Clinic for Preventive Therapy

NBMT-PROC101735 Management of Clients on a Tuberculosis Health Undertaking (TBU) who are Referred to

the Nepean Chest Clinic by the Department of Immigration and Border Protection

(DI&BP) or a DI&BP Authorised Agency

Page 13: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101736 Nepean Chest Clinic: Safe Storage and Transport of Purified Protein Derivative and Bacilli

Calmette Guerin Vaccine

NBMT-PROC101738 Postnatal/Neonatal Phone Call Assessment Form

NBMT-PROC101739 Care of Adult Patients following Laryngectomy Surgery

NBMT-PROC101741 Neonatal Family Discharge Visiting

NBMT-PROC101742 Sucrose (Oral) for Procedural Pain Management in the Children’s Ward and Emergency

Department

NBMT-PROC101743 Antenatal Daily Assessment and Care

NBMT-PROC101744 Six Minute Walk Test (6MWT) for Cardiac Rehabilitation Patients

NBMT-PROC101745 Peritoneal Dialysis Catheter Trimming and Application of New Luer-Lock Adaptor

(Titanium/Plastic) for a Leaking Catheter

NBMT-PROC101749 Inter-hospital Transfers to Nepean Hospital

NBMT-PROC101750 Inpatient Diet Ordering

NBMT-PROC101751 Adult Nutrition Assessment Documentation by Dietetic Staff

NBMT-PROC101752 Emergency Department: Management of Known Organophosphate Poisoning

NBMT-PROC101759 Peripheral Nerve Sheath Infusion

NBMT-PROC101760 Infant Feeding: Management of Women with Blocked Ducts, Mastitis and Breast Abscess

NBMT-PROC101761 Peritoneal Equilibration Test (PET) for Peritoneal Dialysis Patients

NBMT-PROC101762 Management and Care of a Neonate in the Postnatal Period

NBMT-PROC101772 The Viasys™ NicoletOne™ aEEG Monitor: Application and Use in an Infant Patient

NBMT-PROC101776 Transfer of Women and Babies to Blue Mountains District Anzac Memorial Hospital

NBMT-PROC101777 Relative Analgesia (Nitrous Oxide Inhalational Sedation in Dental Procedures)

NBMT-PROC101780 Infant Feeding: Antenatal Assessment and Education in Relation to Infant Feeding

NBMT-PROC101783 Intra-Uterine Foetal Blood Sampling and Transfusion

NBMT-PROC101784 Medical Management of Ectopic Pregnancy Nepean Hospital

NBMT-PROC101785 Nicotine Replacement Therapy for Nicotine Dependent Inpatients, for Initiation only by

Nurses, Midwives, Pharmacists and Medical Officers

NBMT-PROC101786 Accessing Emergency Meals for Patients After Hours

NBMT-PROC101787 Mental Health: Assessment and Care

NBMT-PROC101788 Height and Weight Measuring Equipment and Measuring for Adult Inpatients

NBMT-PROC101790 Nepean Emergency Department Standard Operating Procedures

NBMT-PROC101793 Mental Health: Conducting Home Visits in the Community

NBMT-PROC101794 Child and Family Health: Initial Infant/Child Assessment

NBMT-PROC101795 Child and Family Health: Initial Maternal Assessment

NBMT-PROC101827 Pacifier Use for Term Babies in the NICU

NBMT-PROC101831 Medicine Access Programs (Including Patient Familiarisation Programs, Compassionate

Use and Expanded Access Programs)

NBMT-PROC101832 High Frequency Ventilation of the Neonate Sensormedics 3100A™ Ventilator

NBMT-PROC101833 Initiation of Haemodialysis

NBMT-PROC101834 Intravenous Heparin usage in Haemodialysis Nurse Administration

NBMT-PROC101835 Immune Supportive Oral Care (ISOC)

NBMT-PROC101836 Infants and Children: Acute Management of Altered Consciousness in Emergency

Departments

NBMT-PROC101837 Nurse Initiated Pathology Collection For Western Renal Service

NBMT-PROC101846 QARS: Breast Milk Labelling Audit

Page 14: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101847 Dietitian Transfer of Care Process of Patients to Springwood Hospital

NBMT-PROC101848 Dietitian Transfer of Care Process of Inpatients to Blue Mountains District Anzac

Memorial HospitalNBMT-PROC101849 Dietetic Service to Nepean Hospital Neonatal Intensive Care Unit

NBMT-PROC101850 Development, Management and Endorsement of Policies, Procedures, Forms, Drug

Protocols and Standing Orders

NBMT-PROC101851 Specialling Patients in Acute Care

NBMT-PROC101853 Massive Transfusion Protocol (MTP) for BMDAMH and Lithgow Hospitals

NBMT-PROC101855 Infection Control

NBMT-PROC101856 Blood Ketone Testing with Nova StatStrip Xpress Meter

NBMT-PROC101857 Implementation of Policy Directives, Guidelines and Information Bulletins

NBMT-PROC101860 Initiation of Lactation

NBMT-PROC101865 High Risk Medicines: Suxamethonium, Rocuronium, And Related Muscle Relaxant Drugs

(Neuromuscular Blockade)

NBMT-PROC101867 Neonatal Examination and Daily Assessment

NBMT-PROC101869 Extubation: Extubating Neonates from Mechanical Ventilation

NBMT-PROC101870 Management of Fetal Heart Rate Monitoring in the Women and Children's Health

Outpatient Department

NBMT-PROC101872 Enteral Feeding of Adult Inpatients (Excludes Intensive Care)

NBMT-PROC101873 Enteral Feeding for Adults - After Hours and Weekends/Public Holidays (Excluding

Intensive Care)NBMT-PROC101874 Preoperative Nutrition for Patients Undergoing Surgery for Upper Gastrointestinal

CancerNBMT-PROC101875 Acute Surgical Unit Phone Call Assessment Form

NBMT-PROC101876 Physiotherapists in the Nepean Hospital Emergency Department - Roles &

Responsibilities in the Management of Patients with Acute Musculoskeletal Conditions

NBMT-PROC101877 Insulin Supply from Nepean Diabetes Service

NBMT-PROC101879 Oral Health: QARS Patient ID and Procedure Matching: Phase 1 Time Out

NBMT-PROC101880 Public Interest Disclosures

NBMT-PROC101883 Orthopaedic External Fixation Pin Site Care

NBMT-PROC101884 Death of a Neonate

NBMT-PROC101885 Baptism/Naming Ceremony of a Neonate/Still born or Foetal Loss

NBMT-PROC101886 Nepean Hospital Imaging/Nuclear Medicine: Ventilation and Perfusion Lung Scan

NBMT-PROC101887 Management of Planned Service Disruptions

NBMT-PROC101890 Intraosseous Access in Adults Using the EZ-IO Intraosseous Vascular Access System

NBMT-PROC101891 SHIFT Test (NICU)

NBMT-PROC101893 Telephone Assessment in Birth Unit (Nepean Hospital)

NBMT-PROC101895 Cannulation of the Arterio Venous Fistula and Aterio Venous Graft

NBMT-PROC101896 Dialyser Blood Leak on Haemodialysis

NBMT-PROC101897 Use of Warming Mattress - Supporting Thermoregulation within NICU

NBMT-PROC101901 Management of Antenatal Women of Advanced Maternal Age

NBMT-PROC101906 After Hours Access to Nepean Hospital

NBMT-PROC101907 Takeaway Methadone Doses From Opioid Treatment Clinics Due to Physical Disability

NBMT-PROC101908 Caseload Midwifery Group Practice at Nepean Hospital

NBMT-PROC101909 Preparation & Transfer of a Neonate for Body Composition (PEAPOD) Measurement

