Murrumbidgee Local Health District - Policy, Procedure & Guidelines

Document No Document Name Document Type

MLHD2019-0100 Aboriginal Health Belly Casting Policy

MLHD2021-0889 Aboriginal Health Impact Statement Guideline Guideline

MHDA2019-0220 Absconding - Consumers absent without permission Mental Health Inpatient Units Procedure

WWBH2020-0702 Acute Surgical Unit (ASU) Planned returns for Theatre – Sunday to Thursday Procedure

MLHD2019-0440 Administration of Cytotoxic therapy to non-malignant patients in Deniliquin Hospital Policy

MLHD2019-0053 Administration of Oral Antineoplastic Drugs Policy

WWBH2019-0341 Admission to Hospital in the Home (HITH) Service Procedure

MLHD2020-0395 Adult Enteral Tube Feeding Policy

MLHD2019-0453 After-Hours Medical Radiation Practitioner (MRP) Recall to Duty (Call Back) Policy

MLHD2021-0885 Aged Care Assessment Team - Delegation on My Aged Care Policy

MHDA2019-0125 Alcohol and other Drugs (AOD) Nursing Practice & Patient Safety Policy

MHDA2019-0178 Alcohol and other Drugs (AOD)Nursing Practice & Patient Safety Policy

MLHD2019-0180 Allied Health Inter-facility Handover Procedure

MLHD2020-0584 Antimicrobial Stewardship Policy in MLHD Procedure

MLHD2020-0700 Application of EMLA Cream 5% for Pain Management during Wound Care Procedure

MLHD2021-0882 Appointment of a Privileged Preliminary Risk Assessment Team Procedure

MLHD2020-0863 Appropriate use of silver dressings in wound care approved Guideline

MHDA2020-0851 Assertive Outreach Child and Adolescent Mental Health Service Model of Care (AOCAMHS) Policy

MLHD2019-0401 Assessing Requests for Financial Support of Outpatient Medication Procedure

MLHD2020-0701 Assessment and Management of Hypergranulation Procedure

MLHD2020-0716 Assessment and Management of Skin Tears Procedure

MLHD2019-0406 Assisting Adult Endotracheal Intubation Procedure

WWBH2020-0586 Assisting with Paediatric Intubation in ICU Procedure

WWBH2020-0307 Autologous Blood Transfusion A.B.T. Postoperative Drainage/Reinfusion Policy

MLHD2020-0684 Bariatric or Special Needs Clients Screening Protocol Procedure

MLHD2020-0549 Bladder Irrigation Policy

MLHD2020-0170 Bladder Scan Usage Procedure

MLHD2020-0351 Blood Management Policy

MLHD2020-0696 Booking BreastScreen Victoria Clients for Assessment Policy

MLHD2020-0683 Breast Implants Policy

MLHD2020-0685 Breast Skin Tear Prevention Procedure

WWBH2021-0878 Breastfeeding Friendly Workplace Procedure

MLHD2019-0074 Breastfeeding the Healthy Term Newborn Guideline

WWBH2020-0587 Cancellation of Elective Surgery when Peak Emergency Demands Procedure

MLHD2019-0467 Cancer Services CVAD referral requirements for WWBH Policy

MLHD2020-0694 Care and Maintenance of MLHD Patient Transport Vehicles Procedure

MLHD2019-0225 Care of newborns who are identified high risk families in maternity settings and/or discharged into Community Services Care from MLHD Maternity Units Policy

MLHD2019-0167 Care of the Deceased – Non Coroners Case Policy

MLHD2020-0414 Central Venous Access Device Management Guideline Externally Endorsed

MLHD2019-0055 Cervical Spine (Suspected) Injury (Paediatric): Patient Management Policy

MLHD2019-0061 Cervical Spine management for the patient with suspected cervical spine injury – Adult Policy

MLHD2019-0110 Checking of Neonatal Resuscitation Equipment Policy

MLHD2019-0441 Chemical Management Policy

MLHD2019-0071 Child and Family Health Nursing Service - Follow up Care of Clients who Fail to Attend or are Unable to be Contacted Policy

MLHD2020-0146 Child and Family Health Nursing Service Model Guideline

MLHD2020-0558 Child Protection Training Guidelines for MLHD Policy

MHDA2020-0633 Children and Adolescents with Mental Health presentations - pathway through Emergency Departments Policy

MLHD2019-0399 Cleaning of Vehicles used to Transport Patients/ Clients/ Residents Policy

MHDA2019-0419 Clinical Care of people who may be Suicidal - Non Mental Health Services Policy

GRBH2021-0896 Clinical Emergency Response System (CERS) Adult GBH Procedure

BARH2021-0902 Clinical Emergency Response System (CERS) Barham Koondrook Procedure

BATL2021-0903 Clinical Emergency Response System (CERS) Batlow-Adelong Procedure

BERR2021-0904 Clinical Emergency Response System (CERS) Berrigan Procedure

GRBH2021-0897 Clinical Emergency Response System (CERS) Emergency Department GBH Procedure

GRBH2021-0898 Clinical Emergency Response System (CERS) HITH GBH Procedure

GRBH2021-0909 Clinical Emergency Response System (CERS) Maternity GBH Policy

GRBH2021-0910 Clinical Emergency Response System (CERS) Neonatal GBH Policy

GRBH2021-0899 Clinical Emergency Response System (CERS) Oncology GBH Procedure

GRBH2021-0911 Clinical Emergency Response System (CERS) Paediatric GBH Policy

GRBH2021-0900 Clinical Emergency Response System (CERS) Recovery GBH Policy

GRBH2021-0901 Clinical Emergency Response System (CERS) Renal GBH Procedure

WWBH2021-0914 Clinical Emergency Response System (CERS) Wagga Policy

MLHD2021-0916 Clinical Handover Procedure

MLHD2021-0867 Clinical Images on Personal and Mobile Devices - Management Guideline

