Portfolio Committee No.2 Health Inquiry into the Operation & … · 2019. 9. 24. · Mona Vale...

Portfolio Committee No.2 – Health Inquiry into the Operation & Management of Northern Beaches Hospital

Questions on Notice from 26 August public hearing

The Hon. WALT SECORD: Where would somebody get a copy of that report by the independent verifier?

Mr GAMERON: I will take that on notice.

The Hon. WALT SECORD: Could you provide a copy of that report to the Committee, please?

Mr GAMERON: I will take advice on that.

Answer: The Independent Verifier issued an Operational Readiness Certificate. The Verifier did not provide a report.

The Hon. WALT SECORD: How many sentinel events have occurred at the Northern Beaches Hospital? Dr WOODS: The exact number I would have to take on notice, but I am aware of two which have been

subjected to the full RCA—that is a root cause analysis. It is important to note that the final determination on

whether something is a sentinel event occurs after the completion of a root cause analysis.

Answer: Two. One event is still being reviewed and its final determination as a sentinel event is

yet to be confirmed.

Ms CATE FAEHRMANN: Could you provide the Committee with a breakdown of those positions. When you

said full-time equivalent, I think you said 43 per cent. Is that correct?

Mr ROYLE: Correct.

Ms CATE FAEHRMANN: Would we be able to have a breakdown of each: what those full-time equivalent

represent in terms of junior doctors, senior doctors, nurses and other staff?

Mr ROYLE: I cannot see an issue with that detail being provided.

Answer: As at end of August 2019, there are 1,136 full-time equivalent of staff. Of these, 821 are

full time. The breakdown of positions is as follows:

These figures do not include Junior Medical Officers (JMOs) employed by the Local Health District

who rotate through the NBH as part of their training or Visiting Medical Officers (VMOs) who are

contractors providing specialist services to the hospital.

Admin/Support Services 321 full time staff, 50.94 part time FTE

Medical (employed)

23 full time staff; 23.57 part time FTE

Allied Health

44 full time staff; 17.54 part time FTE

Nursing 433 full time staff; 223.34 part time FTE

Ms CATE FAEHRMANN: Is there a reason why in the project deed, I think, the targets in relation to maternity services have been redacted in the summary that is available for

public viewing?

Mr ROYLE: I have no knowledge of that; I apologise. I would have to refer that to the ministry. I really do not know.

Ms CATE FAEHRMANN: So would it be the Minister who would have redacted it? Would you be able to—

Mr ROYLE: I am sorry, I have no idea on that.

The CHAIR: Just take it on notice.

Ms CATE FAEHRMANN: It is highly unusual, I believe.

The CHAIR: Mr Royle might take that on notice.

Answer: Information about obstetrics services from the Project Deed, including targets and performance threshold, is provided below. Information relating to

penalties applicable in the event that targets are not met remains commercial-in-confidence.

(a) KPIs (non- Service Measures ) Item No

Area ACHS

Indicator Set or NSLHD Service Agreement

Area

KPI Descriptor Target Performance Threshold

ConcludedI

Rectifiable

Remedial Period

Repeated Failure

Monitoring Method

17 Service Specific

Anaesthesia Obstetric Patients commencing surgery within 30 minutes of lower segment caesarean (LSCS) request

{Cl No. 6.2)

Number of obstetric Patients who commence surgery within 30 minutes of request for immediate LSCS

75th Percentile of ACHS Peer Hospitals


Concluded N/A NIA 6 month ACHS Clinical Indicator Report

29 Service Specific

Obstetrics Selected primipara - surgical repair of perineum for fourth degree tear (Cl No. 3.6)

Number of selected primipara undergoing surgical repair of the perineum for fourth degree tear



Concluded N/A NIA 6 month ACHS

Clinical Indicator Report

(a) KPIs (non- Service Measures ) Item No

Area ACHS

Indicator Set or NSLHD Service Agreement

Area

KPI Descriptor Target Performance Threshold

ConcludedI

Rectifiable

Remedial Period

Repeated Failure

Monitoring Method

30 Service Specific

Obstetrics Vaginal birth - blood transfusion (Cl No. 7.1)

Number of women who give birth vaginally who receive a blood transfusion



Concluded N/A N/A 6 month ACHS


31 Service Specific

Obstetrics Babies - birth weight <2750 g

at 40 weeks gestation or beyond (Cl No. 8.1)

Number of babies born with birth weight less than 2750g at 40 weeks gestation or greater



Concluded NIA N/A 6 month ACHS


32 Service Specific

Obstetrics Term babies - Apgar score of

<7 at 5 minutes

post-delivery (Cl No. 9.1)

Number of live born term babies with an Apgar score of less than 7 at 5 minutes post delivery



Concluded NIA NIA 6 month ACHS Clinical Indicator Report

33 Service Specific

Obstetrics General anaesthetic for caesarean section (Cl No. 4.1)

Number of women who had a general anaesthetic for a caesarean section




34 Service Specific

Obstetrics Appropriate prophylactic antibiotic at time of caesarean section (Cl No. 5.1)

Number of women who receive an appropriate prophylactic antibiotic at the time of caesarean section




The Hon. NATASHA MACLAREN-JONES: Another issue that has been raised relates to community

consultation in the lead-up to the design and building of the hospital. What engagement has been made with the

community and with key stakeholders across the Northern Beaches—and also post the opening?

Mr GAMERON: We have regular contact with a number of community groups now. I was not part of the

project team that brought the hospital through to commissioning. However, we can provide that on notice. I am

aware that hundreds of meetings occurred across the years prior to the hospital opening.

Answer: Preliminary community consultation about proposed changes to health services on the

Northern Beaches was undertaken by the NSW Ministry of Health and the Northern Sydney Local

Health District and pre-dated Healthscope’s involvement in the project.

Following its selection as the preferred tenderer to design, build, operate and maintain the new

hospital, Healthscope worked with Northern Sydney Local Health District on community

engagement. More than 100 forums were held to brief organisations in the community, including

local government, community groups and clubs. A series of staff briefings were held prior to the

the hospital’s opening and mail-outs to community members and organisations provided milestone

updates.

We continue to build relationships with the community that we serve and have engaged with

numerous organisations including, but not limited to:

• Hospital volunteers

• Frenchs Forest businesses, organisations and residents

• Elected representatives including local members of parliament and local council

• Community organisations such as Northern Beaches Sydney Surf Life Saving School.

• Clinicians and organisations involved in providing health care to the Northern Beaches community, such as the Sydney North Health Network

• Community action groups and community groups

The Hon. WES FANG: Are there any training positions that were not previously offered at Manly and Mona

Vale that you now offer?

Dr WOODS: I am not sure. I believe that there were representatives from each of those specialties but certainly

not in the numbers.

Mr ROYLE: We could take that on notice and provide that detail.

Answer: Both the number of training places available and the complexity of training experience

has increased at Northern Beaches Hospital over what was previously available at Manly and

Mona Vale hospitals.

Northern Beaches Hospital has 76.25 FTE trainees, increasing to 77.25 in 2020. At the time of

closure, Manly and Mona Vale combined had 71.5 trainees.

There are additional trainee positions available in General Medicine, Obstetrics and Gynaecology,

Psychiatry, Orthopaedics and General Surgery.

It is expected that these training positions will continue to expand, with a number of other

specialties expressing interest in applying for accreditation of training positions.

The Hon. SHAYNE MALLARD: I think that is something that should be noted. Specialists are colocating.

What types of specialists have co-located to this hospital? You were saying that the advantage was that they co-

locate there.

Mr GAMERON: Sure—a full range of paediatricians, orthopaedic surgeons, obstetricians, cardiologists. We

can provide a full list of those co-located to the hospital but there is a significant range of doctors who have their

own rooms based at the hospital.

The Hon. SHAYNE MALLARD: If you provide that on notice you might also provide on notice which ones

are new services to the Northern Beaches that might not have been available from the other two hospitals.

Mr GAMERON: Sure. Pleased to do that.

Answer: There were no on-site private consulting rooms at Manly or Mona Vale hospitals.

Northern Beaches Hospital has the following categories of specialists consulting from private, on

site, consulting rooms:

• breast surgery

• cardiology

• colorectal surgery

• gastroenterology

• general surgery

• geriatric medicine

• medical oncology

• neurology

• obstetrics and gynaecology

• orthopaedics

• paediatrics and fetal cardiology

• paediatrics

• plastic and reconstructive surgery

• rheumatology

• spinal surgery

• vascular surgery

PORTFOLIO COMMITTEE NO. 2 – HEALTH

INQUIRY INTO THE OPERATION & MANAGEMENT OF THE NORTHERN BEACHES HOSPITAL

Supplementary questions – Hearing - 26 August 2019

Questions directed to Mr Richard Royle, Interim Chief Executive Officer, Northern Beaches Hospital:

BED NUMBERS

1. What were the number of beds that was originally proposed for the Northern Beaches Hospital? Answer: 486

2. As of 26th August 2019, what is the total capacity in terms of beds that the Northern

Beaches Hospital has? Answer: 486

3. As of 26th August 2019, exactly how many beds are available and operational?

Answer: As many as necessary on any given day to meet the patient demand.

4. As of 26th August 2019, what number are available for public patients?


5. As of 26th August 2019, what number are available for private patients?


6. How is a bed defined at the Northern Beaches Hospital?

Answer: In accordance with the licensing rules of the NSW Ministry of Health.

