Pennine Acute Hospitals NHS Trust List of Live Policies, … and Procedures... · Bury Division of Integrated Care Clinical Documents : Patient Group Directions : Integrated & Community

Division Document Shelf Document

Reference

Title

Bury Division of

Integrated Care

Clinical Documents : Surgery :

Ophthalmology

NPSU009 Fundus Fluorescein Angiography: Nurse-Led

Bury Division of

Integrated Care

Clinical Documents : General

Medicine

CPME054 Hot Joint: Early Management of the Acute

Bury Division of

Integrated Care

Clinical Documents : Patient

Group Directions : Integrated &

Community Services

PGD284 PGD284 Administration of Naloxone to adult

patients in an emergency situation

Bury Division of

Integrated Care



Community Services

PGD220 PGD220 for Aspirin Dispersable Tablets 300mg for

Management of Patients with Suspected Ischaemic

Chest Pain

Bury Division of

Integrated Care


Group Directions : Anaesthesia

& Surgery

PGD290 PGD290 for Administration of Lidocaine

Hydrochloride 4% with Fluorescein Sodium 0.25%

Eye Drops prior to Applanation Tonometry

Bury Division of

Integrated Care



& Surgery

PGD136 PGD136 Administration of Tropicamide 1% &

Phenylephedrine 2.5% Eye drops prior to Fundus

Fluorescein Angiogram

Bury Division of

Integrated Care



& Surgery

PGD106 PGD106 Administration of Oxybuprocaine

Hydrochloride (Benoxinate 0.4%) Eye Drops Prior

to Biometry

Bury Division of

Integrated Care



Community Services

PGD219 PGD219 for Chloramphenicol 1% Eye Ointment for

Bacterial Conjunctivitis & Superficial Ocular

Infections including Prophylaxis in Corneal

Abrasions / Post Removal of Foreign Body/

Superficial Ocular infections

Bury Division of

Integrated Care



Community Services

PGD191 PGD191 Flucloxacillin Capsules & Syrup for

Treatment of Otitis Externa

Bury Division of

Integrated Care



Community Services

PGD121 PGD121 Administration of Benoxinate

(Oxybuprocaine) Hydrochloride 0.4% w/v Prior to

Applanation Tonometry

Bury Division of

Integrated Care

Clinical Documents : Pain

Management : Adult Pain

Management

CPDI159 Pain in Adult inpatient aged over 18 years;

Assessment & Management of

Bury Division of

Integrated Care

Clinical Documents :

Rehabilitation/Stroke/Rheumatol

ogy : Rheumatology

CPME157 Rheumatology Patients; Use of Intravenous Iloprost

in

Bury Division of

Integrated Care



Community Services

PGD239 PGD239 for Administration by Podiatrists of

Triamcinolone Acetonide Intra-articular, Peri-

articular & Soft Tissue injections to Adult Patients

Bury Division of

Integrated Care



Community Services

PGD186 PGD186 for Co-amoxiclav 625mg tablets & Co-

amoxiclav 250/62 & 125/31 liquid for Animal &

Human Bites

Bury Division of

Integrated Care



Community Services

PGD161 PGD161 Administration of Cyclopentolate &

Phenylephrine in Children’s Ophthalmology Clinic

Bury Division of

Integrated Care



Community Services

PGD200 PGD200 for Paracetamol Tablets & Suspension for

the Treatment of Mild to Moderate Pain or Pyrexia

Bury Division of

Integrated Care



Community Services

PGD310 PGD310 for the administration of intramuscular

(Depo-medrone) methylprednisolone to adults for

the management of active inflammatory

rheumatological disease by specialist rheumatology

nurses

Bury Division of

Integrated Care



Community Services

PGD311 PGD311 for the administration of intramuscular

(Kenalog) triamcinolone to adults for the

management of active inflammatory

rheumatological disease by specialist rheumatology

nurses

Bury Division of

Integrated Care



Community Services

PGD309 PGD309 for the administration of intra-articular

(Kenalog) triamcinolone acetonide injection to adult

patients with joint inflammation and soft tissue

lesions by the rheumatology specialist nurses

Bury Division of

Integrated Care



Community Services

PGD308 PGD308 for the administration of intra-articular

(Depo-medrone) methylprednisolone with lidocaine

injection to adult patients with joint inflammation

and soft tissue lesions by the rheumatology

specialist nurses

Bury Division of

Integrated Care



Community Services

PGD115 PGD115 Administration of Lidocaine Injection to

adult patients with joint inflammation & soft tissue

lesions for use in Physiotherapy

Bury Division of

Integrated Care



Community Services

PGD313 PGD313 for the administration of Triamcinolone

Acetonide to adult patients with joint inflammation

and soft tissue lesions for use in Physiotherapy

Bury Division of

Integrated Care



Community Services

PGD312 PGD312 for the administration of Hydrocortistab

injection to adult patients with joint inflammation

and soft tissue lesions for use in Physiotherapy

List of Live Policies, Procedures, Guidelines and Patient Group Directions at 23 July 2018

Pennine Acute Hospitals NHS Trust

NB This does not include templates, nursing documentation or patient leaflets

Bury Division of

Integrated Care



Community Services

PGD243 PGD243 for supply of Hydrocortisone 1% &

Gentamicin 0.3% (Gentisone HC) Ear Drops for

Otitis Externa

Bury Division of

Integrated Care



Community Services

PGD215 PGD215 for Chlorphenamine Tablets &/ or Syrup

for Relief of Allergic Symptoms

Bury Division of

Integrated Care



Community Services

PGD214 PGD214 for Administration of Salbutamol Solution

for Nebulisation

Bury Division of

Integrated Care



Community Services

PGD212 PGD212 for Glyceryl Trinitrate Spray

Bury Division of

Integrated Care



Community Services

PGD195 PGD195 for Lignocaine 1% for Local Infiltration

Bury Division of

Integrated Care



Community Services

PGD194 PGD194 for Levonelle 1500 For Prevention of

Pregnancy following Unprotected Sexual

Intercourse

Bury Division of

Integrated Care



Community Services

PGD314 PGD314 for Administration of intramuscular (or

subcutaneous) inactivated influenza vaccine to

Individuals in accordance with the national

immunisation programme for active immunisation

against influenza

Bury Division of

Integrated Care



Community Services

PGD192 PGD192 for supply of Flucloxacillin Capsules for

the Treatment of or Prophylaxis against Skin & Soft

Tissue Infections in Adults

Bury Division of

Integrated Care



Community Services

PGD218 PGD218 for Chloramphenicol 0.5% Eye Drops to

patients with Bacterial Conjunctivitis

Bury Division of

Integrated Care



Community Services

PGD205 PGD205 for Human Tetanus Immunoglobulin BP

for Tetanus Prone Injuries

Bury Division of

Integrated Care



Community Services

PGD210 PGD210 for Fusidic Acid 1% Eye Drops

(Fucithalmic) for Superficial Ocular Infections

Bury Division of

Integrated Care



Community Services

PGD203 PGD203 for Absorbed Diphtheria (low dose),

tetanus and poliomyelitis (inactivated) vaccine

(Revaxis®)