WWBH2020-0724 Clinical On-Call Overnight Bedroom Usage Procedure

MHDA2021-0218 Clozapine Management Procedure

WWBH2020-0695 Code Black Duress Activation Response and Training Procedure

GRBH2021-0912 Cognitive Aid - ALS Algorithm GBH Policy

GRBH2021-0913 Cognitive Aid - LUCAS3 GBH Procedure

MLHD2020-0609 Community Care Intake Service Operational Guidelines Policy

MHDA2020-0265 Community Mental Health Drug and Alcohol Service Withdrawal Management Policy

MHDA2021-0250 Community Mental Health Waiting List Management Procedure

MHDA2020-0556 Community Psychiatry Clinics Policy

MLHD2021-0888 Comprehensive Care Planning Guideline

MLHD2021-0883 Compression Therapy - Elasticated Tubular Bandages Procedure

MLHD2019-0190 Consumer, carer and community feedback on publications & training Policy

MLHD2020-0057 Continuity of Medication Management Guideline

MLHD2019-0476 Continuous Renal Replacement Therapy (CRRT) – Regional Citrate Anticoagulation Policy

MLHD2019-0454 Coronary Angiogram – Post Procedural Nursing Care Policy

MLHD2019-0153 Corporate Records Management Policy

MLHD2019-0162 Correct Storage and Management for MLHD Facility Blood Fridges Policy

MLHD2019-0245 COSOP - Critical Operations Standing Operating Procedure – When Medical Officer is Not Available Policy

MLHD2019-0461 Creating, developing and storage of publications: Publications Portal Policy

MLHD2019-0155 Credentialing process for Registered Nurses performing triage in Emergency Departments, MLHD Policy

MLHD2019-0161 Critical Care Advisory Service (part of the MLHD Patient Flow Transport Unit) Policy

MLHD2019-0297 Critical Haemorrhage and Massive Blood Transfusion – ADULT Procedure

MHDA2020-0583 Dementia Behaviour and Management Service (DBAMS) in MLHD Policy

MLHD2019-0107 Diabetes Management for Intrapartum and Postpartum Care in Pregnancy complicated by Gestational Diabetes and Pre-Gestational Diabetes Policy

MLHD2019-0299 Discharge Advice for Adult Mild Closed Head Injury Policy

WWBH2019-0339 Discharge of a Patient from Hospital in the Home (HITH) Program Procedure

MLHD2019-0140 District Patient Transfer Policy Policy

WWBH2019-0340 Documentation and Medical Records Procedure for Hospital in the Home (HITH) Policy

MLHD2020-0727 Documentation and Reporting of Adverse Drug Reactions Procedure

MHDA2019-0163 Drug & Alcohol Referral, Intake and Assessment Policy

MHDA2019-0418 Drug & Alcohol Referral, Intake and Assessment Policy

MHDA2020-0579 Drug and Alcohol Buprenorphine Depot Injection for the Treatment of Opioid Dependence Procedure

MHDA2019-0200 Drug and Alcohol Clinical Intervention Policy

MHDA2019-0259 Drug and Alcohol Transfer of Care Procedure

MLHD2020-0384 Duress Alarm and Telephone Procedure Procedure

MHDA2019-0469 Duress Response Mental Health Inpatient Units Procedure

MLHD2020-0463 Duress/Code Black in Small Facilities Procedure

MLHD2019-0433 Early Pregnancy Assessment Service Policy

MLHD2019-0058 ECG Reading service for lifepak 15 - Hospitals referring to Wagga Wagga Rural Referral Hospital Policy

MLHD2019-0063 ECG Reading service for lifepak 15 - located at Barham, Berrigan, Corowa, Culcairn, Deniliquin, Finley, Holbrook, Jerilderie, Tocumwal Policy

MLHD2019-0062 ECG Reading service for lifepak 15 for Hospitals referring to Griffith Base Hospital - Lake Cargelligo, Hay and Hillston Policy

MLHD2019-0154 Electronic Prescribing and Dispensing Requirements of Cytotoxic Therapy in MLHD Oncology Clinics Policy

MHDA2019-0439 Emergency Department Care of People with Mental Distress Procedure

WWBH2019-0501 Emergency Department Pathology/Radiology Order Sets Procedure

MHDA2020-0679 Emergency Department Physical Assessment for Mental Health Patients Policy

MLHD2019-0278 Emergency Department Triage Process Procedure

MLHD2019-0458 Endotracheal Extubation (planned) Policy

MLHD2020-0159 Essential Standards of Nursing and Midwifery Care Policy

MLHD2019-0330 Establishment and Management of Epidural and Spinal Analgesia and Anaesthesia: Overview for Medical Officers Policy

WWBH2019-0343 External Cephalic Version (ECV) Procedure

WWBH2020-0355 Facility Daily Locking and Unlocking Procedure

WWBH2019-0498 Faecal Management System Procedure

MLHD2019-0313 Falls Prevention and Injury Management for patients and residents who present at emergency departments and/or admitted or receive care in MLHD Facilities Policy

MLHD2019-0164 Falls Risk Screening, Assessment and Management Policy

MLHD2019-0060 Fatigue Management Policy

MLHD2020-0551 Female Indwelling Urinary Catheterisation (IUC) - Adult Externally Endorsed

WWBH2019-0500 First Aid Procedure

MLHD2020-0710 Foot Care Guideline

MLHD2019-0400 General X-ray Requests via a Phone Order from the Visiting Medical Officer Policy