OPERATIONAL READINESS

1. Will you provide a copy of the Independent Verifiers report that indicated the hospital was operationally ready to open?

Answer: The Independent Verifier issued an Operational Readiness Certificate. The Verifier did not provide a report.

TIME IN EMERGENCY DEPARTMENT

1. What were the exact dates when patients were waiting in the Emergency Department longer than 24 hours?

Answer: Patients within the emergency department undergo assessment, diagnostic testing, treatment and active monitoring. The length of stay is not a reflection of waiting times for treatment. We understand the question relates to the length of stay receiving treatment in the Emergency Department rather than waiting time. On this basis, the days on which length of stay exceeded 24 hours were 2, 3, 4, 5, 11 and 15 November 2018.

2. What were the exact dates when patients were waiting in the Emergency Department longer than 12 hours?

Answer: Patients within the emergency department undergo assessment, diagnostic testing, treatment and active monitoring. The length of stay is not a reflection of waiting times for treatment. Emergency Department length of stay between 12 hours and 24 hours is not a metric that is captured as it is not required to be reported.

3. As of 26th August 2019, what is the current average waiting time for patients

accessing the Emergency Department?

Answer: Northern Beaches Hospital’s Emergency Department month to date performance as of August 26 was:

ATS Category Maximum waiting time target

Performance Indicator (%)

NBH August 2019 results

1 Immediate 100 100

2 10 minutes 80 78.23

3 30 minutes 75 76.08

4 60 minutes 70 92.93

5 120 minutes 70 100

This data is calculated by triage category in accordance with the Australasian Triage Scale (ATS). Northern Beaches Hospital is measured against benchmark Key Performance Indicators (KPIs) that are set higher for some categories than other hospitals. This data will be validated by the NSW Bureau for Health Information as part of the normal review process.

SENTINEL EVENTS 1. As of 26th August 2019, how many sentinel events have occurred since the Northern

Beaches Hospital opened? Answer: Two. However, the second event is still being reviewed and its final determination as a sentinel event is yet to be confirmed.

2. Can you provide the details of what occurred for each sentinel event (without identifying any individual patients)? Answer: It is not appropriate to provide further details as to do so would breach patient confidentiality.

3. Can you provide the Root Cause Analysis reports for each of these events?

Answer: The detail contained in an RCA has the potential to breach patient and staff confidentiality and we therefore cannot provide it. The purpose of RCAs is to identify what may have contributed to an event occurring, share system-wide lessons with health care practitioners and others in the health system and minimise the risk of similar events occurring. Northern Beaches Hospital fully participates in the NSW Health clinical governance process.

COMMON ROOMS and BUNDY CARD SYSTEM 1. Was any of the staff common rooms locked overnight?

a. If so, what was the reason behind this decision?

Answer: Sections of the hospital predominantly intended for day-time use, including the Education Centre, are locked at night for security reasons. Junior doctors have 24-hour access to the JMO lounge, workroom and kitchen and bathroom facilities.

Doctors who are on-call and required to be at the hospital but not on duty have access to on-call rooms which provide a bed and desk. They also have access to kitchen, bathroom and toilet facilities, the JMO lounge and computer facilities.

2. Have any doctors ever been required to tap on and off using a Bundy-style system

when they worked at the Northern Beaches Hospital? 3. If so, can you provide details as to how this system operates and who is required to

comply with it? 4. As of 26th August 2019, is a Bundy-style system still in place?

Answer to questions 2-4: Most hospital staff, including junior medical staff directly employed by Northern Beaches Hospital, use an electronic swipe card based on the Kronos time and attendance software. NBH is currently piloting the same system for Junior Medical staff who are employed by the Northern Sydney Local Health District (LHD) and rotate through Northern Beaches Hospital. This has been done in consultation with ASMOF.

Questions directed to Dr Simon Woods, Interim Medical Director, Northern Beaches Hospital:

CLINICAL POLICIES

1. As of 26th August 2019, how many Clinical Policies have been produced and published to assist staff working at the hospital?

Answer: In addition to the Healthscope and Northern Beaches Hospital-specific clinical policies that existed at the time of the hospital’s opening, a further 118 clinical policies have been developed with the majority based on policies from the Local Health District. Some 22 of the pre-existing NBH specific policies have been updated.

2. Can you list the name of each of the Clinical Policies that has been produced and

published?

Answer: In total there are 808 policies accessible to all staff. There is an overlap between

those classified as clinical and others which directly relate to patient care with areas such

as transport and infection control, which are classified separately. There are 501 which

could be definitively considered to relate to patient care issues. The full 808 are listed

below.

Accreditation and Public Disclosure of Outcomes 1.04 Healthscope Administration

Accredited Health Practitioner's Credentials 1.2O Healthscope Administration

Acknowledgement of Country 1.03 Healthscope Administration

Admission of a Patient to Acute Medical Surgical Hospital

2.65 Healthscope Administration

Admission of Patients and Informed Financial Consent 2.01 Healthscope Administration

Admission of Patients by Ambulance 2.04 Healthscope Administration

Admission of Patients - Refusal and Authorisation 2.26 Healthscope Administration

Admissions, exclusion criteria and referral network - adult critical care

NBH-05-10

NBH Administration

Admissions, exclusions and referral criteria - Paediatrics

NBH-05-06

NBH Administration

Admissions, exclusions and referral network - perinatal NBH-05-05

NBH Administration

Advance Care Directives 2.56 Healthscope Administration

Advance care directives NBH-05-12

NBH Administration

Alerts - Documentation and Management of 2.45 Healthscope Administration

Animals, Assistance - Patients 2.41 Healthscope Administration

Auditing, Internal - Quality 2.37 Healthscope Administration

Business Names 1.47 Healthscope Administration

By-Laws, Policies, Procedures and Memoranda 1.07 Healthscope Administration

Car / Motor Vehicle 1.16 Healthscope Administration

Chain of Command - Nursing Staff 2.19 Healthscope Administration

Chemotherapy Governance of NBH-05-37

NBH Administration

Claims for Non Clinical Hours - Senior Medical Staff NBH-05-13

NBH Administration

Clinical Coders - Training and Assessment (prev. Trainee Clinical Coder, New HIM / CC)


Clinical Coding and Checking 2.38 Healthscope Administration

Clinical Indicators previously Clinical Indicators - Minimum Data Set


Clinical Trials and Research 2.11 Healthscope Administration

National Committees and Clinical Webex Teams 2.18 Healthscope Administration

Coding Query Process 2.46 Healthscope Administration

Complaints Management 1.08 Healthscope Administration

Complaints Management Process NBH-05-04

NBH Administration

Consent to Medical / Surgical Treatment 2.17 Healthscope Administration

Consumer-Approved Publications 2.6 Healthscope Administration

Consumers, Partnering with 1.05 Healthscope Administration

Contracts Register - Healthscope Group 1.3 Healthscope Administration

Copyright 1.09 Healthscope Administration

Correct Patient, Correct Procedure, Correct Site 2.15 Healthscope Administration

Credit Card Authorisation 1.51 Healthscope Administration

Critical Systems Review (CSR) 1.36 Healthscope Administration

Day of Surgery – unplanned overnight admission NBH-05-18

NBH Administration

Day Procedure admission and discharge criteria NBH-05-17

NBH Administration

Deaths, In-Hospital - Review of 2.48 Healthscope Administration

Delegations of Authority - Administrative Requests 1.26 Healthscope Administration

Discharge of a Patient 2.5 Healthscope Administration

Discharge of a Patient against Medical Advice - (previously 8.19)


Document Control 1.14 Healthscope Administration

Document Destruction - Criminal Offence 1.06 Healthscope Administration

Document Retention - Non Health Information 1.28 Healthscope Administration

Duplicate UR Management 2.47 Healthscope Administration

Ellis Disclaimer 2.12 Healthscope Administration

Emergency Departments 2.03 Healthscope Administration

Energy Management 1.46 Healthscope Administration

Enrolled Nurses in the Intensive Care Unit 2.53 Healthscope Administration

Environmental Management 1.45 Healthscope Administration

Exclusion from admission NBH-05-07

NBH Administration

Exclusions - Services not Provided 2.31 Healthscope Administration

Fax Streaming 1.25 Healthscope Administration

Forms, Medical Record 2.34 Healthscope Administration

Gifts, Gratuities and Conflict of Interest 1.13 Healthscope Administration

Health Fund - Contract Amendments 1.48 Healthscope Administration

Health Fund - Contract Amendments - Process Map 1.48 Healthscope Administration

Incident Management 2.13 Healthscope Administration

Incident reporting to NSW Health NBH-05-03

NBH Administration

Integration of ED Education Programs NBH-05-36

NBH Administration

Internet Content Management 1.21 Healthscope Administration

Interpreter Service 2.36 Healthscope Administration

Interpreter service - access to NBH-05-09

NBH Administration

JMO Un-Rostered Overtime, Call-Back (Recall) NBH-05-11

NBH Administration

Leave Cover (Executive) - Delegation of Authority 1.27 Healthscope Administration

Logos (Corporate) - Use of 1.43 Healthscope Administration

Marketing and Business Development Plans 1.32 Healthscope Administration

Maximiser Database Use 1.42 Healthscope Administration

Mechanical Ventilation & ICU Hours 2.58 Healthscope Administration

Media and Public Relations 1.17 Healthscope Administration

Medical Company Representatives (MCR) - Site Visits (previously Supplier Representatives - Site Visits)


