POLICIES and PROCEDURES Current Listing As at 16 January 2020 - Copies Available Upon Request

POLICIES AND PROCEDURES Current Listing as at 16 January 2020 - Copies available upon request

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-POLY100002 Organ and Tissue Donation after Death - For the Purpose of Transplantation into the Body of a Living Person and/or for Research or Other Scientific Purposes 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 andTreatment 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 NBMT-POLY101161 Recruitment and Appointment of Postgraduate Fellows Remunerated Under Award Conditions NBMT-POLY101163 Medical Appointments Framework 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-POLY101354 Database Backup (for Locally Managed & 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 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-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-PROC100022 Suctioning Infants and Children 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 Challenges NBMT-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 NBMT-PROC100052 Management of Sudden Unexpected Death in Infancy (SUDI) NBMT-PROC100053 Surveillance of the Newborn following Instrumental Delivery NBMT-PROC100054 Immunisation: Neonatal NBMT-PROC100055 Peripheral Intravenous Cannula in the Neonate: Insertion, 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-PROC100073 Management of Authority to Practice Registration for Allied Health Professionals 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-PROC100523 Removal of Portacath - Nepean Imaging - 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 Administration of Oral Medications to Paediatric Patients while Fasting NBMT-PROC100658 Nurse Initiated Amethocaine Gel 4% (Local AnGel®) for Paediatric Patients NBMT-PROC100660 Haemodialysis Vascular Catheter Accessing 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 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-PROC100727 Management of Threatened Premature Labour 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 Home Visit Risk Assessment for Peritoneal Dialysis (PD) Nurses 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-PROC100774 Notification of Critical Results 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 Balance Twin Bag System NBMT-PROC100780 Continuous Ambulatory Peritoneal Dialysis (CAPD) Exchange - Baxter Freeline Solo Twin-Bag System NBMT-PROC100788 Clinical Emergency Response System- Blue Mountains Hospital: Recognition and Management of the Deteriorating Patient 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 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 Maintenance Department - Raising an online Work Order NBMT-PROC100816 Resuscitation of the Newborn NBMT-PROC100819 Nepean Hospital Medical Imaging/Nuclear Medicine: Bone Scan NBMT-PROC100820 Renal Scan (DTPA/MAG3) With/Without Lasix NBMT-PROC100821 Cerebral Angiography- Nepean Medical Imaging 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 NBMT-PROC100839 Liver Biopsy under Ultrasound Guidance NBMT-PROC100840 Trans-Jugular Liver Biopsy 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 NBMT-PROC100847 Incident Information Management System (IIMS) 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 Cerebral Angiography- Nepean Medical Imaging NBMT-PROC100858 Management of Naso-Pharyngoscopes - Nepean Cancer Care Centre NBMT-PROC100859 Insulin/Glucose Infusion - Nursing Management in Adults NBMT-PROC100860 Neonatal 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-PROC100867 Performing a Nasopharyngeal Aspiration (NPA) for Paediatrics and Neonates 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-PROC100944 Acute Management of Head Injuries in Paediatric Patients NBMT-PROC100945 Umbilical Venous Catheter Insertion in Neonates NBMT-PROC100947 Home Dosing of Patients - Opioid Treatment Program NBMT-PROC100948 Management of Cyanotic Episodes in Neonates in the Postnatal Ward 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 Nepean Imaging - Vascular Stent 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 on the Post Natal Ward and Birth Unit 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 Continuous Subcutaneous Infusion Devices - NIKI T34 TM and NIPRO SurefuserTM+ NBMT-PROC101050 Neonatal Hypoglycaemia Management NBMT-PROC101051 Nappy Rash and Epidermal Stripping in Neonates 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 Humidified High Flow Nasal Cannula Oxygen using Fisher & Paykel Delivery System (Neonatal) 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 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 eQATE Oral Health Clinical Care Record 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-PROC101343 eQATE Oral Health Infection Control Audit 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 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: Clinical Procedure for the 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 Home Visiting of Patients Engaged in NBMLHD Drug and Alcohol Service Programs 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 eQATE Audit - Safer Sleeping Practices for Babies NBMT-PROC101401 eQATE Audit - Ward Medication Storage NBMT-PROC101402 eQATE Audit - National Inpatient Medication Chart (NIMC) NBMT-PROC101403 eQATE Audit - Pharmacist Schedule Eight and 4D Medication 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 NBMT-PROC101424 QARS: Administration of Blood and Blood Products Intravenous Immunoglobulins Developing an Audit; Governance and Monitoring NBMT-PROC101425 eQATE Nursing Directorate S4D & S8 Drug Register Audit 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) 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 Dietetics - Managing Early/Unexpected Inpatient Discharges NBMT-PROC101494 Analgesic Transdermal 'Patch' Medications: Prescribing and Administration NBMT-PROC101496 Renal Biopsy Under Ultrasound Guidance NBMT-PROC101498 How to Tattoo Patients Undergoing Radiotherapy at NCCC NBMT-PROC101499 Medication Reconciliation 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 Coroner's 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-PROC101537 Peritoneal Dialysis Exit Site Care: New Insertion to 1 Week Post-Operation 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 Mental Health: Maintenance and/or Visiting Contractor Staff Accessing the Nepean Hospital Mental Health Unit/s to Carry out Work 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 Child Care Services Infection Control and Hygiene Procedures- 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 for Lithgow Hospital Emergency Department - a 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 2015 NBMT-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 NBMT-PROC101735 ManagementPreventive Therapy 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 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 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 eQATE Audit- Expressed Breast Milk Labelling (not including NICU) 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 Hospital NBMT-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 Cancer NBMT-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 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 Hospital NBMT-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-PROC101979 Prevention of Haemodialysis Catheter-Related Sepsis 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 and 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 NBMT-PROC101991 Infants and Children - Acute Management of Seizures NBMT-PROC101994 Safety & Performance Testing of Biomedical Equipment NBMT-PROC101997 Orthopaedic Outpatient Telehealth Consultations NBMT-PROC101998 Transporting People to and from inpatient Mental Health Settings 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) 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 Dispensing and Checking of Artificial Baby Milk (ABM) and Expressed Breast Milk (EBM) 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 Chemotherapy Drugs NBMT-PROC102075 Dietetics Home Enteral Nutrition (HEN) NBMT-PROC102076 Frequency of Changing Disposable Antimicrobial Impregnated Curtains - Nepean Hospital NBMT-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 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-PROC102122 Admission to Mother and Baby Unit (MABU) and Neonatal Intensive Care Unit (NICU) 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 Department NBMT-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 across NBMLHD 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 NBMT-PROC102182 Sterile Water Injections for Relief of Back Pain in Labour - Procedure for Administration NBMT-PROC102184 Nepean Campus Car 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 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 Electronic Fetal Heart Rate Monitoring 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 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 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-PROC102361 Criteria for Admission to the Falls Room in East Wing BMDAMH 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 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 and Lines NBMT-PROC102438 QARS: Nursing Visual Observations - Drug & Alcohol Inpatient NBMT-PROC102445 Cleaning of Reusable Medical Devices Prior to Disinfection and/or Sterilisation 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 and 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 V2 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 Patient Flow and Bed Management 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 Theatres Telehealth Video Consultations between the Chronic Obstructive Pulmonary Disease (COPD) NBMT-PROC102493 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 Admission Process of Patients with Cutaneous Abscess for Surgical Drainage under General Anaesthesia at Nepean NBMT-PROC102501 Hospital under the Care of the Acute Surgical Unit Chlamydia Outreach Screening Operations Manual - HIV and Related Programs (HARP) Team NBMT-PROC102503 and Nepean and Blue Mountains Sexual Health Clinics 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 Use and Storage of Air Assisted Transfer Device Non Disposable (Hovermats) NBMT-PROC102512 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 Nepean Hospital: Intravenous Hydralazine - Administration for Acute Management of NBMT-PROC102539 Severe Hypertension on the Postnatal Ward Nepean Hospital: Technical Assistant procedure for transporting patients NBMT-PROC102540 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 NBMT-PROC102561 Intravesical Instillation with Bacillus Calmette-Guerin (BCG) Nepean Hospital Surgical Outpatient Department NBMT-PROC102562 Paediatric Acute Review Clinic (PARC) NSW Dried Blood Spot (DBS) Study when screening patients for HIV & Hepatitis C infections NBMT-PROC102563 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-PROC102587 Maternal (In-utero) Transfer within NBMLHD and Tiered Perinatal Network NBMT-PROC102589 Somerset Cottage Early Childhood Education and Care Excursion NBMT-PROC102601 Somerset Cottage Early Childhood Education and Care Evacuation/Emergency Disaster Plan 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 & Nutrician Assessment Pathway NBMT-PROC102610 Mental Health: Referral to the STAR Clinic for Perinatal Mental Health Daily Bed Management allocation of beds for patients ready for discharge from the Intensive Care Unit NBMT-PROC102611 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 Membrane Sweep 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

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)