MLHD2020-0741 Handling Medications in MLHD Health Facilities Guideline

WWBH2020-0570 Handling of COVID 19 positive Deceased Persons Procedure

MLHD2020-0392 Hardcopy Medication Guideline Version Control Policy

MLHD2019-0267 Health Care Record Forms Approval Procedure Policy

MLHD2019-0370 Health Records Tracking Policy

WWBH2021-0880 Helipad Landings and Departures Procedure

MLHD2019-0124 Hepatitis Vaccination in Sexual Health Clinics Policy

MLHD2019-0173 Hepatitis Vaccination in Sexual Health Clinics Policy

MLHD2021-0879 High Output Stomas – Adult Management Guideline

MLHD2019-0056 High-Risk Medicines Management: MLHD Guideline and High-Risk Medicines Register Guideline

MLHD2021-0891 Holistic Wound Assessment Procedure

MLHD2020-0606 Home phototherapy using the Bilisoft phototherapy mat Policy

MLHD2020-0635 Home Visiting and Working Offsite with Consumers Policy

WWBH2019-0336 Hospital in The Home (HITH) Home Visiting Procedure

WWBH2020-0567 Hospital in the Home HITH Therapeutic Venesection Adult Only Procedure

MLHD2019-0221 Hot Works Procedure

MLHD2019-0184 HUMIDIFIED HIGH FLOW NASAL OXYGEN - Post commencement Management Policy

MLHD2019-0185 Humidified High Flow Nasal Oxygen via AIRVO2 Policy

MLHD2019-0371 Hybrid Health Care Record Policy

MLHD2019-0075 Hypoglyceamia Management in Adult Clients Patients with Diabetes Mellitus Policy

MLHD2019-0491 Increased Supervision Policy

MLHD2020-0543 Infant Feeding Guidelines Information for Health Workers Policy

MLHD2019-0109 Infection Prevention and Control Handbook Policy

MHDA2020-0853 Inpatient Admission and Management Flowchart and Guidelines for People with Eating Disorders – Adult Section Guideline

MLHD2019-0473 Inpatient Management Principles for Continuous Glucose and Flash Glucose Monitoring Policy

MLHD2019-0314 Insertion, Management and Removal of an Intra-Arterial Line Policy

MLHD2019-0376 Inter and Intra facility Nursing Transfer of Care: Active eMR sites Policy

MLHD2019-0377 Inter and Intra Facility Nursing Transfer of Care: Non eMR sites Policy

MLHD2021-0917 Inter Facility Transfer of Care, MLHD Admitted Patients Procedure

MLHD2020-0728 Interaction & Management of Dealings with Pharmaceutical Industry Procedure

MLHD2019-0445 Internal Secondment of MLHD staff Policy

MLHD2019-0460 Intra-abdominal pressure monitoring via indwelling urinary catheter Policy

WWBH2020-0677 Intra-Aortic Balloon Pump (IABP) Insertion and Management Procedure

MLHD2019-0191 Involving Consumers and Carers in the Clinical and Organisational Governance of MLHD Policy

MLHD2019-0179 Involving people from diverse backgrounds in Consumer, Carer and Community Engagement Policy

MLHD2019-0165 Iron Replacement Therapy in MLHD Policy

MLHD2019-0503 LUCAS 3 Chest Compression System Policy

MLHD2020-0550 Male Indwelling Urinary Catheterisation (IUC) - Adult Guideline

MLHD2019-0303 Malnutrition Screening Policy

MLHD2020-0664

Management of Clinicians with Practice Conditions Imposed by a National Board or adjudication body on their Australian Health Practitioner Regulation Agency (AHPRA) registration Policy

MLHD2020-0564 Management of Delirium in Older People Policy

MLHD2020-0743 Management of Diabetic Ketoacidosis (DKA) in Adults Guideline

MLHD2019-0246 Management of Healthcare Workers occupationally, potentially exposed to HIV, hepatitis B and hepatitis C Policy

WWBH2020-0404 Management of Incorrect Patient Identification and Filing Errors in Paper Medical Records Procedure

WWBH2020-0717 Management of Neuraxial (Intrathecal or Epidural) Opioid - Single Dose Morphine Procedure

MLHD2019-0470 Management of occluded CVCs using alteplase in adult oncology patients Policy

WWBH2019-0488 Management of Regional Analgesia Procedure

MLHD2019-0244 Management of Restricted Access Health Care Records Policy

MLHD2020-0169 Management of Short-term Respiratory Device Loan Pool for ENABLE Machines Procedure

MLHD2019-0073 Management of Trans and gender diverse people in Sexual Health Services Policy

MLHD2019-0067 Management of Women Experiencing Miscarriage at Rural and Remote Hospitals Policy

MLHD2017-0555 Managing Excess Annual Leave Procedure

MLHD2019-0480 Managing for Performance – Management of nursing and midwifery staff with identified professional practice or performance issues Procedure

MLHD2019-0202 Managing Noise and Preventing Hearing Loss Policy

MLHD2020-0608 Managing Non-Work Related Injuries and Health Conditions Policy

MLHD2019-0383 Managing Recalls in MLHD Policy

MLHD2019-0456 Managing WHS Hazards and Risks Policy

WWBH2020-0585 Manual High Level Disinfection of the Transoesophageal Probe with Cidex OPA Procedure

MLHD2019-0443 Maternity - Application of a fetal scalp electrode Policy

MLHD2019-0106 Maternity - Diabetes in Pregnancy Policy

MLHD2020-0465 Maternity - Initiating the Continuous Epidural Infusion, Managing Epidural Insertion Sites, Catheters and Related Infusion Equipment Procedure

MLHD2019-0199 Maternity - Management of Shoulder Dystocia Policy

MLHD2019-0105 Maternity - Pre pregnancy planning for women with pre-existing type 1 and type 2 diabetes Policy

MLHD2020-0076 MATERNITY - Sterile Water Injections for women experiencing back pain in labour Guideline