Medical Discharge Summary / Doctor's Letter 2.4 Healthscope Administration

Medical Record, paper based - Request for correction of patient information


Medical Record Documentation Audit 2.27 Healthscope Administration

Medical Record Paper-Based - Documentation in (retitled)


Medical Records, Paper-Based - Lost 2.22 Healthscope Administration

My Health Record System 2.66 Healthscope Administration

New Interventional Procedures - Safe Introduction of 2.32 Healthscope Administration

Notification of Disease and Child Abuse 2.25 Healthscope Administration

Open Disclosure 2.3 Healthscope Administration

Pastoral and Spiritual Care 2.05 Healthscope Administration

Pastoral Care Service at NBH NBH-05-08

NBH Administration

Patient Identification Bands 2.08 Healthscope Administration

Patient Satisfaction Surveys 1.33 Healthscope Administration

Photography - Consent for 1.44 Healthscope Administration

Policy and Document Control NBH-05-02

NBH Administration

Policy Compliance Monitoring 1.1 Healthscope Administration

Policy Proforma and Template 1.15 Healthscope Administration

Policy Review, Authorisation and Distribution 1.01 Healthscope Administration

Preadmission of Patients - Acute Hospitals 2.28 Healthscope Administration

Privacy 2.23 Healthscope Administration

Privacy - New Zealand 2.23 Healthscope Administration

Procurement 1.29 Healthscope Administration

Product Recall 2.1 Healthscope Administration

Patient Rounding 2.63 Healthscope Administration

Quality Management 1.18 Healthscope Administration

Release of Health Information 2.24 Healthscope Administration

Removal or Exclusion of Persons from Premises 1.11 Healthscope Administration

Reports - General Managers' 1.12 Healthscope Administration

Retention and Disposal of Health Information 2.21 Healthscope Administration

Rights and Responsibilities - Patients' 2.16 Healthscope Administration

Risk Management - Clinical 2.29 Healthscope Administration

Risk Management and Integrated Risk Register 1.34 Healthscope Administration

Risk Management System - Use of Riskman 1.38 Healthscope Administration

Root Cause Analysis (Statutory) - Clinical 2.02 Healthscope Administration

Scanned Documents in WebPAS - Financial Forms and Certificates


Second Opinion, Right to a 2.35 Healthscope Administration

Self-Funded Hospital Patients 1.5 Healthscope Administration

Sentinel and HSSE Event Identification and Escalation 1.35 Healthscope Administration

Communication for Site Visits - Head Office Staff 1.39 Healthscope Administration

Social Media - Patient Use 1.41 Healthscope Administration

Social Media - Professional Use 1.37 Healthscope Administration

Staff Discounts 2.59 Healthscope Administration

Suicide (Threatened, Attempted or Completed) of an Adult Inpatient in a Non-Mental Health Facility


Top Tips for Safe Health Care (Renamed from Ten Tips for Safer Health Care)


Transfer (Intrahospital) of Patient from the Emergency Department


Transfer of a Patient - Inter-Hospital 2.49 Healthscope Administration

Transport of Patient - Intra Hospital NBH-05-32

NBH Administration

Travel - Company 1.19 Healthscope Administration

Vision and Values 1.02 Healthscope Administration

Accredited Health Professionals' Credentials 1.20 Healthscope Administration

Visitors 2.06 Healthscope Administration

Waste Management 1.49 Healthscope Administration

WebPAS Coding Audit Tool 2.57 Healthscope Administration

webPAS Contingency Process 1.52 Healthscope Administration

Wills & Power of Attorney for Patients 1.24 Healthscope Administration

Allied Health

Clinical Handover – Allied Health Staff NBH-13-01

NBH Allied Health

All Healthscope Corporate Clinical Policies

Acute Asthma Management NBH-06-65

NBH Clinical

Acute Cardiac Rehab NBH-06-34

NBH Clinical

Acute Severe Behavioural Disturbance in Emergency Departments Management

NBH-06-71

NBH Clinical

Admission and Discharge to ICU NBH-06-30

NBH Clinical

Advanced Life Support 8.13 Healthscope Clinical

Animal Visits to Hospital NBH-06-43

NBH Clinical

Arterial Line Management 8.4 Healthscope Clinical

Aseptic Technique 8.38 Healthscope Clinical

Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR)

8.42 Healthscope Clinical

Bed Sticks 8.79 Healthscope Clinical

Bladder Irrigation Continuous -Post Op NBH-06-57

NBH Clinical

Blood Alcohol And Drug Testing NBH-06-59

NBH Clinical

Blood Cultures – Collection of NBH-06-61

NBH Clinical

Blood Fridge - Contents Management and Unused Blood Products


Blood Transfusion - Management of Patient Blood and Blood Products


Blood Transfusion - Massive 8.62 Healthscope Clinical

Blood Transfusion - Massive Transfusion Protocol NBH

NBH-06-05

NBH Clinical

Blood Transfusion (Emergency) of Unmatched Red Cells


BME Acceptance and Commissioning NBH-06-97

NBH Clinical

BME Calibration of biomedical testers NBH-06-106

NBH Clinical

BME Decommissioning of medical equipment NBH-06-98

NBH Clinical

BME Equipment servicing repairs_External NBH-06-101

NBH Clinical

BME Medical Equipment Repairs NBH-06-99

NBH Clinical

BME Periodic Maintenance Schedule NBH-06-102

NBH Clinical

Cardiac Monitoring in Adult Patients NBH-06-67

NBH Clinical

Care Planning Emergency Department NBH-06-17

NBH Clinical

CAT Scans for Headaches 8.48 Healthscope Clinical

Central Venous Catheter (CVC) - Administration of Medications and Fluids


Central Venous Catheter (CVC) - Blood Sampling 8.47 Healthscope Clinical

Central Venous Catheter (CVC) - Dressing 8.47 Healthscope Clinical

Central Venous Catheter (CVC) - Flushing and Locking


Central Venous Catheter (CVC) - Infusion Set - Needleless Connector Change


Central Venous Catheter (CVC) - Insertion 8.47 Healthscope Clinical

Central Venous Catheter (CVC) - Removal 8.47 Healthscope Clinical

Clinical Deterioration - Recognising and Responding to


Clinical Escalation Response System (CERS) NBH-06-02

NBH Clinical

Clinical Handover - Departmental and Intra-Unit 8.18 Healthscope Clinical

Clinical Handover Processes NBH-06-03

NBH Clinical

Cold Therapy 8.49 Healthscope Clinical

Continuous Renal Replacement Therapy (CRRT) using the Gambro Prismaflex

NBH-06-87

NBH

Coordination of Services NBH-06-234

NBH Clinical

Coronary Angiography and Percutaneous Coronary Intervention (PCI)

NBH-06-60

NBH Clinical

Coronary Angioplasty/Angiogram - Patient Preparation NBH-06-66

NBH Clinical

Coronary Care Unit (CCU) - Admission to NBH-06-68

NBH Clinical

Death of a Patient - care of the Body After Death NBH-06-15

NBH Clinical

Death of a patient – Coronial NBH-06-18

NBH Clinical

Death of Infectious Patient - Care of Body after Death NBH-06-16

NBH Clinical

Defibrillation NBH-06-62

NBH Clinical

Delirium and Cognitive Impairment Prevention and Management


Diabetic Ketoacidosis - Management of - Adult NBH-06-56

NBH Clinical

Diet and Nutrition - Adult Inpatients 8.27 Healthscope Clinical

Discharge Planning & Procedure NBH-06-22

NBH Clinical

Domestic Violence - Identifying and Responding NBH-06-20

NBH Clinical

Drains - Management and Removal of NBH-06-

72 NBH Clinical

Elective Cardioversion NBH-06-47

NBH Clinical

Electrocardiogram (ECG) NBH-06-94

NBH Clinical

Emergency Department - Discharge of patients from NBH-06-

73 NBH Clinical

Emergency Department Triage NBH-06-103

NBH Clinical

Emergency Dept. Intra-hospital transfer of patients from ED to Hospital wards

NBH-06-09

NBH Clinical

Emergency Equipment – Location and Content (Hospital Wide)

NBH-06-08

NBH Clinical

Emergency Equipment - LUCAS chest compression system

NBH-06-04

NBH Clinical

Emergency Trolley - Checking and Restocking NBH-06-11

NBH Clinical

End of life care and decision making NBH-06-07

NBH Clinical

Endotracheal Tube - Securing NBH-06-28

NBH Clinical

Enteral Feeding via a Percutaneous Endoscopic Gastrostomy (PEG) or a Percutaneous Jejunostomy Tube