Bury Division of

Integrated Care



Community Services

PGD201 PGD201 for supply of Penicillin V tablets for the

treatment of Bacterial Sore Throat in Adults

Bury Division of

Integrated Care



Community Services

PGD317 PGD317 for the supply & dose adjustment of

Warfarin by Heywood, Middleton & Rochdale

(HMR) anticoagulant service

Bury Division of

Integrated Care


Respiratory/Oncology/Palliative

Care : Oncology

CPME175 Investigation and Management of Malignancy of

Unknown Origin (MUO) / Cancer of Unknown

Primary (CUP)

Bury Division of

Integrated Care



Community Services

PGD285 PGD285 Administration of Lidocaine 5% and

Phenylephrine 0.5% Topical Solution for local

anaesthesia prior to Fibreoptic Endoscopic

Evaluation of Swallowing, Endoscopic Evaluation of

the Larynx, Laryngectomy Voice Prosthesis

Change & Insufflation Testing

Bury Division of

Integrated Care



Care : Palliative Care

EDN033 Death; Care After

Bury Division of

Integrated Care




EDC072 Palliative Care: Pain & Symptom Control

Bury Division of

Integrated Care



Community Services

PGD209 PGD209 for the Administration of Fluorescein

Sodium 1% Eye Drops for the Diagnostic

Examination of the Eye for Suspected Corneal

Abrasions, Ulcers & Foreign Bodies

Bury Division of

Integrated Care



Management

CPDI073 Epidural Infusion Analgesia, Management of Adult

Patients with

Bury Division of

Integrated Care

Clinical Documents : Radiology CPDI223 Pre-procedural management of anticoagulants &

antiplatelets in patients undergoing image guided

procedures, Standard operating procedure for

Bury Division of

Integrated Care

Clinical Documents : Nursing :

Clinical Nursing Procedures

CPIC006 Adult Nasogastric/Orogastric Feeding & Drainage

Tubes, Management of

Bury Division of

Integrated Care



Care : Respiratory

CPME163 Oxygen Therapy for Patients with Interstitial Lung

Disease; Assessment & Prescription of Home

Bury Division of

Integrated Care



Management

CPDI042 Entonox - Inhalational Analgesia (Nitrous Oxide

50%/Oxygen 50%); Care of Adult Patient during

Administration of

Bury Division of

Integrated Care



Management

CPDI129 Anaesthetic Infusions; Continuous infusion &

boluses of Local Anaesthetic via an indwelling

wound catheter (excluding epidural infusions)

Bury Division of

Integrated Care

Clinical Documents : Diabetes &

Endocrinology

CPME178 High Strength Insulin in the hospital setting for adult

patients; management of

Bury Division of

Integrated Care




EDN065 Verification of Death by Registered Nurses

Chief Medical Officer Clinical Documents : Research &

Development

EDRD020 Research Governance


Development

EDRD015 R&D - Fraud, Misconduct & Serious Breach of

Good Clinical Practice


Development

EDRD017 R&D - Retention of Data, Archiving and Destroying

Documents


Development

EDRD014 R&D - Preparing for Sponsor Audits and MHRA

Inspections


Development

EDRD012 Research Training


Development

EDRD011 R&D - Safety Reporting


Development

EDRD010 R&D - Informed Consent in Special Circumstances


Development

EDRD006 R&D - Study Initiation


Development

EDRD002 Ethical Review & Approval; Applications for


Development

EDRD001 R&D - Preparation, Approval & Maintenance of

R&D SOPs


Development

EDRD019 R&D - Auditing of Research Studies Hosted by the

Trust


Development

EDRD018 R&D - Monitoring of Trust Sponsored Studies


Development

EDRD013 R&D - External Monitoring Visits


Development

EDRD009 R&D - Informed Consent


Development

EDRD008 R&D - Case Report Forms


Development

EDRD007 R&D - Study File & Filing


Development

EDRD005 R&D - Definition of Responsibilities


Development

EDRD004 R&D - Approval of NIHR CRN (Portfolio) Research

Studies


Development

EDRD003 R&D - Approval of Non NIHR CRN Research

Studies


Development

EDRD016 R&D - Completion of a study

Chief Medical Officer Clinical Documents :

Miscellaneous (Clinical)

EDQ002 Consent to Examination or Treatment



EDM013 Private care in PAHNT Facilities; Patients receiving

Chief Medical Officer Non Clinical Documents :

Miscellaneous (Non Clinical)

EDC065 Medical Job Planning (Consultant & SAS)


Communication

EDC067 Diagnostic Tests; Clinical Standards (Your request:

Your responsibility)

Corporate Non Clinical Documents :

General Trust Policies

EDF007 Charitable Fundraising Guidelines

Corporate Northern Care Alliance NCAG001 Fit & Proper Persons

Corporate Northern Care Alliance NCAG002 Group Governance Framework Manual

(incorporating Standing Orders of the Board of

Directors, Standing Orders of the Council of

Governors, Reservation and Delegation of Powers,

Standing Financial Instructions and Standards of

Business Conduct Policy)

Corporate Emergency Plans EDG025 Burns Major Incident Plan



EDC075 Bed Management


Governance

NCAG004(18) Development and Management of Policies,

Procedures and Guidelines

Corporate Clinical Documents : Nursing NCAN001(18) Privacy and Dignity



EDN066 child Protection Information Sharing (CP-IS)