MLHD2020-0690 Maternity Management of umbilical cord presentation prolapse (UCP) Policy

MLHD2020-0420 Maternity Postnatal: Discharge Assessment of the Well Neonate (DAWN) Procedure

MLHD2020-0574 Maternity: Fetal Blood Sampling (FBS) Policy

MLHD2020-0578 Maternity: Management of Hypoglycaemia of the Newborn < 28 days Policy

WWBH2019-0499 Maternity: Next Birth After Caesarean Section (NBAC) Procedure

MLHD2019-0474 Maternity: Special Care Nursery (SCN) Access Card Policy

MLHD2019-0064 Maternity: The use of warm water immersion during labour and/or birth Guideline

MLHD2019-0158 Medical Imaging Limited Licence Operator Policy, Governance and Flowchart Policy

MLHD2019-0421 Medication Management by MLHD Patient Transport Unit (PTU) Nurse Escorts Policy

WWBH2021-0417 Medication Management for the Registered Nurse/Midwife and Enrolled Nurse Procedure

MLHD2019-0354 Medicine Access Program Agreements Policy

MHDA2019-0398 Mental Health - Care of Pregnant Women in the Inpatient Unit Procedure

MHDA2020-0195 Mental Health - Community Care Coordination Procedure

MHDA2019-0139 Mental Health - Official Visitors Policy

MHDA2019-0266 Mental Health - Official Visitors Procedure

MLHD2019-0358 Mental Health - Safety of Child Visitors to Mental Health Inpatient Unit Policy

MHDA2019-0334 Mental Health Accredited Persons Procedure

MHDA2019-0424 Mental Health Admission - Adult and Older Persons Acute Inpatient Units Policy

MHDA2019-0207 Mental Health Admission - Recovery Unit (MHRU) Procedure

MHDA2019-0252 Mental Health Admission - T-BASIS Procedure

MHDA2019-0138 Mental Health Assessment - Community Procedure

MHDA2019-0261 Mental Health Assessment - Community Policy

MHDA2019-0229 Mental Health Care in General Hospitals Policy

MHDA2020-0731 Mental Health Drug & Alcohol - Bereavement support in the workplace Guideline

MHDA2021-0256 Mental Health Drug & Alcohol - Serious Incidents Procedure

MHDA2019-0203 Mental Health Drug & Alcohol Catastrophic Fire Danger Rating Days and other Adverse Weather Conditions - managing High Risk Consumers Procedure

MHDA2019-0193 Mental Health Drug & Alcohol Comorbidity Policy

MHDA2019-0479 Mental Health Drug and Alcohol - Consumer Saliva Drug Testing Device Procedure

MHDA2019-0486 Mental Health Drug and Alcohol – Engaging with External Service Providers Procedure

MHDA2020-0712 Mental Health Drug and Alcohol – Family and Carer Support Workers and Consumer Peer Support Workers use of health care records Procedure

MLHD2019-0492 Mental Health Drug and Alcohol - Psychostimulant Withdrawal in the Mental Health Inpatient Settings Policy

MHDA2019-0263 Mental Health Drug and Alcohol - Sexual Safety of MHDA Consumers Procedure

MHDA2020-0711 Mental Health Drug and Alcohol - Staff Debriefing and Support Procedure

MHDA2020-0192 Mental Health Drug and Alcohol Child Protection Issues Policy

MHDA2019-0450 Mental Health Drug and Alcohol Clinical Care Review Policy

MHDA2019-0222 Mental Health Drug and Alcohol Clinical Handover Policy

MHDA2019-0051 Mental Health Drug and Alcohol Clinical Supervision Procedure

MHDA2019-0257 Mental Health Drug and Alcohol Clinical Use of Audio/Video Recording Procedure

MHDA2019-0135 Mental Health Drug and Alcohol Clinical Use of Audio/Visual Recording Procedure

MHDA2020-0295 Mental Health Drug and Alcohol Complaints Management Procedure

MHDA2020-0121 Mental Health Drug and Alcohol Medication Policy

MHDA2019-0264 Mental Health Drug and Alcohol Missed Appointments Procedure

MHDA2020-0206 Mental Health Drug and Alcohol Rights and Responsibilities of Families and Carers Procedure

MHDA2020-0136 Mental Health Drug and Alcohol Services - Cultural Diversity Procedure

MHDA2020-0675 Mental Health Drug and Alcohol Services Guide to Collecting Consumer Stories Guideline

MHDA2019-0132 Mental Health Drug and Alcohol Waiting List Management Policy

MHDA2020-0753 Mental Health Electroconvulsive Therapy (ECT) Procedure

MHDA2019-0444 Mental Health Emergency Consultation Service Procedure

MHDA2019-0172 Mental Health High Dependency Unit Policy

MHDA2019-0251 Mental Health Inpatient Bed Management Policy

MHDA2019-0459 Mental Health Inpatient Clinical Risk Assessment Engagement Management and Observation Procedure

MHDA2020-0494 Mental Health Inpatient Unit - Consumer Mobile phone and personal electronic devices Procedure

MHDA2020-0072 Mental Health Inpatient Unit – Emergency Sedation Guidelines Guideline

MHDA2019-0495 Mental Health Inpatient Unit – Money and Valuables Procedure

MHDA2019-0141 Mental Health Intake and Triage Policy

MHDA2019-0298 Mental Health Intake and Triage Policy

MHDA2020-0255 Mental Health Leave - Acute Units Procedure

MHDA2019-0208 Mental Health Leave - Recovery Unit Procedure

MHDA2020-0317 Mental Health On-Call Manager Procedure

MHDA2020-0746 Mental Health Recovery Unit - Medication Self-Management Pilot Program Procedure

MHDA2019-0210 Mental Health Recovery Unit: Risk Assessment and Management, Engagement and Observation Policy