Epicardial Pacing Wires - Management of the patient with

NBH-06-26

NBH Clinical

Epidurals - Insertion and Management of 8.39 Healthscope Clinical

External Ventricular Drain - Management of NBH-06-114

NBH Clinical

Extubation - Endotracheal Tube 8.77 Healthscope Clinical

Falls Prevention and Management - Patient 8.04 Healthscope Clinical

Fluid Balance Charts 8.91 Healthscope Clinical

Haemodialysis - Air Embolism Management NBH-06-32

Clinical

Haemodialysis Extracorproreal Circuit Anticoagulation NBH-06-236

NBH

Haemodialysis - Management of Intradialytic Hypotension

NBH-06-45

NBH Clinical

Haemodialysis - Management of Machines and Immediate Environment

NBH-06-49

NBH Clinical

Haemodialysis - Managing dialysate potassium levels NBH-06-37

NBH Clinical

Haemodialysis - Transfusion of Blood Products on dialysis

NBH-06-46

NBH Clinical

Haemodialysis Patient Failure to Attend NBH-06-235

NBH Clinical

Hand Hygiene 8.1 Healthscope Clinical

Heat Therapy – ‘Flexeze’ Heat Patch 8.46 Healthscope Clinical

Humidified High Flow Oxygen Therapy via Nasal Cannula

NBH-06-72

NBH Clinical

Hypoglycaemia - Recognition and Treatment of - Adults

NBH-06-53

NBH Clinical

Immunoglobulin - Administration of 8.92 Healthscope Clinical

Implanted Venous Ports - Administration of Medications or Fluids


Implanted Venous Ports - Blood Sampling 8.37 Healthscope Clinical

Implanted Venous Ports - Changing Needleless Connectors


Implanted Venous Ports - De-Accessing and Removal 8.37 Healthscope Clinical

Implanted Venous Ports - Dressing Change 8.37 Healthscope Clinical

Implanted Venous Ports - Flushing and Locking 8.37 Healthscope Clinical

Implanted Venous Ports - General Care, Assessment and Documentation


Implanted Venous Ports - Management of Emergencies


Implanted Venous Ports - Needling and Accessing 8.37 Healthscope Clinical

Intra-Aortic Balloon Pump (IABP) Catheter - Insertion and Management


Intra-Aortic Balloon Pump Macquet - Timing and Weaning

NBH-06-116

NBH Clinical

Jehovah's Witnesses & Transfusions 8.87 Healthscope Clinical

Last Days of Life Care and Management 8.96 Healthscope Clinical

Lumbar Puncture NBH-06-63

NBH Clinical

Major Trauma Criteria NBH-06-141

NBH Clinical

Mechanical Ventilation in ICU NBH-06-27

NBH Clinical

Meningococcal Disease - Management in the Ed NBH-06-80

NBH Clinical

MRI of patients with MR Conditional Cardiovascular Implantable Electronic Devices (CIEDs)

NBH-06-64

NBH Clinical

Nasogastric Tube - Insertion and Care 8.29 Healthscope Clinical

Negative Pressure Rooms NBH-06-48

NBH Clinical

Negative Pressure Wound Therapy NBH-06-231

NBH Clinical

Neurological Observations NBH-06-40

NBH Clinical

Neurovascular Observations NBH-06-41

NBH Clinical

Non-fatal Drowning/Submersion/Immersion NBH-06-154

NBH Clinical

Not for Cardiopulmonary Resuscitation (NFR) - Withdrawal of Treatment


Nursing Care of the Intensive Care Patient NBH-06-31

NBH Clinical

Nurse Initiated XRay (NIXR) NBH-06-150

NBH Clinical

Observations in the ED 8.12 Healthscope Clinical

Observations General - Minimum Standards NBH-06-42

NBH Clinical

Ophthalmology Pts presenting to ED - Management of NBH-06-142

NBH Clinical

Organ and Tissue Donation NBH-06-14

NBH Clinical

Organ and Tissue Donations 8.81 Healthscope Clinical

Pacing, Temporary - Management DRAFT 1 8.19 Healthscope Clinical

Patient Special NBH-06-50

NBH Clinical

Peripheral Intravenous Cannula (PIVC) - Insertion, Management and Removal


Peripherally Inserted Central Catheter (PICC) - Administration of Medications and Fluids


Peripherally Inserted Central Catheter (PICC) - Changing Needleless Connectors


Peripherally Inserted Central Catheter (PICC) - Dressing Change


Peripherally Inserted Central Catheter (PICC) - Flushing and Locking


Peripherally Inserted Central Catheter (PICC) - General Care, Assessment and Documentation


Peripherally Inserted Central Catheter (PICC) - Blood Sampling


Peripherally Inserted Central Catheter (PICC) - Management of Emergencies


Peripherally Inserted Central Catheter (PICC) - Removal


Peritoneal Dialysis - Line Change NBH-06-69

NBH Clinical

Peritoneal Dialysis - Management of NBH-06-70

NBH Clinical

Physical Assessment of ICU Patient: Documentation of

NBH-06-33

NBH Clinical

Pigtail Drains, Removal of 8.8 Healthscope Clinical

Pleural Drains - Insertion of 8.9 Healthscope Clinical

Pleural Drains - Management of 8.9 Healthscope Clinical

Pleural Drains - Removal of 8.9 Healthscope Clinical

Possession of Firearms - Notifying and Managing Risk to Other Persons

NBH-06-71

NBH Clinical

Post-Operative Management of Cardiac Surgery NBH-06-12

NBH Clinical

Pre-operative hair clipping and preparation NBH-06-38

NBH Clinical

Pressure Injury - Prevention and Management of 8.05 Healthscope Clinical

Pulmonary Artery Catheter - Management 8.41 Healthscope Clinical

Pulmonary Artery Catheter - Removal 8.41 Healthscope Clinical

Pulmonary Artery Catheter- Insertion 8.41 Healthscope Clinical

Pulse Oximetry 8.44 Healthscope Clinical

Radial Sheath Removal with TR Band NBH-06-35

NBH

RefeedingSyndrome HKHS NSLHD Clinical

Re-sternotomy (Emergency Chest Opening) NBH-06-25

NBH Clinical

ROTEM - Thromboelastometry guided management of the bleeding patient

NBH-06-32

NBH Clinical

Safe Movement of Patients in Emergency Department NBH-06-10

NBH Clinical

Safe Sleeping - Infants 8.24 Healthscope Clinical

Safe Start (NSW PD) NBH-06-54

NBH Clinical

Sexual Assault, Management of patients presenting post

NBH-06-06

NBH Clinical

Sputum Collection 8.26 Healthscope Clinical

Subcutaneous catheter system (butterfly) management

NBH-06-51

NBH Clinical

Swallow Screening for Acute Stroke Transient Ischaemic Attack (TIA)