System Procedure

Elective Access Non Clinical Documents :


EDM006 Elective Access

Elective Access Non Clinical Documents : Health

Records

EDM008 Health Records; Patient


Records

EDM014 Postal Items; Addressing of Internal & External

Elective Access Non Clinical Documents :


EDM021 Cancer Access


Records

EDM004 Overseas Visitors


Records

EDM012 Health Records: Access to (Subject Access

Requests)


Records

EDM011 Health Records Service

Estates & Facilities Non Clinical Documents :


EDE023 Waste Management



EDE045 Food and Nutritional Care for in-patients



EDG002 Smoke Free Environment

Estates & Facilities Non Clinical Documents : Health

and Safety

EDE008 Food Hygiene Codes of Practice



NCAE001(18) Taxi policy

Finance Non Clinical Documents :


EDE041 Sustainable Procurement

Finance Non Clinical Documents :


EDF004 Anti Fraud, Bribery and Corruption; Local Policy

and Response Plan

Medicine Clinical Documents : Patient

Group Directions : Medicine

PGD289 PGD289 for the Administration of Morphine

Sulphate for Injection

Medicine Clinical Documents : Pathology :

Haematology

CPDI040 Rasburicase for the Prevention and Treatment of

Acute Tumor Lysis Syndrome; Use of

Medicine Clinical Documents : Cardiology CPME142 Implantable Cardioverter Defibrillators (ICD);

Emergency Management of Patients with

Medicine Clinical Documents : Cardiology CPME087 Continuous Positive Airway Pressure (CPAP)

Therapy using the Boussignac Valve & Pressure

Manometer for Adult Patients with Acute

Cardiogenic Pulmonary Oedema; Training

Requirements, Competency Assessment & Use of

Medicine Clinical Documents : Infectious

Diseases

CPME089 Viral Haemorrhagic Fever; Patients Assessed as

being at risk of

Medicine Clinical Documents : Nursing :

Heart Failure Nurse Protocols

CPME055 Heart Failure Exercise Programme; Referral of

Patients onto the

Medicine Clinical Documents :


Care : Oncology

EDC062 Acute Oncology Initial Management



Care : Respiratory

CPME025 Pleural Diseases; Management of



Care : Respiratory

CPME168 Asthma; Acute Adult

Medicine Clinical Documents : Diabetes &

Endocrinology

CPME023 Overvie Diabetes Adult Inpatient Protocols & Guidelines

Overview


Endocrinology

CPME023Part 2 Diabetes Adult Inpatient Protocols & Guidelines

Part 2: Hyperglycaemia & Treatments


Endocrinology


Part 4: Diabetic Emergencies: Diabetic

Ketoacidosis, Acute Coronary Syndrome &

Hypoglycaemia; Management of


Endocrinology


Part 3: Special Inpatient Circumstances: Illness,

Surgery & Enteral Feeding; Management in


Endocrinology

CPME023 Part1 Diabetes Adult Inpatient Protocols & Guidelines

Part 1: Diagnosis & General Management of

Diabetes, Lifestyle & CVS Risk Factors


Endocrinology

CPME150 Insulin Pump Therapy in Adults; Guidelines for the

Provision & Management of

Medicine Clinical Documents : Nursing :

Heart Failure Nurse Protocols

CPME076 Beta Blockers in Patients with Chronic Heart Failure

by the Heart Failure Nurse Specialist; Use of

Medicine Clinical Documents : General

Medicine

CPME140 Seizure Activity of Convulsive Status Epilepsy in

Adult Patients; Diagnosis, Treatment & Clinical

Recording of


Endocrinology

CPME022 Endocrine Test; Adult



Community Services

PGD184 PGD184 for Amoxicillin Capsules & Amoxicillin

Suspension for Treating Acute Otitis Media



PGD037 PGD037 for the Administration of Co-dydramol

10/500mg Tablets



ogy : Stroke Services

CPME174 Intracerebral Haemorrhage: Management of

Spontaneous ICH



PGD193 PGD193 for Ibruprofen Tablets & Ibuprofen Oral

Suspension for Mild to Moderate Pain & Pyrexia


Medicine

CPDI156 Haematology Inpatients and Day Cases; Clinical


Diseases

CPME036 Malaria



PGD185 PGD185 for Administration of Oxybuprocaine

Hydrochloride 0.4% (Benoxinate) Eye Drops


Diseases

EDN014 Tuberculosis


Communication

EDC074 Outlying Surgical and Medical Patients

Medicine Clinical Documents : Acute

Illness Management

EDC052 Major Trauma Team



PGD015 PGD015 Administration of Oxygen in

breathlessness or hypoxia




EDC053 Palliative Care: Care in the last days of adult life

Medicine Clinical Documents : Critical

Care

CPME133 Head Injury in Adult Patients: Assessment and

Early Management



ogy : Stroke Services

CPME082 Stroke; assessment and treatment of stroke

patients


Resuscitation

EDC015 Resuscitation

Medicine Clinical Documents : Cardiology CPME183 Sacubitril Valsartan for the treatment of

symptomatic chronic heart failure with reduced

ejection fraction



PGD291 PGD291 Intra-venous Teicoplanin



Care : Respiratory

CPME083 Nebuliser Compressor Issue



Care : Respiratory

CPME145 Oxygen in Adults in the Acute Setting; prescription

and administration of



Care : Respiratory

CPME184 Community Acquired Pneumonia in Adults

(Management of)

Medicine Clinical Documents : Discharge NCME022 Discharge from hospital and supporting choice

Standard Operating Procedure

Medicine Clinical Documents : Discharge NCME002 Discharge


Medicine

CPME176 FallSafe

Medicine Clinical Documents : Cardiology CPME181 Acute heart failure (Ambulatory care pathway for

suspected)

Medicine Clinical Documents : Acute

Illness Management

CPME172 Sepsis - Early Recognition and Management of

Adult Patients with Suspected Sepsis including

Neutropenic Sepsis

NCA Group Non Clinical Documents :


EDG032 VIPs: Handling of High Profile Visitors & the Media

to the Trust



EDQ003 Freedom of Information Act


Governance

EDQ028 External Agency Visits, Inspections, Accreditations

& National Reports; Responding to the

Recommendations & Requirements of



EDQ014 Records Management



EDG034 Board Assurance Framework



EDH038 Media

NCA Group Diagnostics &

Pharmacy


Group Directions

CPDI105 Patient Group Directions


Pharmacy

Clinical Documents : Radiology CPDI122 Cervical Spine Imaging Following Trauma in Adults