MHDA2019-0478 Mental Health Safe Use of Sensory Equipment in Mental Health Inpatient Units Policy

MHDA2019-0183 Mental Health Searches - Acute Inpatient Policy

MHDA2019-0209 Mental Health Searches - Recovery Unit Procedure

MHDA2019-0496 Mental Health Seclusion and Debrief Procedure

MHDA2020-0182 Mental Health Second Opinion Procedure

MHDA2020-0253 Mental Health Services for Employees of MLHD: A guide for managers Procedure

MHDA2019-0188 Mental Health Transfer of Care – Inpatient Services Procedure

MHDA2019-0396 Mental Health Transfer of Care - Recovery Unit Procedure

MHDA2019-0137 Mental Health Transfer of Care from Specialist Community Mental Health Services Policy

MHDA2019-0260 Mental Health Transfer of Care from Specialist Community Mental Health Services Procedure

MHDA2020-0709 Mental Health, Drug and Alcohol Services Consumer and Carer Participation Procedure

MHDA2019-0428 MHDA Clinical Care of People who may be Suicidal Procedure

MLHD2019-0065 MLHD Approved Clinical Abbreviations Policy

MLHD2019-0101 MLHD Dress Code Policy

MLHD2020-0231 MLHD Exchange of Information Policy

MLHD2020-0576 MLHD Medical Imaging Safety And Quality Manual Policy

MLHD2020-0604 MLHD Nurse Delegated Emergency Care (NDEC) Procedure

MLHD2019-0116 MLHD Patient Transport Manual Policy

MLHD2019-0215 MLHD Patient Transport Service Emergency Assistance to Members of the Public Policy

MLHD2019-0115 MLHD Policy and Practice Manual Policy

MLHD2019-0128 MLHD Policy, Procedure & Guideline Development Policy

WWBH2020-0409 MLHD Volunteer Community Driver use of WWBH Staff Amenities Procedure

MLHD2020-0490 MLHD-QM-MI 4.00 Trophon High-Level Disinfection Policy

WWBH2019-0309 Mortuary Security Policy

MLHD2019-0117 Motor Vehicle Manual Policy

WWBH2019-0356 MRI Access and Safety Policy

MLHD2020-0224 Multi Resistant Staphylococcus Aureus (MRSA) Clearance Policy

MLHD2019-0448 Multi-Resistant Organism Surveillance Procedure for Intensive Care Unit Inpatients Policy

MLHD2019-0328 Nebulised Epoprostenol in the Intensive Care Unit (ICU) Policy

WWBH2019-0049 Nebulised Epoprostenol in the Intensive Care Unit (ICU) Procedure

MLHD2020-0886 Nicotine Replacement Therapy (NRT) - Nurse and Pharmacist Initiated Policy

MLHD2019-0451 Nicotine Replacement Therapy (NRT) supply to MLHD staff Policy

MLHD2019-0157 No Travel Policy - Bushfire Protection Policy

MLHD2019-0333 Noninvasive Ventilation (Adult) Policy

MLHD2019-0099 Normal Birth Guideline Policy

MLHD2020-0548 NSW Elder Abuse Toolkit 2016: Identifying and responding to the abuse of older people Policy

MLHD2020-0723 NSW End of Life Palliative Care Framework 2019-2024 Externally Endorsed

MLHD2020-0042 NSW Health Pathology West Regional and Rural Notification of Critical Results Externally Endorsed

MLHD2020-0544 NSW Sexual Health Standard Operating Procedure Manual 2019 Policy

MLHD2020-0581 NSW State Government Residential Aged Care Facilities and Multipurpose Services: Operational Guidelines Policy

MLHD2019-0152 Nursing & Midwifery Registration Policy

MLHD2019-0485 Nursing & Midwifery: Checking and Administering Medications Policy

MLHD2019-0112 Nursing & Midwifery: Disinfection of Clinical Care Areas & Equipment Policy

MLHD2019-0095 Nursing & Midwifery: Team Leader Guidelines Policy

WWBH2019-0477 Nursing Management and Care of an Epidural Infusion (Adult) Non Obstetric Policy

MLHD2019-0489 Nursing Management of Patient Controlled Analgesia - PCA (Adult) Policy

MLHD2019-0160 Nursing Management of Patients with Febrile Neutropenia Policy

MHDA2020-0681 Off-label Use of Psychotropic Medicines in Mental Health Policy

MLHD2019-0147 Oncology - Administration of Intravenous Cytotoxic Drugs to Adults Policy

MLHD2020-0566 Oncology Medical Information System Downtime Policy

MLHD2020-0562 Oncology: Height and Weight entry into MOSAIQ to Calculate Body Surface Area – MOSAIQ only Policy

MHDA2019-0442 Opioid Response and Take Home Naloxone (ORTHN) Procedure

MHDA2019-0194 Opioid Treatment Program Dosing in MLHD Public Hospitals and Multipurpose Facilities Procedure

MLHD2019-0432 Oral Hygiene in the Critically Ill Adult Patient Policy

MLHD2019-0386 Organ and Tissue Donation after Brain Death Policy

MLHD2019-0388 Organ and Tissue Donation after Circulatory Death (DCD) Policy

MLHD2021-0332 Out of Service Procedure

MLHD2020-0686 Pacemaker/Medical Device Protocol Policy

MLHD2019-0449 Paediatric Admissions to the Intensive Care Unit Policy

WWBH2020-0559 Paediatric attendance at Caesarean Section Birth at WWBH Policy

MLHD2021-0367 Paediatric Intravenous Fluids Procedure

MLHD2020-0070 Paediatric Referral Networks MLHD Policy

MLHD2019-0204 Palliative Care - Continuous Subcutaneous Infusions via NIKI T34 Syringe Driver Procedure and Guidelines Policy