NBH-06-44

NBH Clinical

Talc Pleurodesis NBH-06-13

NBH Clinical

Targeted temperature management after cardiac arrest

NBH-06-52

NBH Clinical

Telephone Triage 8.08 Healthscope Clinical

Temporary Transvenous Pacing Management of Pt undergoing

NBH-06-29

NBH Clinical

TPN 8.84 Healthscope Clinical

Tracheostomy - Accidental Decannulation and Blockage


Tracheostomy - Speaking Valves 8.25 Healthscope Clinical

Tracheostomy - Tube Change and Decannulation 8.23 Healthscope Clinical

Tracheostomy Care 8.21 Healthscope Clinical

Tracheostomy Suctioning 8.2 Healthscope Clinical

Triage 8.07 Healthscope Clinical

Unidentified Person/s Presenting to the ED NBH-06-219

NBH Clinical

Urinary Bladderscan - Portable Unit 8.35 Healthscope Clinical

Urinary Catheterisation - Female 8.32 Healthscope Clinical

Urinary Catheterisation - Male 8.31 Healthscope Clinical

Urine Specimen Collection 8.3 Healthscope Clinical

Vas-Catheter for CRRT - Insertion of NBH-06-81

NBH Clinical

Venous Thromboembolism (VTE) - Prevention 8.06 Healthscope Clinical

Visitors in ICU NBH-06-224

NBH Clinical

Voluntary Assisted Dying (Victoria) 8.98 Healthscope Clinical

Wound Assessment and Management NBH-06-226

NBH Clinical

Wound Care - Basic Dressing Technique NBH-06-227

NBH Clinical

Wound Care - Skin Tear Guidelines NBH-06-232

NBH Clinical

Wound Swab - Procedure NBH-06-76

NBH Clinical

All Healthscope Corporate Governance Policies

Audit, Risk and Compliance Committee Charter 0.1 Healthscope Corporate

Governance

Board Charter 0.09 Healthscope Corporate

Governance

By-Laws 0.11 Healthscope Corporate

Governance

Code of Conduct 0.01 Healthscope Corporate

Governance

Continuous Disclosure 0.02 Healthscope Corporate

Governance

Dealing in Securities 0.056 Healthscope Corporate

Governance

Diversity and Inclusion 0.12 Healthscope Corporate

Governance

Executive Minimum Shareholding Policy 0.15 Healthscope Corporate

Governance

Enterprise Risk Management (ERM) Strategy 0.17 Healthscope Corporate

Governance

Market Disclosure and Communication Strategy 0.04 Healthscope Corporate

Governance

Nomination Committee Charter 0.08 Healthscope Corporate

Governance

Non Audit Services 0.13 Healthscope Corporate

Governance

Non-Executive Director Shareholding 0.16 Healthscope Corporate

Governance

People and Remuneration Committee Charter 0.07 Healthscope Corporate

Governance

Philanthropic Donations 0.03 Healthscope Corporate

Governance

Tax Governance 0.14 Healthscope Corporate

Governance

Whistleblowers 0.05 Healthscope Corporate

Governance

All Healthscope Corporate Finance Policies

Capital expenditure and equipment maintenance / replacement / disposal

3.03 Healthscope Finance

cheque signatories 3.04 Healthscope Finance

Credit card use - corporate 3.12 Healthscope Finance

Submission of Creditors invoices 3.17 Healthscope Finance

Debt collection 3.05 Healthscope Finance

Debt write offs 3.06 Healthscope Finance

Employee Reimbursement - Staff Petty Cash NBH-01-02

NBH Finance

Expenditure, authorisation of 3.01 Healthscope Finance

Expenses - staff 3.07 Healthscope Finance

Financial audit - external 3.09 Healthscope Finance

Information dissemination 3.13 Healthscope Finance

Ledger accounts reconciliation 3.11 Healthscope Finance

Petty cash 3.18 Healthscope Finance

Quarterly debtors review 3.15 Healthscope Finance

Stock count 3.14 Healthscope Finance

Strategic planning and budgeting process 3.02 Healthscope Finance

Supplier invoices 3.08 Healthscope Finance

WebPas payments 3.19 Healthscope Finance

Work cover debtors 3.16 Healthscope Finance

All Healthscope Corporate Human Resource Policies

Blood Testing of Healthcare Workers for Blood-Borne Diseases

4.32 Healthscope HR

Change in Employment Status, Personal or Banking Details

4.02 Healthscope HR

Communications - Internal 4.33 Healthscope HR

Dress Code - Corporate (Wardrobe and Identification) 4.11 Healthscope HR

Education and Training 4.06 Healthscope HR

Employee Master File Audit Report 4.35 Healthscope HR

Equal Employment Opportunity: Harassment and Discrimination

4.23 Healthscope HR

Exit Interviews 4.12 Healthscope HR

Foreigners, Employment of 4.37 Healthscope HR

Grievances 4.09 Healthscope HR

Kronos - Mobile App, Authorisation and Use 4.22 Healthscope HR

Kronos - Staff Sharing 4.25 Healthscope HR

Kronos Timecards - Authorisation of 4.19 Healthscope HR

Leave - Annual 4.01 Healthscope HR

Leave - Compassionate 4.01 Healthscope HR

Leave - Defence Forces 4.01 Healthscope HR

Leave - Jury Service 4.01 Healthscope HR

Leave - Long Service 4.01 Healthscope HR

Leave - Parental (maternity, paternity and adoption) 4.01 Healthscope HR

Leave - PDO, ADO, TIL 4.01 Healthscope HR

Leave - Personal (Sick and Carers) 4.01 Healthscope HR

Leave - special 4.01 Healthscope HR

Living away from Home Allowance 4.27 Healthscope HR

Mandatory Training 4.1 Healthscope HR

Orientation - Employee 4.16 Healthscope HR

Overtime 4.13 Healthscope HR

Payroll Periods 4.3 Healthscope HR

Performance and Conduct Management 4.05 Healthscope HR

Performance Review and Development (previously Performance Appraisals)

4.14 Healthscope HR

Personnel Records 4.17 Healthscope HR

Police / Clearance and Working with Children Checks 4.36 Healthscope HR

Position Descriptions 4.18 Healthscope HR

Recruitment and Selection 4.15 Healthscope HR

Redundancy and Retrenchment 4.2 Healthscope HR

Registration - Nurses and Allied Health Professionals 4.24 Healthscope HR

Relocation - Employee 4.34 Healthscope HR

Salary - Underpayment and Overpayment 4.21 Healthscope HR

Salary Packaging 4.28 Healthscope HR

Salary Packaging Guidelines 4.28 Healthscope HR

Social Media - Employee Use 4.4 Healthscope HR

Sponsorship - Employee Permanent Residency 4.39 Healthscope HR

Sponsorship - Temporary (457 Visa) 4.38 Healthscope HR

Termination of Employment 4.04 Healthscope HR

Timesheets - Authorisation of 4.03 Healthscope HR

Transfer of Employees 4.29 Healthscope HR

Uniform Dress Code and Appearance NBH-02-06

NBH HR

Union Visits (prev. 1.22 under Admin) 4.31 Healthscope HR

Workplace Surveillance NBH-02-05

NBH HR

Casual Employees 4.08 Healthscope HR

Leave Forms – Completion, Authorisation and Submission of Leave Forms to Payroll

4.01 Healthscope HR

Volunteers 4.07 Healthscope HR

Management of patients with Tuberculosis NBH-12-02

NBH Infection Control

Management of the Arjo Huntleigh Pressure Relieving Mattress (Nimbus Mattress

NBH-12-07

NBH

MRO - Screening for Multi-resistant Organisms NBH-12-04


Notification of Infectious Diseases NBH-12-03


HICMR Infection Control Policy manual

All Healthscope Corporate Information Technology Policies

Digital Content - Management and Authorisation (previously Internet Content Authorisation)

7.05 Healthscope IT

Email Management and Retention 7.1 Healthscope IT

Information Security 7.06 Healthscope IT

Information Technology - Acceptable Use 7.01 Healthscope IT

IT Back-Up 7.07 Healthscope IT

All Healthscope Corporate Medication Policies

Administration of Insulin Therapy 18.58 Healthscope Medication

Administration of Ocrelizumab in the Day Medical centre

NBH-07-10 NBH Medication

Adrenaline Nebulisation - Paediatrics NBH-07-

47 NBH Medication

Adverse Drug Reactions - Reporting to TGA (Therapeutic Goods Administration) 18.76 Healthscope Medication

Anaphylaxis - Treatment of by Credentialled Registered Nurse

NBH-07-32

NBH Medication

Antimicrobial Prescribing and Management 18.53 Healthscope Medication

Antimicrobial Stewardship & Appendix A - Prophylactic Use of Antibiotics for adult surg patients

NBH-07-07

NBH Medication

Best Possible Medication History, Obtaining the 18.85 Healthscope Medication

Bivalirudin (Angiomax discontinued)- Administration Guidelines

NBH-07-49

NBH Medication

Buccal Midazolam for home emergency use in Children - Administration

NBH-07-22

NBH Medication

Caring for the imminently dying adult patient - Prescribing guidelines

NBH-07-01

NBH Medication

Continuous Nebulised Iloprost Therapy in ICU NBH-07-29

NBH-07-29

NBH Medication

Continuous Peripheral Nerve Infusions (CPNI) NBH-07-18

NBH Medication

Controlled Drugs - Storage and Administration of 18.56 Healthscope Medication

Cytotoxic Medication IM & Subcut Injections NBH-07-13

NBH Medication

Cytotoxic Medication - Intrathecal Administration NBH-07-54

NBH Medication

Cytotoxic Medication - Oral NBH-07-12

NBH Medication

Cytotoxic Medications – Administration of Intravenous via Central Venous Access Devices

NBH-07-57

NBH Medication

Cytotoxic Medications - Administration of via Peripheral Intravenous Cannula

NBH-07-11

NBH Medication

Cytotoxic Medications Management & Safe Handling NBH-07-14

NBH Medication

Discharge Medication 18.49 Healthscope Medication

Disposal of Medications 18.78 Healthscope Medication

Drugs of Addiction (S8) & Restricted Substances (S4)

NBH-07-02

NBH Medication

Ear Medication - Administration of 18.57 Healthscope Medication

Emergency and Intensive Care Drug Protocols NBH-07-15

NBH Medication

Enema - Disposable - Administration of 18.72 Healthscope Medication

Enrolled Nurse - Administration Medication 18.02 Healthscope Medication

Entonox Procedure NBH-07-23

NBH Medication

Extravasation Guidelines for Cytotoxic Medications NBH-07-55

NBH Medication

Eye Drops / Eye Ointment - Administration of 18.54 Healthscope Medication

Formulary addition and Individual patient use (IPU) requests management

NBH-07-30

NBH Medication

Formulary submission form NBH-07-

30a NBH Medication

Individual Patient Use Medication Request Application Form

NBH-07-30b

NBH Medication

Heparin Infusion 18.65 Healthscope Medication

High Risk Medication Management NBH-07-03

NBH Medication

Hydromorphone 18.19 Healthscope Medication

HYDROmorphone - Safe administration and storage NBH-07-04

NBH Medication

Hyperkalaemia - management of NBH-07-58

NBH Medication

Hypophsophataemia – Treatment of - Adults NBH-07-

31 NBH Medication

Inhaled Medication - Administration of 18.66 Healthscope Medication

Intramuscular Injection Route (Administration of Medication via)

18.59 Healthscope Medication

Intranasal Fentanyl Citrate Administration for Paediatric Patients

NBH-07-24

NBH Medication

Intravenous (IV) Therapy - Medications and Infusions 18.34 Healthscope Medication

Intravenous Insulin Infusion in the Intensive Care Unit NBH-07-

25 NBH Medication

Intravenous Iron Infusions 18.16 Healthscope Medication

Intravenous Vancomycin - Dosing and Administration guidelines

NBH-07-26

NBH Medication

Ketamine Infusion (Adult Acute Setting) 18.14 Healthscope Medication

Ketamine Infusion NBH-07-17

NBH Medication

Magnesium Sulfate Infusion in Severe Asthma - Quick Reference Guide for Paediatric Patients