Pharmacy

Clinical Documents : Medicine

Management

EDT004 Prescribed Medicines to Inpatients


Pharmacy

Clinical Documents : Radiology CPDI194 Radiology Internal Professional Standards:

Multidisciplinary Team Meeting


Pharmacy

Clinical Documents : Radiology CPDI200 Intravenous Opiates and Midazolam by Radiology

Nurses; Administration of


Pharmacy


Management

EDT015 Vancomycin for ICU use; Continuous Infusion of


Pharmacy

Clinical Documents : Radiology CPDI157 Radiographic Imaging & Reporting of Non-

Accidental Injury (NAI) Referrals (Child Protection /

Safeguarding)


Pharmacy

Clinical Documents : Radiology CPDI066 Radiology; Referral to by Non Medical Registered

Health professionals


Pharmacy

Clinical Documents : Radiology DPGDI026 Nephrogenic Systemic Fibrosis (NSF) in Patients

Undergoing Injection of Gadolinium Contrast

Media; Prevention of


Pharmacy

Clinical Documents : Radiology CPDI099 Referral for the Diagnostic Investigation of

Pulmonary Embolus


Pharmacy

Clinical Documents : Radiology CPDI178 CT; Whole Body Computed Tomography in Major

Trauma


Pharmacy

Clinical Documents : Pharmacy CPME152 Stroke; Management of Hypertension Prior to

Thrombolysis in Patients with Acute Ischaemic


Pharmacy

Clinical Documents : Pathology :

Point of Care Testing

CPDI019 Point of Care Testing


Pharmacy

Non Clinical Documents : Health

and Safety

EDE014 Asbestos Management


Pharmacy

Clinical Documents : Pathology DPGDI028 Pathology Provision; Rochdale Infirmary


Pharmacy

Clinical Documents : Radiology DPDI004 Ionising Radiation (Medical Exposure) Regulations

[IR(ME)R]


Pharmacy

Clinical Documents : Radiology DPGDI021 Diabetes Patients on Metformin: IV Contrast

Administration in


Pharmacy

Clinical Documents : Radiology CPDI213 Radiology Service; On Call General


Pharmacy


Group Directions : Support

Services

PGD160 PGD160 Administration of Hyoscine Butylbromide

for Radiological examination of the Gastrointestinal

Tract


Pharmacy


Management

CPME177 Anticoagulation; Management of Oral

Anticoagulation in Patients with Atrial Fibrillation


Pharmacy

Clinical Documents : Pharmacy EDT018 Medicines by Unregistered Practitioners;

Administration of


Pharmacy



Services

PGD150 PGD150 Supply & Administration of Enoxaparin

Sodium (Clexane) for Patients with a Sub-

therapeutic INR who have been newly diagnosed

with venous thrombo-embolism


Pharmacy



Services

PGD101 PGD101 The supply & administration of

Phytomenadione/Vitamin K (Konakion MM

paediatric)


Pharmacy



Services

PGD113 PGD113 The supply & administration of Low

Molecular Weight Heparin: Enoxaparin Sodium

(Clexane injection) during the temporary

interruption of oral anticoagulant therapy


Pharmacy



Services

PGD096 PGD096 The Supply and Dose Adjustment of

Warfarin


Pharmacy

Non Clinical Documents :


EDE048 Laundry & Linen Services; Management of


Pharmacy

Clinical Documents : Pharmacy CPDI173 Opioid-dependent Adult Inpatients; Treatment &

Management of


Pharmacy

Clinical Documents : Radiology DPGDI016 Childrens Radiology; Operational Plan for NMGH


Pharmacy



Services

PGD277 PGD277 Use of Glycerol Suppositories prior to

lower GI investigations


Pharmacy



Services

PGD305 PGD305 Barium Sulphate in Barium Swallow

Examinations Performed by Radiographers.

Administration of


Pharmacy



Services

PGD279 PGD279 For Administration by Radiographers of

Omnipaque as Radiographic Contrast Agents for

Fluoroscopic Investigations


Pharmacy



Services

PGD282 PGD282 Barium Sulphate in video swallow

examinations by radiographers and speech and

language therapists,The administration of


Pharmacy

Clinical Documents : Radiology CPDI217 Endovascular Aneurysm Repair Procedures

(EVAR); Management of Patients requiring


Pharmacy


Blood Transfusion

CPDI072 Cell Salvage; Provision of Autologous

Intraoperative & Postoperative


Pharmacy

Clinical Documents : Radiology CPDI109 Radiology Requests for Patients Deemed Unfit by

the Referrer; Return of


Pharmacy



EDE010 Security


Pharmacy


Management

EDC025 Recorded Drugs; Ordering, Storage &

Administration of


Pharmacy

Clinical Documents : Radiology CPDI218 Nephrostomy and Antegrade Ureteric Stent

Insertion in Radiology, Standard Operating

Procedure for


Pharmacy

Clinical Documents : Pharmacy EDT026 Antimicrobial Stewardship


Pharmacy

Clinical Documents : Pharmacy EDT010 Penicillin Allergy


Pharmacy



EDE031 Reactive and Planned Preventative Maintenance


Pharmacy


Management

EDC020 Unauthorised Drugs or Other Unidentified

Substances brought in by Patients; Dealing with


Pharmacy


Management

EDC016 Transfer of Medicines Between Departments &

Wards When the Pharmacy is Closed


Pharmacy


Blood Transfusion

CPDI012 Fresh Frozen Plasma components; use of


Pharmacy

Clinical Documents : Pharmacy EDT025 Medicines Optimisation


Pharmacy


Blood Transfusion

EDC012 Blood Samples for Transfusion Tests which

Generate a Blood Group; Requesting, Collecting,

and Labelling of


Pharmacy



EDG012 Fire Safety


Pharmacy

Emergency Plans EDG018 Rapid Discharge in Acute Settings: Emergency


Pharmacy


Blood Transfusion

EDC031 Blood Stocks Management Plan: Emergency


Pharmacy


Blood Transfusion

EDC011 Red Cells from the Blood Bank Fridge; Collection of


Pharmacy

Clinical Documents : Surgery :