NBMT-PROC101910 Umbilical Arterial Catheter Insertion, Management and Removal (NICU)

NBMT-PROC101911 Peripheral Arterial Catheter Insertion, Management and Removal

NBMT-PROC101912 NICU Rooming In Room - Use of

Page 15: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101913 Antenatal Clinic: Did not Attend and Unable to be Contacted

NBMT-PROC101914 Enterprise Risk Management

NBMT-PROC101915 Physical Health Care for Mental Health Consumers

NBMT-PROC101916 "Did not wait"• for Mental Health Assessment

NBMT-PROC101917 Administration of Unrostered Overtime & Recall for Junior Medical Staff

NBMT-PROC101918 Emergency Department Guideline for the Management of Iron Deficiency Anaemia in

Adults

NBMT-PROC101942 Magnesium Sulphate prior to Preterm Birth for Fetal Neuroprotection at Nepean

HospitalNBMT-PROC101944 Intubation in Neonates in NICU

NBMT-PROC101945 Amethocaine, Tropicamide, and Phenylephrine Eye Drops for Eye Examination in the

Neonatal Intensive Care Unit

NBMT-PROC101946 Administration and Usage of Trisodium Citrate (Duralock-C®) catheter lock solution

NBMT-PROC101948 Transportation of Inpatients throughout Nepean Campus – External (Dental, Drug and

Alcohol, Cancer Care)

NBMT-PROC101951 Haematology / Oncology Inpatient Management of Febrile Neutropenia

NBMT-PROC101952 Oral Health: Patients Presenting with Dental Trauma

NBMT-PROC101954 Prevention and Management of Constipation for Patients on Peritoneal Dialysis

NBMT-PROC101955 eMR2: Orientation of New Staff at Blue Mountains District ANZAC Memorial Hospital &

Springwood Hospital

NBMT-PROC101956 eMR2: Recovery at Springwood & Blue Mountains District ANZAC Memorial Hospital

NBMT-PROC101960 Prevention of Early Onset Group B Streptococcus (GBS) Disease in Neonates

NBMT-PROC101961 Cervical Collar Application and Care- Philadelphia®

NBMT-PROC101962 Cervical collar- VISTA© or ASPEN©:Application and Care

NBMT-PROC101963 Management of Postpartum Haemorrhage (PPH)

NBMT-PROC101964 Drug and Alcohol: In-Patient Withdrawal Management Unit Daily Patient Case

Conference (Huddle) & Weekend Responsibilities

NBMT-PROC101965 Drug and Alcohol: Management of Individuals Self Presenting to the Centre for Addiction

Medicine (Walk Ins) During Usual Business Hours

NBMT-PROC101966 After Hours Management of the Drug and Alcohol Central Intake Telephone Service

NBMT-PROC101969 Paediatric Presentations with Behavioural or Mental Health Issues - Nepean Hospital

NBMT-PROC101970 Mental Health: Sexual Safety

NBMT-PROC101973 Booking Long Distance (Aeromedical) Patient Transport

NBMT-PROC101974 Blue Mountains and Lithgow Hospitals: After Hours Access to Unmanned Blood Product

Refrigerator and Clinical Management of the Transfused Patient

NBMT-PROC101976 Inhaled Nitric Oxide Therapy in Infants with Persistent Pulmonary Hypertension

NBMT-PROC101978 eMR Access for Nursing and Midwifery Agency Staff

NBMT-PROC101981 eQATE Mental Health Clinical Documentation Audit

NBMT-PROC101983 Work Health and Safety - Safe Use of Liquid Nitrogen and Other Non Flammable

Cryogenic Liquids NBMT-PROC101984 Work Health and Safety Incidents Reportable to SafeWork NSW

NBMT-PROC101985 Work Health and Safety Plant Management

NBMT-PROC101986 Work Health & Safety Prevention of Falls from One Level to Another

NBMT-PROC101987 Work Health and Safety Confined Spaces

NBMT-PROC101988 Work Health and Safety Asbestos Management

NBMT-PROC101989 Work Health and Safety for Workers

NBMT-PROC101990 Work Health and Safety Hazardous Chemical Management

Page 16: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC101991 Infants and Children - Acute Management of Seizures

NBMT-PROC101994 Management of Biomedical Equipment for Safety and Performance

NBMT-PROC101997 Orthopaedic Outpatient Telehealth Consultations

NBMT-PROC102000 Escalation Process and Expectations of the Drug and Alcohol Executive on Call

NBMT-PROC102004 Offering Clear Fluids in Recovery

NBMT-PROC102005 Paediatric Ambulatory Short Stay (PASS)

NBMT-PROC102006 Postnatal Care in the Home - Midwifery@Home (M@H) and Caseload/Midwifery Group

NBMT-PROC102007 Documentation Requirements for Electronic Fetal Monitoring (EFM) at Nepean Hospital

NBMT-PROC102008 Assessment and Care of a Woman Following Lower Segment Caesarean Section (LSCS)

NBMT-PROC102011 Blood Borne Virus (BBV) Procedure for Haemodialysis Patients of the Western Renal

Services

NBMT-PROC102012 Oral Health - Implementation and Governance of the NSW Oral Health Fee for Service

Scheme

NBMT-PROC102014 Duress Alarm: Operating instructions and Duress Response for Mental Health Inpatient

Units

NBMT-PROC102016 Management of suspected or cytotoxic intravenous drug extravasation - Nepean Cancer

Services

NBMT-PROC102019 Neuraxial Analgesia for Labour: Patient-Controlled Epidural Analgesia (PCEA) with

Programmed Intermittent Epidural Boluses (PIEB)

NBMT-PROC102021 Absent Without Leave (AWOL) from a Declared Mental Health Facility

NBMT-PROC102022 Umbilical Cord Blood Collection for Blood Gas Analysis at Birth

NBMT-PROC102024 Paediatric Patients Requiring 1:2 Nursing Care - High Dependency Patients

NBMT-PROC102025 The Deteriorating Obstetric Patient - 2222 Nepean

NBMT-PROC102026 Referral Pathway for Maternal Fetal Medicine (MFM) Clinic

NBMT-PROC102030 Electronic Medical Record (eMR) Downtime

NBMT-PROC102031 Nepean Emergency Department Transfer of Care (ToC) - Ambulance to Hospital

NBMT-PROC102032 Post Anaesthetic Care Unit Discharge Criteria

NBMT-PROC102034 Emergency Pagers Nepean Hospital

NBMT-PROC102035 Infant Feeding: Dispensing and Checking of Expressed Breast Milk (EBM), Pasteurised

Donor Human Milk (PDHM) and Breastmilk Substitutes (BMS)

NBMT-PROC102036 Paediatric Surgical Admissions: Children's Ward Nepean Hospital

NBMT-PROC102037 Modified Barium Swallow (Video-fluoroscopic Swallow Study - VFSS) Imaging Nepean

NBMT-PROC102046 JMO Job List - e-ordering of requests for JMOs at Nepean Hospital

NBMT-PROC102056 Student Access to eMR

NBMT-PROC102059 Prevention of Prohibited Substance Use at the Inpatient Withdrawal Management Unit

NBMT-PROC102060 Screening for Malnutrition of Paediatric Inpatients

NBMT-PROC102061 Nutrition Assessment of Adults Using a Validated Tool: Subjective Global Assessment

(SGA)

NBMT-PROC102063 Administration of Natalizumab within Nepean Hospital

NBMT-PROC102067 Sexual Health Services Standard Operating Procedures Manual

NBMT-PROC102069 Cardiac Monitoring for CCU, W5B and CCL

NBMT-PROC102070 Haemodiafiltration - Procedure and Indications

NBMT-PROC102071 Clinical Midwifery Consultant - E Order consultation Nepean Hospital