MLHD2019-0427 PALLIATIVE CARE – Subcutaneous Cannula Insertion and Management Policy

MLHD2019-0390 Palliative Care Outcomes Collaboration SNAP Palliative Care & PCOC Clinical Assessment Procedure Policy

MLHD2019-0156 Patient Directed Visiting Policy

MLHD2019-0223 Patient Flow Procedure Policy

BOOR2019-0102 Patient Flow Referral Pathways Boorowa MPS MLHD Policy

MLHD2019-0216 Patient Transport Officer Responsibilities Policy

MLHD2020-0068 Patient Transport Officers Transferring Adult Patients receiving Oxygen via nasal prong at no greater than 4L/min Policy

MLHD2019-0217 Patient Transport Service Escort Responsibilities Policy

MLHD2019-0097 Perineal suturing guideline for registered midwives Guideline

MLHD2019-0197 Perioperative: Aseptic Technique Procedure

MLHD2020-0150 Perioperative: Correct Attire Procedure

MLHD2021-0327 Perioperative: Electrosurgical Equipment Procedure

MLHD2021-0431 Perioperative: Environmental Cleaning Procedure

MLHD2019-0104 Perioperative: Management of elective paediatric cases in Level NPS -2 Facilities Guideline

MLHD2019-0174 Perioperative: Management of Hypothermia Procedure

MLHD2020-0413 Perioperative: Management of Sharps Procedure

MLHD2019-0198 Perioperative: Management of Sterile Stock Procedure

MLHD2020-0575 Perioperative: Microbiological testing of flexible endoscopes Procedure

MLHD2020-0175 Perioperative: Patient Positioning Procedure

MLHD2020-0196 Perioperative: Patient Skin Antisepsis Procedure

MLHD2019-0119 Perioperative: Pre-Procedure Fasting Management Guideline

MLHD2019-0171 Perioperative: Specimen identification, collection and handling Procedure

MLHD2020-0573 Perioperative: Steris System 1 Biological Monitoring Procedure

MLHD2019-0468 Perioperative: Surgical hand scrub, gowning, gloving and removal Procedure

MLHD2020-0176 Perioperative: Tourniquet Use Procedure

MLHD2020-0572 Perioperative: Use of Steris Machines Procedure

MLHD2020-0329 Perioperative: Visitors in the Perioperative Environment Procedure

MLHD2019-0326 Permanent data logging of Community Health Vaccine Specific Fridges Policy

MHDA2019-0493 Physical Health Care across Mental Health Drug & Alcohol Services Procedure

WWBH2020-0412 Pneumatic Tube System (PTS) Use Policy

MLHD2020-0302 Post-Exposure Prophylaxis following Non-Occupational Exposure to HIV Policy

MLHD2020-0542 Pregnancy Care Guidelines Policy

MLHD2020-0634 Preparation of Infant Formula Policy

MLHD2020-0582 Preparation, Handling & Storage of Rapid Sequence Induction Kits Policy

MLHD2019-0335 Prescription of bed pole Policy

MLHD2020-0554 Pressure Injury Guidelines Guideline

MLHD2020-0588 Proning of the Intubated Patient in Intensive Care Policy

MLHD2020-0143 Property - Expense Leases Policy

MLHD2020-0305 Property - Expense Leases Policy

MLHD2020-0306 Property - Income Leases Policy

MLHD2020-0678 Provision and Management of Epidural and Spinal Analgesia and Anaesthesia Policy

MLHD2019-0213 PTU Emergency Assistance to Members of the Public Policy

MLHD2019-0387 Pulse Contour Cardiac Output (PiCCO) Policy

YOUN2020-0462 Quiet Room - Young Emergency Department Policy

MLHD2019-0506 Radiation Dose Management – Complex Interventional Imaging Policy

MLHD2020-0577 Radiation Safety Management Plan 2020 Policy

MLHD2020-0373 REACH (Recognise, Engage, Act, Call, Help is on the way) Patient and Family Activated Escalation Procedure

MLHD2019-0181 Recognition and Care of the Unwell/Deteriorating Client accessing Community Based Services Policy

MLHD2020-0674 Recognition and Management of Compromised Airway Policy

MLHD2019-0118 Records Management: Corporate Manual Policy

MLHD2019-0094 Recruitment into Nursing & Midwifery Development Positions Policy

WWBH2019-0308 Register of Deceased Persons Procedure

MLHD2019-0113 Registered Nurse in Charge of Hospital Policy

MLHD2019-0096 Registered Nurse in Charge of Ward, also in Charge of a Hospital <100 beds Policy

MLHD2019-0098 Registered Nurse Transition to Professional Practice program Policy

MLHD2020-0434 Rehabilitation Inpatient Outreach Service for MLHD Procedure

MLHD2019-0391 Release of Bodies from MLHD Facilities Policy

MLHD2019-0472 Relocation Incentive Procedure Policy

MLHD2020-0662 Remote Work from Home Procedure Policy

MLHD2019-0038 Renal Emergency Management of Haemolysis on Haemodialysis Procedure

MLHD2019-0039 Renal Failure to Attend Dialysis and Missed Haemodialysis Sessions Procedure

MLHD2019-0247 Renal Initiation of Intermittent haemodialysis for Acute Kidney Injury Policy

MLHD2019-0484 Renal Peritoneal Dialysis (PD) Administration Intraperitoneal Heparin Policy

MLHD2019-0294 Renal: Administering a Bolus and the Management of Intradialytic Hypotension by Administering a Bolus during Haemodialysis Policy

MLHD2019-0276 Renal: Administration of Anticoagulant Therapy during Haemodialysis Policy

MLHD2019-0277 Renal: Administration of Erythropoiesis Stimulating Agents (ESA) During Haemodialysis Policy