NBH-07-19

NBH Medication

Medication able to be administered in NBH patient areas

NBH-07-28

NBH Medication

Medication - Orders and Administration 18.01 Healthscope Medication

Medication Management Plan 18.75 Healthscope Medication

Medication Safety Governance 18.89 Healthscope Medication

Methotrexate (Oral), Safe administration of NBH-07-05

NBH Medication

Narcotic Infusion/Patient-Controlled Analgesia (PCA) and CADDS


Nasal Medication - Administration of 18.71 Healthscope Medication

Neuromuscular Blocking Agents, Safe administration of

NBH-07-06

NBH Medication

Nitrous Oxide Administration for paediatric patients NBH-07-27

NBH Medication

Nurse Initiated Medication MBH-07-17

NBH Medication

Oral Medication - Administration of 18.6 Healthscope Medication

Oral Medication - Devices to Assist Administration 18.55 Healthscope Medication

Ordering Medication - Verbal 18.5 Healthscope Medication

Potassium Chloride - Storage and Administration 18.51 Healthscope Medication

Prescription Pads - The Management and Storage of NBH-07-21

NBH Medication

Psychotropic Medications - Recommended Maximum Daily Doses

NBH-07-33

NBH Medication

Rectal Medication - Administration of 18.68 Healthscope Medication

Registered Nurse-Initiated Medications 18.52 Healthscope Medication

Schedule 4 Drugs Identified as Having Abuse Potential - Security and Custody of


Self Administration - Medication Patient 18.03 Healthscope Medication

Standardised Medication Orders 18.17 Healthscope Medication

Standing Orders - Medication NBH-07-16

NBH Medication

SO_03 Dialysis_Heparin cvad Standing Order NBH SO_03 NBH Medication

SO_04 Dialysis_Heparin loading dose Standing Order NBH

SO_04 NBH Medication

SO_05 Dialysis_Heparin maintenance Standing Order NBH


SO_07 Dialysis_Heparin priming Standing Order NBH SO_07 NBH Medication

SO_08 Dialysis_Lignocaine1% Standing Order NBH SO_08 NBH Medication

SO_11 Day Med Heparin Standing order SO_11 NBH Medication

SO_12 Day Med Hydrocortisone Standing Order SO_12 NBH Medication

SO_13 Day Med Promethazine Standing Order SO_13 NBH Medication

SO_14 ED_Amethocaine-Standing Order NBH SO_14 NBH Medication

SO_15 _ED Histoacryl-Standing Order NBH SO_15 NBH Medication

SO_16 ED_Entonox-Standing Order NBH SO_16 NBH Medication

SO-20 ED_Panadeine Forte-Standing Order NBH SO_20 NBH Medication

SO_21 ED_Salbutamol-Standing Order NBH SO_21 NBH Medication

SO-22 ED_Diphtheria Tetanus ADT-Standing Order NBH

SO_22 07-16 outlines the

review

Medication

SO_23 ED_Normal Saline Infusion-Standing Order NBH


SO_24 ED_Topical ALA Standing Order NBH SO_24 NBH Medication

SO_25 ED_Ondansetron Standing Order NBH SO_25 NBH Medication

SO_26 OBS_Oxytocin Standing Order NBH SO_26 NBH Medication

SO_27 OBST_oxytocin prevention of PPH Standing Order NBH


SO_28 OBST_ Diclofenac Tablets EC Standing Order NBH


SO_29 OBST_Syntometrine Standing Order NBH SO_29 NBH Medication

SO_30 OBST_Metoclopramide in Labour Standing Order NBH


SO_31 OBST_Lignocaine Standing Order NBH SO_31 NBH Medication

SO_32 OBST_Oxytocin 40 units infusion Standing Order NBH


SO_35 ED_Ibuprofen Standing Order SO_35 NBH Medication

SO_36 ED_Oral rehydration for paediatric patients SO_36 NBH Medication

Subcutaneous Injection 18.61 Healthscope Medication

Suppository Medication via Colostomy - Administration of


Temperature-Sensitive Medications, Storage of 18.86 Healthscope Medication

Tirofiban - Administration of NBH-07-48

NBH Medication

Topical Medication - Administration of 18.74 Healthscope Medication

Vaginal Medication - Administration of 18.7 Healthscope Medication

Vincristine, Administration of NBH-07-08

NBH Medication

Warfarin Administration 18.73 Healthscope Medication

All Healthscope Corporate Mental Health Policies

Admission and Transfer within MH services – Escalation of Decision Making

NBH-08-58

NBH Mental Health

Admission of Children & Youth MH Patients to MH Service

NBH-08-05

NBH Mental Health

Admission to Mental Health Inpatient Units NBH-08-06

NBH Mental Health

Aggression seclusion & restraint in mental health facilities in NSW

NBH-08-08

NBH Mental Health

Aggression seclusion & restraint in MH facilities - guideline focused upon older people

NBH-08-09

NBH Mental Health

Assessing, addressing & Managing environmental Risks - Inpatient areas & Ligature risks

NBH-08-13

NBH Mental Health

Children (0-17 years) Years Visiting MH Inpatient Units

NBH-08-15

NBH Mental Health

Children of parents with MH (COPMI) Referral Pathways & Service Delivery

NBH-08-24

NBH Mental Health

Clinical Care of People Who May be Suicidal NBH-08-16

NBH Mental Health

Clinical Handover & Clinical Review Meetings NBH-08-17

NBH Mental Health

Clinical Risk Assessment, Engagement and Observation

NBH-08-01

NBH Mental Health

Monitoring Protocol for Clozapine Induced Myocarditis NBH-08-

19 NBH Mental Health

Community Treatment Orders NBH-08-


Consumer Carer Participation NBH-08-23

NBH Mental Health

Consumer Leave NBH-08-01

NBH Mental Health

Driving Restrictions 9.03 Healthscope Mental Health

Domestic Violence - identifying and Responding to NBH-08-26

Healthscope Mental Health

Duress Alarm Systems 9.11 Healthscope Mental Health

ECT Services Monitoring & Audit Procedure NBH-08-28

NBH Mental Health

Emergency Services Accessing Clinical Information MHS during High Risk Situations

NBH-08-29

NBH Mental Health

Family and Carer Participation NBH-08-30

NBH Mental Health

Fire and Emergency Evacuation from Mental Health Units

NBH-08-57

NBH Mental Health

Forensic & High Risk Civilian Patient Referrals to CFMHS

NBH-08-31

NBH Mental Health

Environmental Risks in Patient Areas, Managemet of 9.25 Healthscope Mental Health

Gender Identity Sensitivity and Cultural Safety 9.04 Healthscope Mental Health

Inpatient Management of Alcohol Withdrawal NBH-08-33

NBH Mental Health

Involuntary Treatment - Recommendation for 9.17 Healthscope Mental Health

Items of Risk in a Mental Health Environment 9.24 Healthscope Mental Health

Management of Benzodiazepine Withdrawal NBH-08-34

NBH Mental Health

Management of Correspondence between the Mental Health Tribunal and Mental Health Service (MHS)

NBH-08-03

NBH Mental Health

Management of Intoxication NBH-08-35

NBH Mental Health

Management of NSW Police Force Officers' Firearms in NBH

NBH-08-36

NBH Mental Health

Management of Opioid Withdrawal NBH-08-37

NBH Mental Health

Management of patients with ASBD in ED NBH-08-38

NBH Mental Health

Olanzapine Pamoate Long Acting Injecting (LAI) Administration

NBH-08-43

NBH Mental Health

Patient Agreement 9.14 Healthscope Mental Health

Patient Experience Measures Management NBH-08-59

NBH Mental Health

Patient Sexual Safety in MH Inpatient units NBH-08-44

NBH Mental Health

Patients under MHAct 2007 admitted to General Hospital

NBH-08-45

NBH Mental Health

Physical Health Care of Patients within MH Service NBH-08-46

NBH Mental Health

Polydipsia – Management of Psychogenic Polydipsia and Water Intoxication

NBH-08-07

NBH Mental Health

Recovery-Based Care Planning and Evaluation (prev Care Planning and Evaluation)

9.02 Healthscope Mental Health

Search of Patient Room and Belongings 9.13 Healthscope Mental Health

Security - External Entry and Exit Control for Mental Health Facilities


Substance-use Assessment NBH-08-51

NBH Mental Health

Transcranial Magnetic Stimulation (TMS) - Continuum of care


Transfer of Care From Mental Health Inpatient Services

NBH-08-47

NBH Mental Health

Transcranial Magnetic Stimulation (TMS) - Intra-procedure Care


Therapeutic Outings for Patients 9.1 Healthscope Mental Health

Transport of people between healthcare facilities who are mentally ill

NBH-08-52

NBH Mental Health

Trust fund procedures, Mental Health NSW PD NBH-08-56

NBH Mental Health

Urine Drug Screening and Use of Breathalysers NBH-08-


Visit by official visitors NBH-08-54

NBH Mental Health

Weighted Blanket Use within MH NBH-08-55

NBH Mental Health

All Healthscope Obstetric Corporate Policies

Admission - Antenatal Patient NBH-09-20 NBH Obstetrics

Assumption of Care by Community Services NBH-09-35 NBH Obstetrics

Blood Collection in SCN NBH-09-38 NBH Obstetrics

Breast Expression - Guidelines for NBH-09-69 NBH Obstetrics

Breastfeeding and Hepatitis C Positive Mothers NBH-09-54 NBH Obstetrics

Carboprost - Use in PPH NBH-09-53 NBH Obstetrics

Cardiorespiratory monitoring - neonatal NBH-09-14

NBH Obstetrics

Care of the dying baby NBH-09-44

NBH Obstetrics

Circumcision in the neonate NBH-09-41

NBH Obstetrics

Cleft Palate and Lip NBH-09-42

NBH Obstetrics

Cooling - Neonate Whole Body NSW PD NBH-09-117

NBH Obstetrics

Decreased Fetal Movements in Pregnancy - identification and management of

NBH-09-91

NBH Obstetrics

Discharge of Mother and baby Home NBH-09-74

NBH Obstetrics

Doula - Involvement During Labour and Delivery 11.11 Healthscope Obstetrics

Expressed Breast Milk (EBM) 11.01 Healthscope Obstetrics

Fetal Heart Rate Monitoring NBH-09-04

Healthscope Obstetrics

First Stage Labour – Care of a Woman with Normal Risk Pregnancy and Management

NBH-09-09

NBH Obstetrics

Gastric Tubes in Neonates NBH-09-

45 NBH Obstetrics

Hepatitis B Vaccination and Hepatitis B Immunoglobulin (HBIG) - Neonates

NBH-09-58

NBH Obstetrics

HigherDextrose Concentration Solution - Neonate NBH-09-119

NBH Obstetrics

Homebirth Transfer to Hospital NBH-09-12

NBH Obstetrics

Humidicrib, Care of the Neonate NBH-09-02

NBH Obstetrics

Hypertensive Crisis 11.02 Healthscope Obstetrics

Hypoglycaemia Bld Glucose Monitoring Monitor HKHS GE2013_005

NSLHD NBH Obstetrics

Induction of Labour - Artificial Rupture of Membranes (ARM)