NBMT-PROC102074 Dispensing and Administration of Intrathecal (IT) Chemotherapy Drugs

NBMT-PROC102075 Dietetics Home Enteral Nutrition (HEN)

Page 17: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102076 Frequency of Changing Disposable Antimicrobial Impregnated Curtains - Nepean

HospitalNBMT-PROC102077 Adult Parenteral Nutrition (PN)

NBMT-PROC102078 Identification, Prevention and Nutritional Management of Refeeding Syndrome in Adults

NBMT-PROC102080 Treatment of Haemodialysis Catheter-Related Sepsis

NBMT-PROC102088 Booking an Imaging Procedure that requires Anaesthetic Support

NBMT-PROC102096 Nepean Hospital Cardiac Catheterisation Laboratory (CCL) Call Out Process

NBMT-PROC102097 Nursing Management of Central Line Infusions in NICU

NBMT-PROC102098 Adult Peritoneal Dialysis (PD) Catheter Insertion

NBMT-PROC102099 Management of malignant pleural effusion using the Pleurx® Drainage System

NBMT-PROC102100 Adequacy Testing for Peritoneal Dialysis (PD)

NBMT-PROC102101 Management and Escalation Plan for Adult and Paediatric Inpatients with Extended

Fasting or Extended Inadequate Oral Intake

NBMT-PROC102102 eMR2 Cleaning of the WOW computers

NBMT-PROC102103 Death Certificate Process

NBMT-PROC102104 Administrative Management of Recommendation for Admission Form

NBMT-PROC102105 QARS Aseptic Technique and Standard Precautions Audit Tool

NBMT-PROC102112 Hyperosmolar Hyperglycaemic State (HHS) - Management in Adults with Diabetes

NBMT-PROC102123 Collection of Blood Products from Department of Transfusion Medicine (Blood Bank) at

Nepean Hospital

NBMT-PROC102127 Mental Health Service Advance Statements

NBMT-PROC102130 Adrenaline, Lignocaine and Amethocaine (ALA), Laceraine Topical Solution in Emergency

Departments (Paediatrics)

NBMT-PROC102131 Oral Prednisolone in the Treatment of Asthma for Paediatric Patients in the Emergency

DepartmentNBMT-PROC102132 IV Paracetamol Use for Paediatric Patients Admitted on the Children's Ward

NBMT-PROC102141 Emergency Department Medical Assessment Unit

NBMT-PROC102142 Chest Compression System: LUCAS 2. Recognition and Management of the Deteriorating

Patient

NBMT-PROC102144 Patients requiring Residential Aged Care Facility Placement from Nepean Hospital

NBMT-PROC102145 Use of CoolSense for Procedural Pain on Paediatric Patients

NBMT-PROC102146 Hospital Based Subcutaneous Immunoglobulin (SCIg) Program

NBMT-PROC102148 Management of the Emergency Department Short Stay Unit - Nepean Hospital

NBMT-PROC102152 The Respiratory Care Unit in W4A at Nepean Hospital

NBMT-PROC102153 Paediatric Pain Management in the Post Anaesthetic Care Unit

NBMT-PROC102154 Contamination of Peritoneal Dialysis Extension Line Western Renal Service PD Unit

NBMT-PROC102158 Co-administration of Antiviral Medication for Hepatitis C Virus within NBMLHD Opioid

Treatment Program Clinics

NBMT-PROC102159 Consultant (Staff Specialist) Approval for MBS Item Numbers Charged in Nepean Women

& Children’s Health Outpatient Department (W&CH OPD)

NBMT-PROC102160 Work Health and Safety - Managing Noise and Preventing Hearing Loss at Work

NBMT-PROC102162 Patients requiring Emergency Interventional Radiology

NBMT-PROC102165 Drug and Alcohol - Management of Patient Non-Attendance

NBMT-PROC102166 Completing the Drug and Alcohol Global Care Plan

NBMT-PROC102179 Drug and Alcohol - Management of Chapter 16A Requests and Responses by

Administration and Clinical Staff

NBMT-PROC102180 Adult Urethral Catheterisation

Page 18: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102182 Sterile Water Injections for Relief of Back Pain in Labour - Procedure for Administration

NBMT-PROC102184 Nepean Campus Parking

NBMT-PROC102185 National Adult Inpatient Medication Chart (MR 70/72) (NIMC)

NBMT-PROC102186 Purchasing and Use of Gift Cards, Goods or Other Items for Reimbursement of Time or

Incentive Payment

NBMT-PROC102187 Medication Administration (Paediatrics and Neonates) - Oral Liquid Medicines

NBMT-PROC102188 Neonatal Resuscitation on S4EP and S4EA Nepean Hospital

NBMT-PROC102189 Blood Glucose Monitoring for Diabetic Clients Attending Outpatients Cardiac

Rehabilitation Exercise Programs

NBMT-PROC102190 Administration of Inhaled Salbutamol for mild to moderate asthma for Paediatric

Patients in the Emergency Department

NBMT-PROC102191 Fetal Blood Sampling in Labour

NBMT-PROC102192 Medical Clinical Handover: Interventional Radiology Medical Staff Nepean Hospital

NBMT-PROC102193 Visiting Medical Officer Timesheet Verification

NBMT-PROC102194 Clinical Emergency Response at Springwood Hospital

NBMT-PROC102195 Patients Visual Observation at the Inpatient Withdrawal Unit

NBMT-PROC102196 Use of Adaptive Cutlery during Mealtimes at Nepean Hospital

NBMT-PROC102198 Community Mental Health Team Referral Process

NBMT-PROC102199 Mental Health: 7 Day Follow Up Post Discharge from an Inpatient Facility

NBMT-PROC102200 Phototherapy at Home - Jaundice Management Nepean Hospital

NBMT-PROC102201 Readmission to Neonatal Intensive Care Unit (NICU) of an Infant following Discharge

NBMT-PROC102202 Management of Antepartum Haemorrhage (APH)

NBMT-PROC102203 Use of Milk Warmers in Nepean Neonatal Intensive Care Unit (NICU)

NBMT-PROC102204 Wound Nurse Practitioner Referral Process for Blue Mountains Wound Clinic

NBMT-PROC102207 Admitted Absconding Patient Procedure - Not for Mental Health Patients

NBMT-PROC102208 Nepean Hospital Campus Lockdown

NBMT-PROC102210 Sexual Safety of Patients within the Inpatient Withdrawal Management Unit, Centre for

Addiction Medicine (CAM)

NBMT-PROC102211 Leave Entitlements for Staff Affected by Emergencies

NBMT-PROC102212 Aspen Vista® 464 TLSO and 637 LSO: Application and Care

NBMT-PROC102213 Nepean Anxiety Disorders Clinic (NADC), Mental Health Service Referral Process

NBMT-PROC102214 Gastrografin Imaging Studies

NBMT-PROC102215 Prescribing Gastrografin® in Adult Adhesive Small Bowel Obstruction

NBMT-PROC102216 After Hours Nepean Escalation Process and Expectations of the Nepean Executive on

Call; the After Hours Nurse Manager; Nurse Unit Managers and Team Leaders

NBMT-PROC102217 Code Black - Personal Threat

NBMT-PROC102218 Induction of Labour

NBMT-PROC102219 Paediatric Observations

NBMT-PROC102220 Telehealth Video Consultations between the Heart Failure CNC and Exercise Physiologist

for Heart Failure Patients

NBMT-PROC102221 9th Birthing Room - Birth Unit Nepean Hospital

NBMT-PROC102222 Emergency Department (ED) - Direct Admission to Inpatients Wards Nepean