Theatres

NPDI004 Swabs, Sharps & Instruments; Checking of


Pharmacy

Clinical Documents : Radiology CPDI220 Radiation; Protection of Staff and Patients Exposed

to Ionising Radiation through the Work of the

Pennine Hospitals NHS Trust


Pharmacy

Clinical Documents : Radiology CPDI174 Forensic Imaging Investigations


Pharmacy



Services

PGD231 PGD231 Administration by Radiographers of

MultiHance (Gadobenate dimeglumine) as a

Radiographic Contrast Agent


Pharmacy



Services


ProHance (Gadoteriol) as a Radiographic Contrast

Agent


Pharmacy

Clinical Documents : Radiology CPDI140 Imaging of Patients with an Acute Stroke


Pharmacy

Emergency Plans EDG006 Major Incident Plan: Fairfield General Hospital


Pharmacy

Emergency Plans EDG007 Major Incident Plan: North Manchester General

Hospital & Community Services


Pharmacy

Emergency Plans EDG009 Major Incident Plan: Royal Oldham Hospital


Pharmacy

Emergency Plans EDG008 Major Incident Plan: Rochdale Urgent Care Centre


Pharmacy

Clinical Documents : Community

North Services

CPDI176 Community Nurses Controlled Drugs


Pharmacy


North Services

CPDI191 Controlled Drugs Intermediate Care Units


Pharmacy


North Services

CPDI196 Medicines; for Community Staff Employed by PAT


Pharmacy


Management

EDT003 Intravenous Potassium


Pharmacy

Clinical Documents : Nursing EDN031 Medicines; Training in the safe administration of


Pharmacy


Haematology

CPDI045 Chemotherapy for Adult Patients; Intrathecal

Cytotoxic


Pharmacy


and Safety

EDE050 Electrical Safety (not including Medical Devices)


Pharmacy


Management

EDC017 Ordering, Storage and Administration of Controlled

Drugs


Pharmacy


Management

EDC024 Medication to Patients Discharged Outside

Pharmacy Working Hours; Supply of


Pharmacy


Haematology

CPDI069 Rituximab Infusions in the Treatment of Non-

Hodgkins Lymphoma; Administration of


Pharmacy

Clinical Documents : Pharmacy EDT019 Electrolyte Disturbances; Treatment of Adult

Patients Management of


Pharmacy



Services

PGD240 PGD240 PGD for Administration of Lidocaine 1%

with Adrenaline (Epinephrine) 1:200000 for Use

During Interventional Breast Procedures under

Imaging Guidance


Pharmacy


Microbiology

CPDI024 Transmissible Spongiform Encephalopathies (TSE)

including Creutzfeldt - Jakob Disease (CJD)


Pharmacy



EDE001 Gas Systems; Piped Medical


Pharmacy


North Services

CPDI187 Medicines Transcribing (for use by Community

Services North)


Pharmacy



EDC069 Admittance of Medical Device Company

Representatives to the Trust


Pharmacy


Blood Transfusion

CPDI201 Bleeding in patients receiving antithrombotic agents

or who require emergency/elective anticoagulant

reversal


Pharmacy

Emergency Plans EDG021 Recovery Plan


Pharmacy


Blood Transfusion

EDC006 Blood and Blood Components; Administration of


Pharmacy


Blood Transfusion

CPDI182 Blood component transfusion; Senior Nurses and

Advanced Practitioners providing the written

instruction for


Pharmacy



EDE053 Medical Devices Involved in Incidents;

management of


Pharmacy


and Safety

EDE020 Medical Devices & Equipment; Training &

Assessment for Safe use of


Pharmacy


Blood Transfusion

CPDI137 Human Albumin Solution 4.5% & 20%; Use of


Pharmacy


Blood Transfusion

CPDI011 Platelet Transfusion in adults and children/neonates


Pharmacy



Services

PGD316 PGD316 for Administration by Radiographers of

Omnipaque (Iohexol) as a Radiographic Contrast

Agent


Pharmacy



Services


Niopam (Iopamidol) as radiographic contrast

agents


Pharmacy

Clinical Documents : Infection

Control

EDE018 Trust Cleaning


Pharmacy

Emergency Plans EDE044 Lockdown Plan; Trust Generic


Pharmacy

Clinical Documents : Pathology CPDI030 Post-Mortem Consent; Adult Hospital


Pharmacy

Clinical Documents : Pharmacy CPDI111 Drug Prescription & Administration record; Use of

the PAHNT


Pharmacy



CPDI155 Vaccinations in Infectious Diseases & Adult Travel

Outpatient Clinics; Stock Control, Prescription &

Administration of


Pharmacy


Blood Transfusion

CPDI036 Special requirements for blood components,

Guideline for


Pharmacy

Emergency Plans CPME078 Pandemic Influenza; Guidance for the Management

of


Pharmacy

Clinical Documents : Radiology CPDI169 Reporting Protocol for Specialist Fluoroscopy

Radiographers


Pharmacy


Blood Transfusion

CPDI205 Blood Management - Patient Blood Management of

Medical Patients


Pharmacy


Blood Transfusion

CPDI063 Blood Management - Patient Blood Management

prior to Surgery


Pharmacy


Management

CPDI222 Cardiology Continuous Infusion Charts


Pharmacy


Blood Transfusion

CPWC149 Anaemia in Pregnancy & Post Partum; Prevention,

Screening, Investigation & Management of


Pharmacy

Clinical Documents : Radiology CPDI113 Ultrasound for Obstetrics & Gynaecology


Pharmacy

Emergency Plans EDG033 Reserve Forces; employment of staff in the


Pharmacy

Clinical Documents : Radiology DPDI003 Radiology Reporting


Pharmacy


Blood Transfusion

EDC007 Blood Transfusion; Indications for Red Cell

transfusion "The Green Policy"