NBH-09-36

NBH Obstetrics

Induction of Labour - Cervical Catheter NBH-09-38

NBH Obstetrics

Induction of Labour - Prostaglandins for Cervical Ripening

NBH-09-39

NBH Obstetrics

Jaundice - Recognition and Assessment in the Neonate NSW GL

NBH-09-03

NBH Obstetrics

Lower Segment Caesarian Section (LSCS) - Obstetric Emergency

11.05 Healthscope Obstetrics

Maternity In The Home (MITH) NBH-09-51

NBH Obstetrics

Maternity Unit Lockdown Policy NBH-09-

17 NBH Obstetrics

Midwifery Group Practice NBH-09-50

NBH Obstetrics

Miscarriage Management 11.04 Healthscope Obstetrics

Monitoring of the infant in SCN NBH-09-19

NBH Obstetrics

Neonatal Abstinence Syndrome NBH-09-45

NBH Obstetrics

Neonatal Continuous Positive Airway Pressure (CPAP)

NBH-09-55

NBH Obstetrics

Neonatal Resuscitation NBH-09-103

NBH Obstetrics

Neonates in Birth Units and Maternity Units NBH-09-181

NBH Obstetrics

Newborn Screening Test NBH-09-13

NBH Obstetrics

Newborn security, identification band NBH-09-05

NBH Obstetrics

Nipple Shields - Use of NBH-09-52

NBH Obstetrics

Oxygen therapy via headbox NBH-09-07

NBH Obstetrics

Oxygen therapy via humidicrib NBH-09-06

NBH Obstetrics

Oxytoxcic Induction and Augmentation of labour NBH-09-37

NBH Obstetrics

Perinatal Depression, Management of (prev. Post-Natal Depression, Management of)

11.08 Healthscope Obstetrics

Persistent Pulmonary Hypertension of the Newborn NBH-09-46

NBH Obstetrics

Placenta - Request to retain NBH-09-33

NBH Obstetrics

Positioning Guidelines for Premature Infants in the SCN

NBH-09-47

NBH Obstetrics

Pulse Oximetry Screening of Neonates NBH-09-08

NBH Obstetrics

Postpartum Haemorrhage - Identification, Prevention and Management

NBH-09-19

NBH Obstetrics

Pregnancy Day Assessment Unit - Indications for Referral

NBH-09-43

NBH Obstetrics

Rh(D) Immunoglobulin NBH-09-40

NBH Obstetrics

Second Stage Labour - Care of a Woman with Normal Risk Pregnancy and Management of Delay

NBH-09-10

NBH Obstetrics

Septic Workup in SCN NBH-09-

48 NBH Obstetrics

Shoulder Dystocia A124 11.07 Healthscope Obstetrics

State Wide Infant Hearing Screening Program NBH-09-12

NBH Obstetrics

Sterile Water Injections for Relief of Low Back Pain in Labour

NBH-09-80

NBH Obstetrics

Surrogate Births 11.1 Healthscope Obstetrics

Thermoregulation in SCN NBH-09-49

NBH Obstetrics

Third Stage of Labour Active and Physiological Management

NBH-09-21

NBH Obstetrics

Threatened Premature Labour and Birth NBH-09-

62 NBH Obstetrics

Umbilical Cord Prolapse 11.03 Healthscope Obstetrics

Vaginal Birth After Caesarean Section VBAC NBH-09-

18 NBH Obstetrics

Vaginal Birth After Caesarean Section VBAC 11.09 Healthscope Obstetrics

Vaginal Examination NBH-09-19

Water for Immersion in Labour and Birth NBH-09-115

NBH Obstetrics

All Healthscope Corporate Paediatric Policies

Abdominal Pain - Infants and Children - Acute Management of

NBH-11-33

NBH Paediatric

Acute Management of Asthma - Infants and Children NBH-11-19

NBH Paediatric

Advanced Life Support - Paediatric 13.06 Healthscope Paediatric

Bacterial Meningitis - Acute Mgt of -Infants and Children

NBH-11-36

NBH Paediatric

Bronchiolitis Acute Management - Children and Infants NBH-11-20

NBH Paediatric

Child protection- identifying escalating and reporting risk of harm

NBH-11-02

NBH Paediatric

Child Wellbeing & Protection P&P NSW PD NBH-11-41

NBH Paediatric

Children and Youths guidelines for care NBH-11-04

NBH Paediatric

Children and Youths safety and security NBH-11-03

NBH Paediatric

Close observation beds nursing high acuity paediatric patients

NBH-11-08

NBH Paediatric

Community Acquired Pneumonia - Acute mgt of - Infants and Children

NBH-11-37

NBH Paediatric

Congenital Conditions_ Reporting Requirements NSW Register of

NBH-11-34

NBH Paediatric

Croup - Acute Mgt of in Children and infants NBH-11-29

NBH Paediatric

Early Diagnosis and management of children with Acute Scrotal Pain

NBH-11-17

NBH Paediatric

Fever Management Acute - Children and Infants NSW PD

NBH-11-13

NBH Paediatric

Head Injury - Acute Management of in Children and Infants

NBH-11-30

NBH Paediatric

Humidified High Flow NC O2 Guideline for Paeds Wards & EDs

NBH-11-42

NBH Paediatric

Hypoglycaemia (Not Diabetic) in Infants and Children - Management

NBH-11-12

NBH Paediatric

Information Sharing – Child Protection NBH-11-05

NBH Paediatric

Intraosseous Insertion and Management in Infants Children and Adolescents

NBH-11-18

NBH Paediatric

Lumbar Puncture - Paediatrics NBH-11-

15 NBH Paediatric

Oxygen Therapy in Paediatrics NBH-11-14

NBH Paediatric

Nasogastric and Orogastric Tube Insertion and removal 13.08

Healthscope Paediatric

Paediatric Clinical Assessment 13.03 Healthscope Paediatric

Paediatric Intramuscular Injections 13.04 Healthscope Paediatric

Paediatric Opioid Infusions via PCA or NCA 13.05 Healthscope Paediatric

Paediatric patients in Day Surgery. NBH-11-07

NBH Paediatric

Paediatric Patients in PARU NBH-11-09

NBH Paediatric

Paediatric Patients, Care of 13.01 Healthscope Paediatric

Pain Assessment - Paediatric 13.02 Healthscope Paediatric

SCAN _ Suspected Child Abuse and Neglect NSW PD NBH-11-32

NBH Paediatric

SCHN (Sydney Children Hospital Network) Available at: https://www.schn.health.nsw.gov.au/our-policies/index/clinical:

SCHN Paediatric

Security - Newborn and Paediatric (prev under Obstetrics)

13.07 Healthscope Paediatric

Seizure Management Acute in Children & Infants ≥ 28days NSW GL

NBH-11-10

NBH Paediatric

Sore Ear -Otitis Media Acute Management of - Infants & Children

NBH-11-36

NBH Paediatric

Sudden Infant Death Syndrome (SIDS) and safe sleeping for infants

NBH-11-40

NBH Paediatric

Sudden Unexpected Death in Infancy - Mgt of NSW GL2008_070

NBH-11-31

NBH Paediatric

Unsettled and crying Infant - Acute Management of NBH-11-43

NBH Paediatric

Visitor policy - paediatrics NBH-11-06

NBH Paediatrics

Wet Dressing for eczema in children NBH-11-11

NBH Paediatric

All Healthscope Corporate Perioperative Policies

Accountable Items - Counting of 12.05 Healthscope Perioperative

Administration of Analgesia NBH-10-07

NBH Perioperative

Admission procedure for ward patients. NBH-10-08

NBH Perioperative

Air / Water pistols Operation of Compressed NBH-10-09

NBH Perioperative

Allograft Bone/Tissue and Tissue Storage/Frozen Bone

NBH-10-11

NBH Perioperative

Anaesthesia Services During Routine Hours NBH-10-28

NBH Perioperative

Anaesthetic Machine – Checking of NBH-10-18

NBH Perioperative

Antiembolic Measures - mechanical prophylaxis NBH-10-12

NBH Perioperative

Aseptic Technique NBH-10-13

NBH Perioperative

Borrowing/Lending Equipment NBH-10-06

NBH Perioperative

Brachytheraphy Safety in OT NBH-10-15

NBH Perioperative

Bronchoscope Tracking Sheet NBH-10-16

NBH Perioperative

Care of the Patient in the Interventional Suite NBH-10-17

NBH Perioperative

Cleaning & Disinfection of Flexible Endoscopes NBH-10-19

NBH Perioperative

Cleaning and Maintenance of Operating Tables NBH-10-20

NBH Perioperative

Cleaning of Cannulated Instruments 12.06 Healthscope Perioperative

Cleaning of Respronic Total Face Mask NBH-10-21

NBH Perioperative

Corrective Warming Therapy, use of NBH-10-22

NBH Perioperative

CSSD computer down time Procedure NBH-10-80

NBH Perioperative

Decontamination of Anaesthetic & PARU Equipment NBH-10-03

NBH Perioperative

Decontamination of Instruments for repair NBH-10-23

NBH Perioperative

Discharging patients from the Post Anaesthetic Recovery Unit (PARU)