MLHD2020-0568 Renal: Administration of Intraperitoneal Antibiotics Policy

MLHD2019-0240 Renal: Blood Collection via Haemodialysis Access Policy

MLHD2019-0274 Renal: Blood Transfusion During Haemodialysis Policy

MLHD2019-0239 Renal: Changing the Extracorporeal Circuit During Haemodialysis Treatment Policy

MLHD2019-0235 Renal: Commencement & Completion of Haemodialysis Treatment Policy

MLHD2019-0481 Renal: Continuous Ambulatory Peritoneal Dialysis (CAPD) Baxter Freeline Solo Policy

MLHD2019-0482 Renal: Continuous Ambulatory Peritoneal Dialysis (CAPD) Baxter Physioneal 40 (Twin Bag – Double Chamber) Policy

DENI2019-0037 Renal: Deniliquin Renal Unit Procedure Portal Externally Endorsed

MLHD2019-0271 Renal: Disinfection, Decalcification and Cleaning of Fresenius 4008 and 5008 Haemodialysis Machines Policy

MLHD2019-0280 Renal: Dry Weight, Fluid Management & Isolated Ultrafiltration in Haemodialysis Policy

MLHD2019-0035 Renal: Emergency Cardiac Arrest Management During Haemodialysis Procedure

MLHD2019-0497 Renal: Emergency Fire Evacuation and Patient Management Policy

MLHD2019-0041 Renal: Emergency Management of a Blood Leak Alarm in Fresenius 5008 Machines Procedure

MLHD2019-0289 Renal: Emergency Management of a Blood Leak Alarm in Fresenius 5008 Machines Policy

MLHD2019-0291 Renal: Emergency Management of Air Embolism during Haemodialysis Policy

MLHD2019-0040 Renal: Emergency Management of Fresenius 5008 Machines due to Power Failure Policy

MLHD2019-0288 Renal: Emergency Management of Fresenius 5008 Machines due to Power Failure Policy

MLHD2019-0233 Renal: Haemodialysis Cannulation and Monitoring of an Arteriovenous Fistula (AVF) / Arteriovenous Graft (AVG) Policy

MLHD2020-0720 Renal: Haemodialysis Management Using Central Venous Access Device (CVAD) Procedure

MLHD2020-0249 Renal: Haemodialysis Primary Nursing Patient Care & Assessment Procedure

MLHD2019-0273 Renal: Hepatitis B Screening & Vaccination Regime for Adult Chronic Renal Failure Clients Policy

MLHD2019-0248 Renal: Initiation of Maintenance Haemodialysis in End Stage Kidney Disease (ESKD) Policy

MLHD2020-0697 Renal: Intradialytic Blood Volume Monitoring (BVM) & Blood Temperature Monitoring (BTM) in Haemodialysis Patients Using Fresenius 5008 Machine Procedure

MLHD2019-0275 Renal: Intravenous Antibiotic administration during Haemodialysis Treatment Policy

MLHD2019-0272 Renal: Management and Screening of Blood Borne Viruses in Haemodialysis Units Policy

MLHD2019-0281 Renal: Management of blocked Haemodialysis Central Venous Catheter Using Alteplase Policy

MLHD2019-0292 Renal: Management of Dialysis Disequilibrium Syndrome (DDS) Policy

MLHD2020-0699 Renal: Management of Haemodiafiltration in Haemodialysis Procedure

MLHD2020-0748 Renal: Monitoring of Water Quality for Haemodialysis, Haemodiafiltration and Haemofiltration Procedure

MLHD2019-0483 Renal: Patient Suitability for Different Haemodialysis Settings Policy

MLHD2019-0504 Renal: Peritoneal Dialysis - Catheter Adapter Replacement & Line Change Policy

MLHD2019-0475 Renal: Peritoneal Dialysis (PD) – Disposal of PD Effluent Policy

MLHD2019-0502 Renal: Peritoneal Dialysis (PD) Tenckhoff Miniline Change Policy

MLHD2019-0487 Renal: Peritoneal Dialysis Catheter Flush using Baxter Freeline Solo Twin Bag Policy

MLHD2019-0237 Renal: Recirculating of Blood in Extracorporeal Circuit Procedure

MLHD2019-0505 Renal: Sterile Collection of Peritoneal Effluent for Culture Policy

MLHD2019-0189 Reporting Structure for Consumer, Carer and Community Engagement Policy

MLHD2019-0103 Request for clinical information for people seeking access to the National Disability Insurance Scheme (NDIS) Guideline Policy

WWBH2020-0311 Requesting / Planning a Viewing of Deceased Persons Procedure

MLHD2020-0595 Return to Work - Policy Statement Policy

MHDA2019-0230 Rights and Responsibilities of Consumers in MLHD Mental Health and Drug and Alcohol Services Procedure

MLHD2019-0187 Root Cause Analysis (RCA) Consultation Procedure Policy

MLHD2020-0563 Safe Administration and use of Personal Protective Equipment whilst administering intravesical Bacillus Calmette-Guerin (BCG) Guideline

MLHD2019-0047 Safe Introduction of New Interventions and Technologies.pdf Procedure

MLHD2020-0545 Safe Sleep and Responsive Settling Policy

MLHD2019-0059 SAFE START- Families NSW Supporting Families Early Policy

MLHD2021-0915 Safety Huddles Guideline

MLHD2019-0452 Same Gender Accommodation Allocation Policy

MLHD2019-0331 Scope Buddy Endoscope Flushing Aid Policy

MLHD2019-0168 Shift Handover of Nursing/Midwifery Care at the Patient Bedside Policy

MLHD2019-0304 Short Term Oxygen Therapy Provision Policy

MLHD2021-0881 Speech Pathology Clinical Prioritisation Guideline

MLHD2020-0708 Spirometry Use Procedure

MLHD2019-0108 Standards for clinical competence & recency of practice for the Perioperative Nurse/Midwife Policy