Pharmacy



Services


Primovist (Gadoxetate disodium) as a Radiographic

Contrast Agents


Pharmacy



EDE012 Issue of Equipment to Home, Policy for


Pharmacy

Clinical Documents : HSDU EDE043 Decontamination of Re-usable Medical Devices


Pharmacy



EDE017 Vehicle Parking


Pharmacy


Management

EDC023 Medicines; Self Administration by Adult In-patients

of


Pharmacy

Clinical Documents : Pharmacy CPDI199 Parkinson's Disease in Patients who are nil by

mouth (NBM) or have Compromised

Swallow:Guideline for the Management of


Pharmacy

Clinical Documents : Pharmacy EDT007 Antibiotic (Adult Patients)


Pharmacy


Management

CPDI180 Ulcerative Colitis; Administration of Intravenous

Ciclosporin in Acute Severe


Pharmacy


Management

CPDI227 Vitamin D Deficiency in Adults, Children &

Pregnancy, Management of


Pharmacy


Management

EDC018 Medicines


Pharmacy


Blood Transfusion

EDC005 Transfusion Reactions; Management of


Pharmacy

Emergency Plans EDG031 Evacuation (Trust Evacuation Strategy)


Pharmacy


Management

EDC033 Non Medical Prescribing


Pharmacy



EDE019 Medical Devices; Management & Use of


Pharmacy



EDE056 Approval of changes or introduction of new medical

devices


Pharmacy

Clinical Documents : Radiology CPDI167 Magnetic Resonance Imaging for Patients Referred

with Suspected Metastatic & Non-Metastatic Spinal

Cord Compression


Pharmacy



EDE030 Pest Control


Pharmacy

Clinical Documents : Neonatal DPWC015 Neonatal Doses


Pharmacy

Clinical Documents : Pathology CPDI061 Labelling & Safe Handling of Pathology Samples &

Request Forms


Pharmacy

Emergency Plans EDI015 Service Continuity


Pharmacy

Clinical Documents : Radiology CPDI225 Interventional Radiology (IR) day case unit at the

Oldham Care Organisation


Pharmacy

Clinical Documents : Pharmacy EDT017 Loading Doses; Adult


Pharmacy

Clinical Documents : Radiology CPDI160 Nephropathy in Patients Undergoing Injection of

Radiographic Contrast Agents; Prevention of


Pharmacy

Clinical Documents : Radiology CPDI230 Magnetic Resonance Imaging Protogram, Standard

Operating Procedure for


Pharmacy


and Safety

EDE015 Water Systems; Safe management of


Pharmacy

Clinical Documents : Critical

Care

CPME010 Intravenous Human Immunoglobulin Policy for

Adults


Pharmacy


Blood Transfusion

CPDI064 Patients Who Decline Blood Components including

Jehovah's Witnesses (Management of all)


Pharmacy

Clinical Documents : Radiology CPDI075 Breast Interventional Procedures; Protocol &

Scheme of Work for Consultant

Radiographer/Clinical Specialist Mammographer

Performing Image Guided


Pharmacy


Blood Transfusion

EDC009 Blood: Management of a Massive Blood Loss


Pharmacy

Clinical Documents : Radiology CPDI233 Percutaneous Ultrasound and CT Guided Drainage


Pharmacy

Clinical Documents : Radiology CPDI232 Percutaneous Trans hepatic Cholangiogram (PTC),

Biliary Drainage and Stenting


Pharmacy


Blood Transfusion

CPDI043 Blood & Blood Components - Transfer Between

Hospitals within the Trust and other Hospitals


Pharmacy

Clinical Documents : Radiology CPDI110 Radiology Auto-reporting

Nursing Clinical Documents : Wound

Management

CPME024 Wounds; Prevention and Management of

Nursing Non Clinical Documents :

Governance

EDQ006 Patient Information: Production of

Nursing Clinical Documents : Nursing EDC003 Breaking Significant News


Governance

EDG010 Handling Clinical Negligence Claims, Liabilities to

Third Parties Claims (LTPS), Property Expenses

Scheme Claims (PES) HM Coroner Inquests &

Making Clinically Related Ex-Gratia Payments


Management

CPME001 Wound Management; Use of Negative Pressure

Wound Therapy in

Nursing Clinical Documents : Nursing EDN015 Visitors Policy & Visitor Code: Hospital


Governance

EDG016 Legal Advice Request



EDN011 Religious & Faith Requirements Relevant to

Hospital Admissions; Guidance for Staff

Nursing Clinical Documents :

Safeguarding Vulnerable People

: Adult

EDG030 Homelessness; Hospital Discharge Prevention of


Management

CPME005 Leg Ulcers; Prevention and Management of



EDG003 Bleep (for the call out of Medical staff)


Management

CPME085 Aseptic Technique in Wound Management


Governance

EDQ032 Clinical Audit & Effectiveness



EDN044 Carers 2013 - 2018

Nursing Clinical Documents : Nursing EDN038 Rostering; Nursing & Midwifery


Governance : Health & Safety

EDQ012 Risk Management Strategy &



: Adult

EDN036 Safeguarding Training (Adult & Child Protection /

Safeguarding)


Management

CPME003 Wound Management; Use of Sterile Larvae in



: Children

NCWC003 Fabricated and Induced Illness (Child Protection /

Safeguarding); Management of

Nursing Non Clinical Documents : Health

and Safety

EDQ007 Health and Safety



: Children

DPWC008 Babies Being Transferred into the Care of the Local

Authorities



: Adult

EDN010 Safeguarding (Adult & Child Protection)

Nursing Clinical Documents : Nursing EDN039 Staffing Shortfalls; Escalation of Nursing &

Midwifery Staffing Shortfalls & Booking of

Temporary Staffing



: Adult

CPME144 Alcohol Withdrawal Syndrome



: Adult

EDN040 Abuse; Allegations Against Staff who Work with

Children & Adults at Risk (safeguarding)



EDQ038 Contractors; Control and Management of

Nursing Clinical Documents : Nursing EDC054 Clinical Communication/Handover



: Children

NCWC001 Child Protection (Safeguarding)


and Safety

EDQ026 sharps injury/exposure to blood and body fluids;

Prevention of



: Adult

EDN042 Domestic Abuse



: Adult

EDN057 E-Safety



: Adult

EDN055 Dementia Strategy



EDQ017 Alert Notices Generated Via the Central Alerting

System: Distribution & Management of


Governance

EDG004 Complaints Handling



: Adult

EDN058 Patient Experience



: Adult

EDN048 Learning Disability (Safeguarding)