NBMT-PROC102223 Administration and Management of Contracts between Medical Locum Agencies and

NBMLHD

NBMT-PROC102225 Iron Infusion Procedure in Adults - Prescribing, Handling, Preparation and

Administration

Page 19: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102226 Dobutamine Management

NBMT-PROC102232 Managing Domestic and Family Violence Experienced and Disclosed by Members of Staff

NBMT-PROC102236 NBMLHD Clinical Procedure Safety

NBMT-PROC102237 Attendance and Leave Entitlement Procedures for Junior Medical Staff

NBMT-PROC102238 Contractor Management

NBMT-PROC102239 Transfer of Admitted Children from the Emergency Department to the Children's Ward

(Nepean Hospital)

NBMT-PROC102240 Methoxyflurane via Penthrox Inhaler for Procedural Pain Management in Adults ( = 16

years )

NBMT-PROC102241 Severe to Life Threatening Management of Asthma in Paediatrics

NBMT-PROC102242 Management of Unacceptable Behaviours of Patients and Visitors at NBMLHD

NBMT-PROC102244 QARS Falls Audit for the Emergency Department (ED)

NBMT-PROC102245 Documentation of Vital Signs by Allied Health Professionals or Allied Health Assistants

NBMT-PROC102246 Protected Mealtimes for Inpatient Wards

NBMT-PROC102247 Purchase of Oral Nutritional Supplements for Renal Patients within the NBMLHD Renal

Service

NBMT-PROC102248 Use of the In Theatre Camera for Obstetric and Gynaecological Surgical Teaching

(Nepean)

NBMT-PROC102249 Nepean Family Obesity Service VLCD

NBMT-PROC102251 Direct Appointment of Aboriginal Employees from Temporary or Fixed Term Contracts to

Permanent Positions

NBMT-PROC102252 Provision for Play Areas for Inpatients

NBMT-PROC102253 Nepean Family Obesity Service Outpatient Telehealth Consultations

NBMT-PROC102256 QARS: NSQHS Deteriorating Patient: Between the Flags Inpatient Audit

NBMT-PROC102257 QARS: NSQHS Deteriorating Patient: Emergency Department Audit

NBMT-PROC102258 Skin-to-Skin Contact in the Operating Theatre and the Recovery Unit

NBMT-PROC102259 Escalation or Prioritisation of Medical Imaging Services

NBMT-PROC102260 Management of Fasting Peri-operative Patients

NBMT-PROC102262 QARS audit standard 3: Compliance with Transmission Based Precautions

NBMT-PROC102263 QARS Audit Standard 3 Integrity of Sterile Stock and Clean Items Storage for Patient Use

in Clinical Areas

NBMT-PROC102264 QARS audit standard 3: Weekly Inspection of Shared Patient Care Equipment

NBMT-PROC102265 QARS Template

NBMT-PROC102266 Radiation Therapy: Correct patient, Correct Procedure and Correct Site

NBMT-PROC102267 Clinical Escalation Plan for Neonatal Intensive Care Unit (NICU)

NBMT-PROC102268 Adult Urgent Start Peritoneal Dialysis

NBMT-PROC102269 Delayed Cord Clamping For Preterm Infants

NBMT-PROC102270 QARS: Maternity - Fetal Heart Rate Monitoring Tool NBMLHD

NBMT-PROC102271 Nepean Midwifery Lead Antenatal Clinic for Women with Gestation Diabetes (Diet

Controlled)

NBMT-PROC102272 Infant Feeding: Management of Engorged Breasts

NBMT-PROC102273 Infant Feeding: Bottle Feeding - Preparation and Administration of Breast Milk

Substitute (BMS)

NBMT-PROC102274 Adoptive Breastfeeding and Relactation

NBMT-PROC102275 Nepean Hospital Surgical Outpatient Orthopaedic Clinic

Page 20: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102276 Safe Disposal of a Suspected Prohibited Substance at the Inpatient Withdrawal

Management Unit, Centre for Addiction Medicine (CAM)

NBMT-PROC102277 Extreme Heat and Heatwave Procedures

NBMT-PROC102278 Onboarding, Orientation and Mandatory Training

NBMT-PROC102279 Postnatal Ward Team Leader Responsibilities - Nepean Hospital

NBMT-PROC102280 E3i Close Observation Beds

NBMT-PROC102281 Leech Therapy

NBMT-PROC102282 Operative Vaginal Delivery

NBMT-PROC102283 Pasteurised Human Donor Milk Bank - Use in NICU

NBMT-PROC102284 Venepuncture for the Collection of Blood for Laboratory Analysis

NBMT-PROC102285 Medical Air Failure in Nepean NICU

NBMT-PROC102286 Use of Air Assisted Transfer Device in the Nepean Hospital

NBMT-PROC102288 Recommendation for Admission (RFA) Management and Receipt

NBMT-PROC102289 Surveillance of Growth and Wellbeing for Infants in the First 12 months within Child and

Family Health Services

NBMT-PROC102290 Renal Nutrition Outpatient Services for Patients - Referral & Prioritisation Guide

NBMT-PROC102291 Management of Incorrect Dose (Overdose) of Buprenorphine or

Buprenorphine/Naloxone Administered in NBMLHD Opioid Treatment Program Clinics

NBMT-PROC102293 Telepsychiatry Consultation between a Mental Health Medical Officer Located at

Nepean Hospital Mental Health Service and Patients in the Emergency Department at

Lithgow and Blue Mountains Hospital who Require a Mental Health Assessment

NBMT-PROC102294 Third Door Admissions

NBMT-PROC102295 Vulnerable Patients

NBMT-PROC102298 Admission to Portland Tabulam Health Centre

NBMT-PROC102299 Cervical Screening and Therapeutic Intervention to Prevent Preterm Delivery (Nepean

Hospital)

NBMT-PROC102300 Management of Acute Severe Hypertension in an Antenatal Patient

NBMT-PROC102301 Newborn Hearing Screening - State-Wide Infant Screening Hearing (SWISH)

NBMT-PROC102302 Antenatal/Gynaecology Team Leader Responsibilities Nepean Hospital

NBMT-PROC102304 Follow-up of Patients who Do Not Attend General Outpatient Clinics

NBMT-PROC102305 Nepean Hospital - HealthRoster and the Role of all Nurse Unit Managers and Roster

Office Clerks for Contingency Staffing Replacement

NBMT-PROC102306 Children's Ward Non Patient Load Team Leader Responsibilities

NBMT-PROC102308 Preventing, Minimising and Managing Challenging Behaviours in the Inpatient

Withdrawal Unit

NBMT-PROC102309 Conducting Mortality and Morbidity Meetings and Reporting of Clinical Reviews

NBMT-PROC102310 Management of Intoxicated Presentations in NBMLHD Opioid Treatment Program Clinics

NBMT-PROC102311 Have You Got Your Pit Crew Ready? Preparation for Procedures/Assessments in

Children's Ward Nepean Hospital

NBMT-PROC102312 CSF Leak Testing in the Nuclear Medicine Department

NBMT-PROC102313 Inpatient Gate Leave

NBMT-PROC102315 QARS: Level Two Procedure - Time Out Audit

NBMT-PROC102316 QARS: Level One Procedure - Time Out Audit

NBMT-PROC102317 Management of Echogenic Bowel in the Fetus

NBMT-PROC102318 Management of Chronic Kidney Disease Patients with Parathyroidectomy

Page 21: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102319 Primary Care and Community Health: Audiometry

NBMT-PROC102320 Management of First Year Graduate Nurses and Midwives Undertaking a Transition to