NBH-10-49

NBH Perioperative

Disposal of Explanted Items and Human Tissue Not Required for Pathological Examination

NBH-10-25

NBH Perioperative

Donor Parts - Organs, Bone and Skin NBH-10-93

NBH Perioperative

Electrosurgical Equipment NBH-10-26

NBH Perioperative

Emergency Surgery 12.01 Healthscope Perioperative

Emergency surgery theatre access NBH-10-27

NBH Perioperative

Fasting Guidelines 12.02 Healthscope Perioperative

Fire and Evacuation Procedure in Interventional Suite NBH-10-29

NBH Perioperative

Fire Risk Minimisation and Management - Surgical 12.04 Healthscope Perioperative

Food and Beverages in the Operating Room 12.08 Healthscope Perioperative

Fresenius Agila PK Infusion Pumps NBH-10-10

NBH Perioperative

Heat Sealers - Dust Covers - use of NBH-10-31

NBH Perioperative

Hip instruments - checking of NBH-10-33

NBH Perioperative

Hydrogen Peroxide Boosters - checking of NBH-10-34

NBH Perioperative

Inhalation Anaesthetic Agents NBH-10-35

NBH Perioperative

Instrument Tray List NBH-10-36

NBH Perioperative

Laser Safety in the Operating Theatre NBH-10-37

NBH Perioperative

Loan Lifter Operating Procedures NBH-10-38

NBH Perioperative

Loan Sets - Operating Room 12.03 Healthscope Perioperative

Local Anaesthetic Toxicity Management NBH-10-39

NBH Perioperative

Malignant Hyperthermia NBH-10-02

NBH Perioperative

Management of Patients and Employees with Latex Allergies

NBH-10-40

NBH Perioperative

Mechanical Equipment NBH-10-92

NBH Perioperative

Microbiological monitoring of flexible endoscopes and automated Flexible endoscope reprocessors (AFER'S)

NBH-10-41

NBH Perioperative

MRI under general anaesthesia NBH-10-30

NBH Perioperative

Newborn Resuscitaire Governance and Functionality within the Operating Theatre

NBH-10-32

NBH Perioperative

Observers in the Interventional Suites NBH-10-42

NBH Perioperative

Operating the Monitor in PARU NBH-10-43

NBH Perioperative

Packing of Anaesthetic Equipment NBH-10-45

NBH Perioperative

Pathology Specimens in the Interventional Suite - care & handling of

NBH-10-48

NBH Perioperative

Patient Admission to Interventional Suite from the ward

NBH-10-49

NBH Perioperative

Patient belongings and valuables in Day Surgery. NBH-10-50

NBH Perioperative

Patient care in the Post Anaesthesia Recovery Unit (PARU)

NBH-10-46

NBH Perioperative

Patient Controlled Epidural Infusion or Continuous (CEA)

NBH-10-47

NBH Perioperative

Perioperative Attire NBH-10-53

NBH Perioperative

Pharyngeal Packs- Insertion and removal of NBH-10-54

NBH Perioperative

Philosophy of Interventional Suite Services NBH-10-51

NBH Perioperative

Physeptone (Methadone Hydrochloride) Administration of

NBH-10-52

NBH Perioperative

Positioning the Patient NBBH-10-55

NBH Perioperative

Pre admission and Discharge Planning procedure for Day Surgery and ward patients.

NBH-10-85

NBH Perioperative

Preparation of the Operating Room for Surgery NBH-10-57

NBH Perioperative

Preparation of the Skin for Surgery NBH-10-58

NBH Perioperative

Preventing and managing pressure injuries when using Tourniquet

NBH-10-59

NBH Perioperative

Prosthetic and patient rebatable items - Handling and documentation of

NBH-10-60

NBH Perioperative

Recording / receiving & dispatch of loan equipment NBH-10-61

NBH Perioperative

Role of the Interventional Suite Staff NBH-10-76

NBH Perioperative

Safe use of Chemicals in CSSD NBH-10-62

NBH Perioperative

Scheduling of Admissions to Day of Surgery Centre NBH-10-64

NBH Perioperative

Scheduling of procedures in Interventional Suites NBH-10-63

NBH Perioperative

Scrubbing, Gowning & Gloving NBH-10-65

NBH Perioperative

Sharps Management NBH-10-66

NBH Perioperative

SSD Index Washer NBH-10-89

NBH Perioperative

SSD - Operation of Trolley washer NBH-10-91

NBH Perioperative

SSD - Steriliser Operation Belimed NBH-10-88

NBH Perioperative

SSD -Sterrad - Loading 100NX Plasma Steriliser NBH-10-87

NBH Perioperative

SSD - Sterrad Steriliser- Unloading 100NX NBH-10-86

NBH Perioperative

SSD Ultrasonic Cleaner - Operation of Bandelin NBH-10-90

NBH Perioperative

Staffing NBH-10-67

NBH Perioperative

Staffing for Endoscopy NBH-10-71

NBH Perioperative

Standards of Professional Nursing Practice NBH-10-68

NBH Perioperative

Sterile Field - Medication Management In 12.07 Healthscope Perioperative

Sterilisation Service Department Attire NBH-10-72

NBH Perioperative

Steriliser breakdown NBH-10-70

NBH Perioperative

Storage of Autologous Skin for Future Grafting NBH-10-05

NBH Perioperative

Storage of Sterile Items NBH-10-73

NBH Perioperative

Sugammadex Sodium - Administration of NBH-10--74

NBH Perioperative

Surgical Draping NBH-10-75

NBH Perioperative

Transfer of Patient to the Intensive Care Unit NBH-10-77

NBH Perioperative

Urine Testing – prior to Gynaecological Surgery NBH-10-78

NBH Perioperative

Visitor access restrictions to Endoscopy and Day Surgery unit

NBH-10-79

NBH Perioperative

Visitors in the Interventional Suite NBH-10-04

NBH Perioperative

Weighing of Sponges for Blood Loss During Surgical Procedures

NBH-10-84

NBH Perioperative

All Healthscope Corporate Work Health & Safety Policies

Aggression Incident Management 6.15 Healthscope WHS

Aggression Management for Staff in the Community 6.15 Healthscope WHS

Allergy Management for Workers - Latex 6.19 Healthscope WHS

Asbestos Management 6.12 Healthscope WHS

Bariatric Patients - Management of 6.22 Healthscope WHS

Blood & Body Fluid Exposure Incidents (BBFEI) - Management of

NBH-03-05

NBH WHS

Bullying in the Workplace 6.16 Healthscope WHS

Chemical Management 6.07 Healthscope WHS

Code of Conduct for Visitors and Patients 6.15 Healthscope WHS

Communication - WHS 6.5 Healthscope WHS

Consultation - WHS 6.5 Healthscope WHS

Contractor Safety 6.11 Healthscope WHS

Cyotoxic Spill NBH-03-02

NBH WHS

Cytotoxic Drugs and Related Waste, Safe Handling of 6.17 Healthscope WHS

Cytotoxic Waste and Linen - Management and Disposal of

NBH-03-03

NBH WHS

Debriefing of Critical Incidents - Employees (formerly under HR)

6.28 Healthscope WHS

Disaster Management and Recovery Plan 6.25 Healthscope WHS

Documentation - WHS (prev Health and Safety Documentation)

6.4 Healthscope WHS

Drugs and Alcohol (formerly numbered 1.23) 6.03 Healthscope WHS

Electrical Equipment Safety - Portable Devices 6.2 Healthscope WHS

First Aid Management in the Workplace 6.24 Healthscope WHS

Formalin - Safe Use of 6.26 Healthscope WHS

Hazard Management and Risk Assessment 6.08 Healthscope WHS

Immunisation for Vaccine Preventable Diseases for Healthcare Workers


Incident Reporting and Investigation 6.09 Healthscope WHS

Injury Management 6.02 Healthscope WHS

Injury Management Policy - Single Page Display Version


Internal Auditing Program - WHS 6.27 Healthscope WHS

Manual Handling, Safer 6.06 Healthscope WHS

Medical Assessment, Pre-Employment 6.14 Healthscope WHS

Mercury - Safe Use and Disposal 6.21 Healthscope WHS

Personal Protective Equipment (PPE) 6.23 Healthscope WHS

Pregnancy - Staff 6.04 Healthscope WHS

Purchase, Hire and Lease (WHS Requirements) 6.1 Healthscope WHS

Radiation Safety 6.18 Healthscope WHS

Records Management - WHS 6.4 Healthscope WHS

Return to Work after a Non-Work-Related Injury or Illness


Smoking at Healthscope Facilities 6.05 Healthscope WHS

Staff Health - Cytotoxic Monitoring for staff NBH-03-04

NBH WHS

WHS Policy - Single Page Display Version 6.01 Healthscope WHS

Work Health and Safety 6.01 Healthscope WHS

Workplace Aggression and Violence Management - Principles and Prevention (prev. Aggression Management - Principles and Prevention)


Date post:	30-Aug-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times