Nursing Clinical Documents : Nursing EDN056 Nursing & Midwifery Council; Referral of a

Registrant to the


and Safety

EDQ023 Latex; Management of


and Safety

EDQ021 First Aid


and Safety

EDQ016 Display Screen Equipment



EDG022 Volunteer



: Children

NCWC007 Child Protection Concerns (Child

Protection/Safeguarding): Hospital Discharge for

Children where there are



: Adult

NCWC010 Harm to Children, Young People and Vulnerable

Adults (Safeguarding); Management of

Patients/Visitors who Pose a Risk of


Workforce & OD : Human

Resources

EDH023 Interpretation & Translation



: Adult

EDN049 Restraint; Adult Patient



: Adult

DPWC011 Female Genital Mutilation; Safeguarding Guidelines

for Dealing with Actual or Suspected Cases of FGM


and Safety

EDQ019 Slips Trips & Falls; Prevention of Staff & Visitor


Governance

EDQ033 Clinical Audit & Effectiveness



EDG013 National Institute for Health and Clinical Excellence

Guidance; Implementation of



: Adult

EDC064 Mental Health Act 1983


Management

CPME002 Pressure Ulcers; Prevention and Management of



: Children

EDN053 Admission of Children to Adult Wards



EDQ040 Health & Safety Strategy 2016-18

Nursing Clinical Documents : Nursing EDG019 Transfer; Adult

Nursing Clinical Documents : Infection

Control

CPDI214 Policy for the Management and Control of

Carbapenemase Producing Enterobacteriaceae

(CPE)


Control

CPDI023 Supp1 MRSA ICP


Control

CPDI023 Methicillin Resistant Staphylococcus Aureus

(MRSA) Policy


Control

CPDI017 Isolation; Patient Isolation


Control

CPDI006 Outbreak Control & Ward Closure



: Children

EDG027 Child and Adult Safeguarding Supervision

Nursing Clinical Documents : Nursing EDN054 Single Sex Accommodation



: Adult

EDN050 Alcohol; Identification and Brief Advice (IBA) for

Nursing Clinical Documents : Nursing EDN041 Urinary Catheters, Insertion & Management of


Control

CPDI115 Surveillance and Notification

Nursing Clinical Documents : Nursing NCME001 Chaperone



: Children

EDN047 Restraint & Holding Children


Control

EDN035 Aseptic Non Touch Technique (ANTT)®



: Adult

NCSU013 Missing Patient


Control

CPDI085 Blood Cultures; Collection of


Control

CPDI008 Clostridium Difficile


Control

CPDI016 Diarrhoea & Vomiting



: Adult

EDN037 Deprivation of Liberty Safeguards



EDQ035 Risk Assessment for New & Expectant Mothers


Governance : Risk Management

EDQ039 Mortality Review

Nursing Clinical Documents : Nursing EDN009 Patient Identification



EDN004 Clinical Record Keeping


Control

CPDI086 Standard Precautions

Nursing Clinical Documents : Nursing EDC070 Escalation Policy & Reporting Procedure for

Extended Patient Waits

Nursing Clinical Documents : Nursing EDN051 Intentional rounding



: Adult

NCWC011 Protection of Adults at Risk of Abuse and Neglect

(Adult Safeguarding)



: Adult

EDN052 Learning Disabilities and Autism Good Practice

Guidance; Care Pathway for People with



EDQ041 Stress at work; managing



EDG017 Specialling Patients (previously Enhanced Patient

Observation)



: Adult

EDQ029 Mental Capacity Act (Adult & Child Protection /

Safeguarding)



EDC040 Optical Radiation (Laser) Safety


Governance

EDQ037 Quality Improvement Strategy



EDG014 Work Wear



EDQ043 Mortality Review



EDQ008 Incident Reporting & Investigation; including

Serious Incident Framework & Duty of Candour &

Learning from Deaths

Nursing Clinical Documents : Nursing EDN005 Bed Rails: Appropriate use of



: Adult

EDC057 Alcohol Strategy

Surgery Clinical Documents : Surgery :

Theatres

DGSU010 Code of Practice Advanced Scrub Practitioner,

Theatre Department

Surgery Clinical Documents : Medicine

Management

EDT020 Proton Pump Inhibitors in Relation to Clostridium

difficile Associated Diarrhoea; Prescribing


Urology

CPSU051 Single Intravesicle Instillation of Mitomycin C using

a Mito-in Device; Administration of

Surgery Clinical Documents :

Gastroenterology

CPSU009 Ascitic Drains for Abdominal Paracentesis;

Insertion, Management and Removal of

Surgery Non Clinical Documents :

Workforce & OD : Learning &

OD

CPME018 Arterial Blood Sampling in Adult Patients Skills

Development Workbook

Surgery Clinical Documents : Surgery CPSU060 Balloon Gastrostomy Tube into a Gastrostomy or

Jejunostomy; The insertion of


Gastroenterology

CPME148 Ulcerative Colitis; The Management of Acute

Severe

Surgery Clinical Documents : Patient


& Surgery

PGD263 PGD263 Naseptin Nasal Cream (Chlorhexidine

0.1% and Neomycin 0.5% cream)



& Surgery

PGD262 PGD262 Chlorhexidine Gluconate 0.2%

Mouthwash



& Surgery

PGD261 PGD261 Mupirocin 2% Nasal Ointment



& Surgery

PGD260 PGD260 Chlorhexidine Gluconate 4% Solution

Surgery Clinical Documents : Critical

Care

CPDI215 Sedation & Analgesia within Critical Care



& Surgery

PGD294 PGD294 for 20% Human Albumin Solution for

Albumin Replacement during Abdominal

Paracentesis

Surgery Clinical Documents : Surgery CPSU058 Obese Patients Requiring Surgery; Care

Management of


Anaesthesia

DPGDI027 Anaesthetic Preoperative Assessment; Location of


Care

CPDI013 Critical Care; Adult


Theatres

CPSU085 23 hour Surgical Unit on the Rochdale site,

Operational Policy for


Care

CPDI096 Non Invasive Ventilation (NIV) in Adult Patients with

Acute Type 2 Respiratory Failure in Acute Wards &

Level 2 Critical Care Areas; Use of


Theatres

NCSU016 Peri-Operative Record: Operating Department


Theatres

CPSU066 Day Surgery Minor / Clinic Procedure Record


Theatres

CPSU054 Day Surgery Unit Record

Surgery Clinical Documents : Surgery CPSU019 Peri-operative Fasting in Adults and Children