Professional Practice Program

NBMT-PROC102321 Public Toilet Safety Checks

NBMT-PROC102325 QARS: Level Three Procedure - Time-Out Audit

NBMT-PROC102326 QARS: Nursing Patient Safety Handover Checklist Audit

NBMT-PROC102329 Identification and Review Process for Non-SAC 1 Clinical Incidents

NBMT-PROC102330 Transfer of Nepean Cancer Care Centre Patients to and from the Nepean Medical

Imaging Department

NBMT-PROC102331 Coordination of Electroconvulsive Therapy

NBMT-PROC102332 Searching People and their Property in Inpatient Withdrawal Management Unit

NBMT-PROC102333 Co-administration of Additional Medications within NBMLHD Opioid Treatment Program

Clinics

NBMT-PROC102336 QARS Patient Identification and Alert Band Audit

NBMT-PROC102345 Transfer of Nepean Mental Health Centre Patients to and from the Nepean Medical

Imaging Department

NBMT-PROC102346 Transfer of Nepean Hospital Drug and Alcohol Service Patients to and from Nepean

Hospital Medical Imaging Department

NBMT-PROC102347 Oral Health: Tooth Identification Prior To and During Tooth Extraction

NBMT-PROC102348 Managing the Prioritisation of People on the Blue Mountains Access Client List

NBMT-PROC102349 Mental Health Inpatient Therapeutic Leave

NBMT-PROC102351 Cardiac Monitoring, East Wing, Blue Mountains Hospital

NBMT-PROC102353 Nepean Women's Health Escalation Process and Expectations

NBMT-PROC102354 Blood Pressure Profile in Nepean Fetal Maternal Assessment Unit (FMAU) Birth Unit

NBMT-PROC102355 Admission of a Paediatric Patient for Non-Medical Reasons/Social Reasons and Babies

under 10 Days of Age with Maternal Sepsis at Blue Mountains District Anzac Memorial

Hospital

NBMT-PROC102356 Borderline Viability - Nepean Maternity Unit

NBMT-PROC102357 MRO Colonisation in NICU

NBMT-PROC102359 Overnight Garaging of NBMLHD Fleet Vehicles

NBMT-PROC102363 Engagement and Observation in Mental Health Inpatient Units

NBMT-PROC102364 QARS Engagement and Observation in Mental Health Inpatient Units Audit

NBMT-PROC102365 Receiving Vaccine Deliveries at Blue Mountains District ANZAC Memorial Hospital

(BMDAMH), in Hours and Out of Hours

NBMT-PROC102366 QARS Oral Health Referral and Transfer of Care Audit

NBMT-PROC102367 QARS Oral Health Sterilisation Audit

NBMT-PROC102372 Triage for Adult Referrals to the Healthy Weight Management Clinic, Nepean Blue

Mountains Family Metabolic Health Service

NBMT-PROC102374 Oral Health: External Specialist Referrals

NBMT-PROC102376 Conducting a Patient Risk Assessment for Harm to Self and Others within Community

Based Drug and Alcohol Treatment Services

NBMT-PROC102379 QARS: Oral Health Scanning into Patient Electronic Dental Record

NBMT-PROC102380 White Level Inspections

NBMT-PROC102381 Maternal Assisted Caesarean Section

NBMT-PROC102383 Care Coordination for Adolescent Patients (16-18 years) Admitted to the Nepean

Inpatient Withdrawal Unit

Page 22: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102384 Oral Health - Management of Patients with Identified Risk of CJD in a Dental Setting

NBMT-PROC102391 Nicotine Replacement Therapy for Inpatient Mental Health Consumers

NBMT-PROC102392 Chemical Handling and Purchase

NBMT-PROC102393 Sterilisation Area Processes

NBMT-PROC102394 QARS: Nursing and Midwifery Clinical Handover Audit

NBMT-PROC102395 QARS: Documentation Compliance of Consent for Medical Procedure Treatment for

Adult (SMR020.001) and Paediatric (SMR020.003) Form

NBMT-PROC102396 Reprocessing of the Fisher & Paykel AIRVO™ 2 Unit for the Post Anaesthetic Care Unit

NBMT-PROC102397 Appropriate Requesting of Mobile Radiographs at Nepean Hospital

NBMT-PROC102398 QARS Audit Standard 3: Central Venous Access Device (CVAD)

NBMT-PROC102399 QARS Audit Standard 3 Peripheral Intravenous Cannula (PIVC)

NBMT-PROC102400 Oral Health: CERS (Clinical Emergency Response System) Recognition and Management

of the Deteriorating Patient at the Oral Health Setting

NBMT-PROC102401 Sterilising Services

NBMT-PROC102402 General Movements Assessments in Neonates in the Nepean Neonatal Intensive Care

Unit (NICU) and in the Nepean NICU Developmental Follow up Clinic

NBMT-PROC102403 Modified Sleep Study (Trolley Study) for Low Risk Paediatric Patients - Children’s Ward

Nepean Hospital

NBMT-PROC102404 Surgical Management of Placenta Accreta, Increta, Percreta

NBMT-PROC102405 Paediatric Postoperative Nausea and Vomiting

NBMT-PROC102406 Low Flow Nasal Cannula Oxygen for Neonatal and Paediatric Patients Using AIRVOTM2

NBMT-PROC102407 Paediatric Diabetes Management for Type 1

NBMT-PROC102408 Loading and Unloading of the Theatre Dirty Instrument Trolley

NBMT-PROC102409 Paediatric Sepsis Management for the Children's Ward

NBMT-PROC102410 Criteria for Boarder Babies

NBMT-PROC102411 Referral Of Newborns Identified with Outer Ear Anomalies for Early Ear Moulding

NBMT-PROC102412 Selection and Safe Dosage of Dental Local Anaesthetics Injections at Oral Health Settings

NBMT-PROC102413 Dating of a Recommendation for Admission (RFA)

NBMT-PROC102414 Admission of Patients with Cutaneous Abscess to Day Surgery for Surgical Drainage

under General Anaesthesia at Nepean Hospital

NBMT-PROC102415 Management of Surgical Sessions - Leave

NBMT-PROC102421 Transbronchial Cryobiopsy (TBC) at Nepean Hospital

NBMT-PROC102422 Safety Huddles for Inpatient Facilities

NBMT-PROC102423 Work Health and Safety - Managing Electrical Risks

NBMT-PROC102424 Restriction of Children Under the Age of 16 Years to Designated Areas where

Chemotherapy (Cytotoxic) and / or Hazardous Drugs are Dispensed and / or

Administered across NBMLHD Cancer Services

NBMT-PROC102425 Transportation of Reusable Medical Devices from Operating Theatres Prior to and

Following a Surgical Procedure and Ward Areas

NBMT-PROC102426 Release of Reusable Medical Device after Reprocessing

NBMT-PROC102427 Traceability of Reprocessed Semi Critical and Critical Reusable Medical Devices

NBMT-PROC102428 Mental Health: Transfer of Care

NBMT-PROC102437 QARS: User Applied Labelling of Injectable Medicines, Fluids & Lines

NBMT-PROC102438 QARS: Nursing Visual Observations - Drug & Alcohol Inpatient

NBMT-PROC102445 Cleaning of Reusable Medical Devices Prior to Disinfection and/or Sterilisation

Page 23: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102446 Handling of Specialised Reusable Medical Devices

NBMT-PROC102452 Triaging Patients and Managing Radiation Therapy Treatment Appointments and

Waiting List

NBMT-PROC102454 Primary Care and Community Health - Toy Selection, Cleaning and Maintenance

NBMT-PROC102458 Clinical Handover in Primary Care and Community Health

NBMT-PROC102459 Enteral Feeding for Intensive Care

NBMT-PROC102460 Falls Injury Prevention and Management of Adults in Primary Care and Community