MLHD2020-0547 Strive for 5 National Vaccine Storage Guidelines Policy

MLHD2019-0416 Stroke Transfer Protocol: Accessing Stroke Unit Care in MLHD Procedure

MLHD2020-0353 Supply of Emergency Medications for Outpatients After Hours Procedure

MLHD2019-0066 Supra Pubic Catheters (SPC) - Adult Policy

MLHD2020-0345 Surgical Drain Management, Shortening and Removal Procedure

MHDA2020-0725 Telehealth for Specialist Psychiatry and Addiction Medicines Clinics Procedure

GRBH2020-0877 Telemetry guideline Procedure

WWBH2020-0369 Telemetry Monitoring Policy

MLHD2019-0471 Temporary Transvenous Pacing Procedure

MLHD2020-0571 Total Contact Casting (TCC) Policy

MLHD2019-0408 Tracheostomy Clinical Management Bundle (Adult) Policy

WWBH2019-0316 Trans Oesophageal Echocardiogram (TOE) and Direct Current Cardioversion (DCCV) Policy

GRBH2020-0850 Transfer of Medications between Griffith Base Hospital and St Vincent’s Private Hospital Procedure

MLHD2020-0560 Transition of Care from Maternity and or Community Care Intake to Community Based Child and Family Health Nursing Service Policy

MHDA2019-0254 Transitional Behaviour Assessment and Intervention Service (T-BASIS) Unit Discharge Procedure Procedure

MHDA2019-0300 Transport of a Patient with a Mental Health Illness Policy

MLHD2020-0212 Transporting Patients Luggage and/or Personal Aids Policy

MLHD2019-0205 Transporting Patients with their Medical Records Policy

MLHD2019-0111 Traumatic Bereavement Care Policy

MHDA2019-0166 Use of Alcolmeters™ Procedure (To test alcohol concentration by breath analysis) Policy

DENI2019-0457 Use of CHARM Electronic Medication Management Program for Administration of Chemotherapy at Deniliquin Hospital Oncology Unit Policy

WWBH2020-0698 Use of Staff and Patient Medical Imaging and MRI Lockers Procedure

WWBH2020-0410 Use of the Patient Transport Transfer Lounge Procedure

WWBH2019-0320 Wagga Wagga Health Service - Clinical Emergency Response System (CERS) Policy

WWBH2020-0352 Waste Disposal Procedure

MLHD2019-0232 Work Health and Safety (WHS) Incident Management Policy

MLHD2020-0594 Work Health Safety and Wellbeing - Policy Statement Policy

MLHD2020-0357 Working in Isolation Policy

MLHD2019-0455 Workplace camera surveillance Policy

MLHD2021-0893 Wound Debridement - Conservative Sharp Wound Debridement Procedure

MLHD2021-0892 Wound Debridement - Silver Nitrate Applicator Stick Procedure

MLHD2021-0884 Wound Debridement: Ultrasonic Generator Sonoca-185 - Low Frequency Ultrasonic Debridement (LFUD) Procedure

MLHD2019-0114 Wound Prevention & Management Framework Guideline

WWBH2019-0368 WWBH Access Control Procedure

MLHD2019-0447 WWBH Adult Burns Management Process Procedure

WWBH2019-0361 WWBH After Hours Medication Management Policy

WWBH2019-0426 WWBH Booking the Main Foyer for Health Promotion and BBQ Area Activities Procedure

WWBH2020-0350 WWBH Decontamination of the Emergency Department Sexual Assault Examination Suite Procedure

WWBH2020-0310 WWBH Handling of a Deceased Persons Procedure

WWBH2020-0378 WWBH Inter-Department Transfer to Transit Unit Procedure

WWBH2020-0381 WWBH Laser Safety in the Operating Theatres Policy

WWBH2020-0318 WWBH Paediatric Procedures Policy

WWBH2019-0446 WWBH Thrombolysis for Acute Ischaemic Stroke Procedure

WWBH2019-0344 WWBH Trauma Team Activation Criteria Policy

WWBH2019-0346 WWBH Trauma Team Composition and Expected Roles Policy

WWBH2019-0379 WWHS Accountable Drugs - Schedule 4D (S4D) and Schedule 8 (S8) Management Procedure

WWBH2019-0315 WWHS Bowel Regime for Enteral Fed Patients in the Intensive Care Unit Policy

WWBH2019-0325 WWHS Library - After Hours Access Procedure

WWBH2019-0342 WWHS Management of Healthcare Workers occupationally, potentially exposed to HIV, hepatitis B and hepatitis C Policy

WWBH2019-0347 WWHS Management of Paediatric Cuffed Endotracheal Tube Pressure Policy

WWBH2019-0337 WWHS Medical Review of Hospital in the Home (HITH) Patients Policy

WWBH2019-0319 WWHS Plasmapheresis in ICU (Total Plasma Exchange) Policy

WWBH2019-0321 WWHS Staff Amenities Locker Use Policy

WWBH2019-0402 WWRRH Anaesthetic Conserving Device (AnaConDa) Policy

WWBH2019-0382 WWRRH Delivery and Removal of Linen Procedure

WWBH2019-0437 WWRRH Drain Output Documentation Policy

WWBH2019-0366 WWRRH Infection Prevention and Control - Infection Control Trolleys Policy

WWBH2019-0394 WWRRH Infection Prevention and Control – Management of Patients with Multi-Resistant Organisms (MRO) in Sub-Acute Units Policy

WWBH2019-0372 WWRRH Infection Prevention and Control Transmission Based Precautions: Patient Placement Policy

WWBH2019-0436 WWRRH Intravenous Flecainide Challenge Policy

WWBH2019-0422 WWRRH Nursing Guide to Assisting with a Pericardiocentesis Policy