Health

NBMT-PROC102461 White Level Inspections – Primary Care & Community Health

NBMT-PROC102462 Measuring and Interpreting Vascular Access Flow and Recirculation in the Western Renal

Service

NBMT-PROC102463 Management of Postpartum Hypertension

NBMT-PROC102464 Antenatal Management of Fetal Spina Bifida – Nepean

NBMT-PROC102465 Aspirin for the Prevention of Pre-Eclampsia

NBMT-PROC102466 Patient Controlled Analgesia (IV) Fentanyl for Labour

NBMT-PROC102467 QARS Venous Thromboembolism (VTE) Audit

NBMT-PROC102474 Waiting for What; Management and Escalation Process

NBMT-PROC102475 QARS: Inpatient Nutrition Care Audit

NBMT-PROC102477 QARS: After Hours Medical Handover Audit (Nepean & Blue Mountains Hospitals)

NBMT-PROC102479 QARS: Primary Care & Community Health Clinical Documentation Audit

NBMT-PROC102480 Approval Process for Publications and Conference Submissions by Nursing and

Midwifery Staff

NBMT-PROC102481 Management of Failure to Progress in Labour for Women with Spontaneously

Established Labour

NBMT-PROC102483 QARS NSW Vaccine Management and Storage Audit 2020

NBMT-PROC102484 Management of Cerebral Spinal Fluid Drainage via External Ventricular Drain or Lumbar

Drain Outside ICU at Nepean Hospital

NBMT-PROC102485 Asthma Management - Stretching Inhaled Salbutamol by a Paediatric Registered Nurse

on the Children's Ward

NBMT-PROC102486 Haemoglobin Monitoring and Dose Adjustment of Erythropoiesis-Stimulating Agents

(ESAs) in Chronic Dialysis Patients

NBMT-PROC102487 Clinician Performed Ultrasound (CPU) in Neonatal Intensive Care Unit (NICU) Nepean

Hospital

NBMT-PROC102489 Mental Health Bed Management and Patient Flow

NBMT-PROC102490 Inpatient Withdrawal Management Unit: Team Leader Responsibilities

NBMT-PROC102491 Telehealth Video Consultations between the Heart Failure CNC and Community CNS for

Heart Failure Patients

NBMT-PROC102492 Management of S8/S4D Drug Keys and Drug Cupboards within Nepean Hospital

Operating TheatresNBMT-PROC102493 Telehealth Video Consultations between the Chronic Obstructive Pulmonary Disease

(COPD) Leading Better Value Care (LBVC) Clinical Team and a Physiotherapist or Nurse

for COPD Patients

NBMT-PROC102494 Intravenous Cannulation and Venepuncture in Paediatric Patients Performed by a

Registered Nurse NBMT-PROC102501 Admission Process of Patients with Cutaneous Abscess for Surgical Drainage under

General Anaesthesia at Nepean Hospital under the Care of the Acute Surgical Unit

NBMT-PROC102503 Chlamydia Outreach Screening Operations Manual - HIV and Related Programs (HARP)

Team & Nepean and Blue Mountains Sexual Health Clinics

Page 24: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102505 Fleet Vehicle Management and Usage in Community Based Motor Vehicle Pools

NBMT-PROC102509 Nepean Hospital Massive Transfusion Protocol (MTP)

NBMT-PROC102510 Electronic Patient Journey Board - A Multidisciplinary Team Meeting BMDAMH and

Springwood Hospitals

NBMT-PROC102511 Cancellation on Day of Surgery - Operating Suite to Bookings

NBMT-PROC102512 Use and Storage of Air Assisted Transfer Device Non Disposable (Hovermats) in the Blue

Mountains and Springwood Hospitals

NBMT-PROC102514 Post Assault Analysis

NBMT-PROC102515 Vaccine Storage and Cold Chain Management

NBMT-PROC102516 Registered Nurse as Surgical Assistant at BMDAMH

NBMT-PROC102517 Use of Oxygen BMDAMH

NBMT-PROC102518 Minimum Requirements for the Deployment of Clinical Staff away from their Usual Place

of Employment

NBMT-PROC102520 Detecting and Addressing Variations in Growth and Wellbeing for Children 12 Months to

5 Years

NBMT-PROC102521 Primary Care and Community Health: Nurse Immunisation Clinics

NBMT-PROC102523 QARS Physical Health for Mental Health Consumers Audit - INPATIENT SETTINGS

NBMT-PROC102524 QARS Physical Health for Mental Health Consumers Audit - COMMUNITY SETTINGS

NBMT-PROC102525 Deferral of Surgery

NBMT-PROC102526 Car Park Use and Management for the Lemongrove Campus

NBMT-PROC102527 Team Leader (In Charge) OTP Clinics (Gateway, Woodlands & Lithgow)

NBMT-PROC102528 Manual Cleaning of a 180 Series Olympus Duodenoscope

NBMT-PROC102529 Bookings for all Nuclear Medicine and Positron Emission Tomography (PET) Scans

NBMT-PROC102530 Telehealth Video Consultations between the Chest Clinic Nurse and Patients

NBMT-PROC102533 Use and Approval of Overtime within NBMLHD Mental Health Services

NBMT-PROC102536 Low Flow Oxygen / Air (or combination) Administration (Neonatal)

NBMT-PROC102537 Paediatric Height and Weight Measuring Equipment and Procedures

NBMT-PROC102539 Nepean Hospital: Intravenous Hydralazine –Administration for Acute Management of

Severe Hypertension on the Postnatal Ward

NBMT-PROC102540 Nepean Hospital: Technical Assistant procedure for transporting patients to/from the

Medical Imaging Department

NBMT-PROC102541 Payment of Entitlements Relating to a Deceased Employee

NBMT-PROC102546 Primary Care and Community Health - No Response to a Scheduled Home Visit

NBMT-PROC102547 QARS: Radiation Therapy: Correct Patient, Correct Procedure and Correct Site

NBMT-PROC102549 Oral Health - Management of Patients Presenting with Herpes Simplex Infection

NBMT-PROC102552 Performing an Amniotomy for Women in Labour or for the Purpose of Augmentation or

Induction of Labour

NBMT-PROC102553 Perinatal Loss - Management

NBMT-PROC102554 Intrapartum Assessment of Fetal Head Positon with Bedside Ultrasound

NBMT-PROC102555 Transfer of Labouring Woman >37 Weeks between S4EA and Birth Unit

NBMT-PROC102556 Multi-factorial Strategies for Falls Risks in Hospital

NBMT-PROC102557 Performing Neonatal X-rays within NBMLHD

NBMT-PROC102558 Acute Tocolysis for Fetal Entrapment, Retained Placenta and Uterine Inversion, using

Glyceryltrinitrate (GTN) in Operating Theatre

NBMT-PROC102559 3rd Stage of Labour and Management of Retained Placenta

NBMT-PROC102560 Admission to the Inpatient Withdrawal Management Unit at Nepean Hospital

Page 25: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102561 Intravesical Instillation with Bacillus Calmette-Guerin (BCG) Nepean Hospital Surgical

Outpatient Department

NBMT-PROC102562 Paediatric Acute Review Clinic (PARC)

NBMT-PROC102563 NSW Dried Blood Spot (DBS) Study when screening patients for HIV & Hepatitis C

infections at the Drug and Alcohol Service

NBMT-PROC102564 Entry into Pharmacy After Hours and in an Emergency

NBMT-PROC102565 Neonatal Lumbar Puncture

NBMT-PROC102566 Transfer of Patients and Medical Records under Collaborative Care Model with Nepean

Private Hospital

NBMT-PROC102567 Fever in Infant under 3 Months

NBMT-PROC102568 QARS: Pressure Injury Prevention Audit

NBMT-PROC102569 Transfer of Patients from Lithgow Hospital

NBMT-PROC102571 Management of Instruments, Accountable Items and Other Items Used Surgery or

Procedures

NBMT-PROC102574 Medical Imaging – Nepean Hospital - Imaging Nasogastric Tubes

NBMT-PROC102575 Vaginal Examination in Labour

NBMT-PROC102586 Paediatric Use of Ondansetron

NBMT-PROC102589 Somerset Cottage Early Childhood Education and Care Excursion

NBMT-PROC102601 Somerset Cottage Early Childhood Education and Care Emergency and Evacuation

NBMT-PROC102603 Episiotomy and Infiltration of the Perineum

NBMT-PROC102604 Professional Licence Requirements

NBMT-PROC102605 Professional Registration Requirements

NBMT-PROC102607 Nicotine Replacement for Inpatient Withdrawal Management Unit Patients

NBMT-PROC102608 Inpatient Fractured Neck of Femur – Nepean Hospital Dietitian Referral & Nutrition

Assessment Pathway

NBMT-PROC102610 Mental Health: Referral to the STAR Clinic for Perinatal Mental Health

NBMT-PROC102611 Daily Bed Management allocation of beds for patients ready for discharge from the

Intensive Care Unit to optimise ICU capacity and timely access to Intensive Care

NBMT-PROC102615 Pharmacy Imprest Management and Medication Rooms in Mental Health Facilities

NBMT-PROC102616 Somerset Cottage Early Childhood Education and Care Staffing Arrangements and

Supervision

NBMT-PROC102617 Birth Unit Triage (Nepean)

NBMT-PROC102618 Paediatric Meningitis Management (confirmed or suspected disease)

NBMT-PROC102619 Sweeping the Membranes

NBMT-PROC102620 Use of the Pharmacy Lamson

NBMT-PROC102622 Radial Access Compression Device use Post Coronary Angiogram and Percutaneous

Coronary Intervention

NBMT-PROC102623 Supportive and Palliative Care (S&PC) Volunteers in Inpatient Settings in NBMLHD

NBMT-PROC102627 Evacuation in the Event of a Fire within NBMLHD Facilities

NBMT-PROC102629 Building Handover

NBMT-PROC102631 Incremental Peritoneal Dialysis for Western Renal Service (WRS)

NBMT-PROC102632 Admission, Transfer and Escalation for Neonatal and Paediatric Patients at Lithgow

Hospital

NBMT-PROC102633 Venous Thromboembolism (VTE) Prophylaxis in the Postnatal Patient

NBMT-PROC102637 Midline Catheter Insertion (Intermediate Length Peripheral Venous Access)

NBMT-PROC102639 Pre-mixed solution Heparin 25,000 units in 50mL Normal Saline

Page 26: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102640 Provision of Clear Fluid to Paediatric Patients on the Children's Ward awaiting Elective

Surgery at Nepean Hospital

NBMT-PROC102641 Patient Controlled Analgesia and Nurse Controlled Analgesia in Paediatric Patients at

Nepean Hospital

NBMT-PROC102642 Obstetric Admission Criteria (Lithgow Hospital Only)

NBMT-PROC102644 Nepean Anxiety Disorders Clinic: Did Not Attend (DNA): Management of Consumer Non

Attendance at Appointments

NBMT-PROC102645 Nepean Hospital Surgical Outpatient Urology Clinic (Surgery E)

NBMT-PROC102651 Medicinal Cannabis

NBMT-PROC102652 Management of the Workforce People and Culture Intranet Site

NBMT-PROC102653 Management of the Human Resources A-Z Enquiries Database

NBMT-PROC102655 Neonatal Hepatitis Prevention and Vaccination Program

NBMT-PROC102656 Targeted Domestic Violence Screening of Women over 16 who Present to Nepean

Hospital Emergency Department with Specific Indicators

NBMT-PROC102657 Mental Health: Transport and Escort

NBMT-PROC102658 Responding to the Needs of People with Disability in NBMLHD Hospitals

NBMT-PROC102660 Removal of Chest Port - Nepean Medical Imaging Department

NBMT-PROC102661 Hydrotherapy Pool

NBMT-PROC102665 Fever and Petechial Rash

NBMT-PROC102666 Admission to Intensive Care Unit, Nepean Hospital

NBMT-PROC102667 Teaching Carers how to Manage Subcutaneous Medications Using the Caring@Home

Resources in Home-Based Palliative Care Settings

NBMT-PROC102671 Opioid Treatment Program: Temporary and Permanent Transfers

NBMT-PROC102672 Transport of a Patient who is Clinically Deteriorating from the Drug and Alcohol

Inpatient Withdrawal Management Unit

NBMT-PROC102673 BMDAMH Nutrition Outpatient Services

NBMT-PROC102675 Clients Applying for NDIS

NBMT-PROC102676 Drug and Alcohol Service: Transfer of Care

NBMT-PROC102677 Use of Electronic Scales to Measure the Balance of Methadone at OTP Clinics

NBMT-PROC102680 Nepean Hospital Nursing Hours Per Patient Day (NHPPD)

NBMT-PROC102682 Nepean Hospital Permanent Nurse Pool (PNP)

NBMT-PROC102683 Deteriorating Patient: Neonatal Emergency Blue Light Calls within Nepean Hospital

NBMT-PROC102684 Neonatal Intensive Care Unit (NICU) and Special Care Nursery (SCN) Patient Flow and

Electronic Patient Journey Board

NBMT-PROC102685 Nepean Postnatal Clinic Referrals

NBMT-PROC102686 Group Facilitation across the Drug and Alcohol Service

NBMT-PROC102688 NSW Health Pathology Procedures

NBMT-PROC102689 COVID-19 Screening Clinics Swabbing

NBMT-PROC102690 Management of Schedule 8 Medication Errors and Other Serious Medication Errors by

Nursing and Midwifery Staff

NBMT-PROC102691 Accessing Brokerage Funding for Patients of the Drug and Alcohol Service

NBMT-PROC102692 Limiting Cash Payments to Contain the Spread of COVID-19 - Handling of Money within

Nepean Blue Mountains Local Health District (NBMLHD)

NBMT-PROC102693 Hospital In The Home (HITH) and Outreach Physiotherapy Service: Nepean Hospital

NBMT-PROC102694 Mobile CXR Imaging for Suspected or Confirmed COVID-19 Patients in NBMLHD

Page 27: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102695 COVID-19 Personal Protective Equipment: Donning and Doffing PPE within Nepean

Hospital Intensive Care Unit

NBMT-PROC102696 QARS: National Standard Medication Chart (NSMC) Audit

NBMT-PROC102697 QARS: Pharmacists Only “In-Patient” Ward Medication Storage Audit

NBMT-PROC102698 Mental Health: COVID-19 Related Provision of Personal Protective Equipment (PPE) to

External Services Entering Mental Health Inpatient Units within NBMLHD

NBMT-PROC102699 Personal Protective Equipment (PPE): Sequence for Donning and Doffing of PPE for

Suspected or Confirmed COVID-19 Patients

NBMT-PROC102700 COVID-19 - Booking Emergency Accommodation for Staff and Patients

NBMT-PROC102703 Communication Process in Theatres Between Obstetric and NICU Teams - Nepean

NBMT-PROC102704 COVID-19 Facility Screening - Visitors and Staff

NBMT-PROC102705 Communication Media from External Sources in Mental Health Facilities

NBMT-PROC102706 Referring Children and Adolescents to the Child and Youth Mental Health Service

(CYMHS) for Eating Disorders Treatment

NBMT-PROC102708 Deployment of the Mental Health Disaster Primary Response Team

NBMT-PROC102709 Administration of NSW Health Grant Funding for Non-Government Organisations

NBMT-PROC102711 QARS: Maternity Continuum Documentation Tool

NBMT-PROC102712 Temperature Monitoring and Alerts – Fridges/Freezers in NICU & SCN, Nepean Hospital

NBMT-PROC102713 Suctioning and Performing Nasopharyngeal Aspiration or Nasopharyngeal Swabs for

Infants and Children

NBMT-PROC102714 Care and Maintenance of a Peripherally Inserted Central Catheter (PICC) includes:

accessing or de-accessing; line change; weekly dressing; taking bloods / blood cultures

NBMT-PROC102715 Application of Fetal Scalp Electrode (FSE) in Birth Unit

NBMT-PROC102716 Use of the Fibroscan Machine within the Drug and Alcohol Service

NBMT-PROC102717 COVID-19 Temporary Change to Ministry of Health Policy: Home Dosing for Opioid

Treatment Program / Opioid Assisted Treatment

NBMT-PROC102718 Blue Mountains Maternity COVID-19 Admission and Care

NBMT-PROC102720 Management of Intoxicated Presentations in Community Based Programs

NBMT-PROC102721 Mental Health: Physical Health Care for Child and Youth Mental Health Service (CYMHS)

Consumers

NBMT-PROC102722 Off-Unit Groups and Activities Involving NBMLHD Inpatient Mental Health Consumers

and Staff

NBMT-PROC102723 COVID-19 Leave Management and Leave Application Form

NBMT-PROC102724 Midline: Care and Maintenance: Accessing OR De-accessing; Line Change; Weekly

Dressing; Taking Bloods / Blood Cultures

NBMT-PROC102726 Roster Office Procedure during COVID-19

NBMT-PROC102727 Management and Care of Woman with Decreased Fetal Movements - Blue Mountains

Maternity Unit

NBMT-PROC102728 Haemodialysis Utilising Central Venous Access Device (CVAD) with Luer Access Device –

Commencement, Completion and Dressing Change

NBMT-PROC102729 Neonatal Pain Management

NBMT-PROC102730 Blue Mountains Hospital: Escalation for Women’s and Children’s Health Patients

NBMT-PROC102731 TAM Staff- Fatigue Risk Management

NBMT-PROC102732 QARS: VMO’s Use of Interpreters for Consent in the RFA

NBMT-PROC102733 QARS Nursing Directorate S8 & S4D Drug Register Audit

NBMT-PROC102734 Patient Flow and Bed Allocation during COVID-19

Page 28: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102736 iDose for OTP Clinics - Gateway and Woodlands

NBMT-PROC102737 Management of Contract End Dates within StaffLink

NBMT-PROC102738 Nepean Dietitian General Adult Outpatient Service

NBMT-PROC102739 Postnatal Care in Maternal Acute Respiratory Infection Unit (MARIU)

NBMT-PROC102740 COVID-19: Telepsychiatry consultation between a Mental Health (MH) Clinician located

at Nepean Hospital Mental Health Centre or Blue Mountains Hospital and patients in the

Emergency Department (ED) at Nepean Hospital

NBMT-PROC102741 COVID-19: Tracheostomy and Laryngectomy Management in the Nepean Emergency

Department

NBMT-PROC102742 Oral Health: QARS Infection Control Audit

NBMT-PROC102743 Management of Undifferentiated and Confirmed COVID-19 Patients for Paediatrics

NBMT-PROC102744 Business Continuity Plan Drug and Alcohol Service, Gateway Clinic - Nepean Hospital

NBMT-PROC102745 Business Continuity Plan - Drug and Alcohol Service, Blue Mountains OTP Clinics -

Woodlands and Lithgow

NBMT-PROC102746 Business Continuity Plan: Drug and Alcohol Service, Centre for Addiction Medicine

NBMT-PROC102747 Managing Asset Refurbishment and Replacement Program (ARRP) Projects

NBMT-PROC102749 NBMLHD COVID-19 Drive through Screening Clinics

NBMT-PROC102750 Patient Flow for Patients requiring NIV/CPAP/HFNP in COVID (Green)

NBMT-PROC102751 Removing Deceased COVID-19 Patients from the Emergency Department

NBMT-PROC102753 Management of the Ambulatory Procedure Centre Short Stay Unit

NBMT-PROC102754 Disposal of NBMLHD Real Estate (Property)

NBMT-PROC102755 Inter-Hospital Transfers (IHT) from Nepean Hospital to Hawkesbury District Health

Service (HDHS)

NBMT-PROC102756 ICT - Security Incident Response

NBMT-PROC102757 Post Fall Huddle after a Fall or Near-Miss Fall

NBMT-PROC102761 COVID-19 Temporary Change to MoH Policy Takeaway and Unsupervised Dosing in NSW

Public Opioid Treatment Program

NBMT-PROC102773 Community Mental Health Case Review

NBMT-PROC102778 Post-operative Nursing Care and Observations for the First 24hrs

NBMT-PROC102779 Peritoneal Dialysis Exit Site Management (a) New insertion (b) 6 weeks post insertion (c)

Exit site infection

NBMT-PROC102780 Cancer Services COVID-19 Low Risk Febrile Neutropenic Clinic – ED (Nepean Hospital

Only) Avoidance Strategy

NBMT-PROC102781 Management of Aerosol Generating Procedures (HHFNP/BiPAP/CPAP) for patients with

Suspected and Confirmed COVID-19

NBMT-PROC102782 Spontaneous Rupture of Membranes (SROM) at Term

NBMT-PROC102783 “Treatment commenced” How to commence care for patients who present to NBMLHD

Emergency Departments

NBMT-PROC102784 QARS: Audit of Outpatient Services

NBMT-PROC102785 Maternity Acute Respiratory Infection Unit (MARIU)

NBMT-PROC102787 Arterial Blood Gas Sampling (Direct Arterial Puncture): Procedure, Learning Package, and

Competency Assessment

NBMT-PROC102788 Investigation of Possible Health Care Worker Acquisition of COVID-19 in a Health Care

Setting

NBMT-PROC102789 Febrile Neutropenic Patients ‘Low Risk’ Pathway (Nepean Hospital Only) – Early

Discharge with Daily Support

Page 29: DOCUMENT ID DOCUMENT TITLE - Ministry of Health

NBMT-PROC102790 Maternity - Postnatal Ward Covid19 Isolation Rooms

NBMT-PROC102797 Admission to Mother and Baby Unit (MABU)

NBMT-PROC102798 Admission for Neonatal Intensive Care Unit (NICU) and Special Care Nursery (SCN)

NBMT-PROC102800 Postoperative Peritoneal Dialysis (PD) Catheter Flushing

NBMT-PROC102801 Management of COVID-19 Patient Paper Records and Forms in Clinical Areas

NBMT-PROC102802 Admission of Women to Day Surgery for Dilatation and Curettage (D&C) following

Miscarriage at Nepean Hospital

NBMT-PROC102803 Cleaning the CleanSpace Respirators (PAPR) Motor Unit, Mask and Head Strap

NBMT-PROC102806 Performance Review Interviews for Visiting Medical Officers

NBMT-PROC102807 ORTHN: Overdose Response With Take Home Naloxone Procedure For South Court

Primary Care NSP (Needle and Syringe Program). Procedure For NSP Setting And

Outreach Services Targeting At-Risk Populations

NBMT-PROC102808 QARS: Aboriginal Health Cultural Engagement Audit

NBMT-PROC102809 Internet and Intranet Publishing

NBMT-PROC102811 Adult Inpatient Falls Prevention and Management Audit

NBMT-PROC102812 Recording of Nurse Allocations in Mental Health Units