Surgery Clinical Documents : Surgery CPSU055 Pregnancy Testing in Patients Scheduled for

Procedures under General & Regional Anaesthesia

Surgery Clinical Documents : Surgery EDC063 Arterial Thrombolysis



& Surgery

PGD163 PGD163 Administration of intravenous Hartmann's

solution to adult patients in an emergency



& Surgery

PGD067 PGD067 Administration of Intravenous 0.9%

Sodium Chloride to an Adult Patient in a Medical

Emergency



& Surgery

PGD064 PGD064 Administration of Flumazenil Injection by

the Nurse Endoscopist



& Surgery

PGD128 PGD128 Administration of Hyoscine N Butyl

Bromide by Nurse Endoscopists



& Surgery

PGD077 PGD077 for the Supply & Administration of a

Disposable Phosphate Enema by Registered

General Nurses in the Endoscopy Environment



& Surgery

PGD076 PGD076 for the Administration of Oxygen to a

Patient within the Endoscopy Environment



& Surgery

PGD078 PGD078 for Administration of Xylocaine Spray

(Lidocaine) by Nurse Endoscopist & Registered

General Nurses Assisting in Endoscopy

Procedures



& Surgery

PGD063 PGD063 Administration of Midazolam Injection by

Nurse Endoscopist



& Surgery

PGD287 PGD287 for the Supply & Administration of Entonox

during Endoscopic Procedures by Registered

Nurses assisting the Endoscopist with the

procedureSurgery Clinical Documents : Critical

Care

CPDI198 Mechanical Ventilation on the Intensive Care Units;

Weaning of Adult Patients from

Surgery Clinical Documents : Nursing :

Clinical Nursing Procedures

NPDI002 Flexi Seal Faecal Management System; Insertion &

Management of the


Anaesthesia

DGWC001 Staffing Levels; Governing Safe Staffing Levels for

Obstetric Anaesthetists & Assistants on Labour

Ward


Anaesthesia

CPDI147 Anaphylactic Reactions Associated with

Anaesthesia: Management of Suspected



& Surgery

PGD283 PGD283 Dispense & administer moviprep bowel

preparation for colonic imaging by registered

general nurses



& Surgery

PGD238 PGD238 Administration of Tetracaine 4% gel

(Ametop) to children and adults for cannulation



& Surgery

PGD236 PGD236 Administration of oral paracetamol

tablets/soluble tablets for adult postoperative day

case patients for the treatment of post-operative

pain

Surgery Clinical Documents : Nutrition &

Dietetics

NCPDI002 Enteral Feed for Adults; Procedures relating to the

supply of

Surgery Clinical Documents : Pain


Management

CPDI033 Spinal; Post Operative Management of Intrathecal

Local Anaesthetics & Opioids in Adults to Produce

Spinal Analgesia


Anaesthesia

CPWC059 Difficult Airway and Failed Intubation (for use in

Obstetric Theatres)

Surgery Clinical Documents : Acute

Illness Management

CPDI083 intravascular devices and procedures for the

preparation and administration of injectable

pharmaceutical products; insertion, management

and removal of

Surgery Clinical Documents : Surgery CPSU017 Venous Thromboembolism (deep vein thrombosis

& pulmonary embolism) In Patients 18 years of age

& over admitted to hospital; Prevention of

Surgery Clinical Documents : Surgery CPSU002 Vascular Patient; Initial Management & Transfer of

the Emergency

Surgery Clinical Documents : Pain


Management

CPDI010 Analgesia Infusion in Adults: Patient Controlled

Surgery Clinical Documents : Acute

Illness Management

CPDI133 Adult Critical Care Outreach Services Operational

Policy


Care

CPSU075 Tracheostomy including the Tracheostomy Care

Bundle and Emergency Algorithms: Management

of Adult patients with


Dietetics

CPDI148 Part 5 Nutrition Support in Adults Part 5: Refeeding

Syndrome in Adult Patients; Management of

Surgery Clinical Documents : Surgery NCSU018 Correct Patient, Procedure and Site Surgery

Surgery Clinical Documents : Surgery CPSU079 Surgical Skin Site Preparation


Care

CPDI084 Intra-arterial Devices for Blood Pressure Monitoring

& Arterial Blood Sampling in adult patients;

Insertion Management & Removal of


Care

CPDI095 Continuous Positive Airway Pressure (CPAP) in

Acute Type I Respiratory Failure Patients within

Critical Care /J4 Hi-Care; Institution of


Theatres

NCSU023 Theatre Department Equipment Failure


Theatres

NCSU014 Theatre Co-ordinator: Operational Policy for


Theatres

DGSU007 Time Owing Operating Theatres


Theatres

CPSU052 Latex Allergy Cases in Theatres


Theatres

NCSU021 Warming Devices within the Theatre Department;

Use of


Dietetics

CPDI148 Part 1 Nutrition Support in Adults Part 1: Guidelines for the

Management of Nutritional Screening, Assessment

& Monitoring


Dietetics

CPDI148 Part 2 Nutrition Support in Adults Part 2: Guidelines for

Oral Nutrition Support


Dietetics

CPDI148 Part 3 Nutrition Support In Adults Part 3 Guidelines for

Enteral Tube Feeding


Dietetics

CPDI148 Overvie Nutrition Support in Adults Part 0: Hospital Setting

Guideline Overview



& Surgery

PGD237 PGD237 Administration of instillagel to adults for

urethral catheterisation


Theatres

CPDI136 intravenous opioids postoperatively in theatre

recovery by the recovery nurse/operating

department practitioner


Dietetics

CPDI181 Dysphagia; Management of Adult Patients with


Theatres

CPSU078 Death in Theatre; Management of

Surgery Clinical Documents : Surgery CPSU056 Latex Allergy Screening in the Pre-operative

Assessment Clinic


Anaesthesia

CPME141 Cortisol Deficiency in Adults (e.g. Addison's

Disease, hypopituitarism, adrenal suppression due

to long term steroid use); Management of Primary

& Secondary

Surgery Clinical Documents : Surgery CPSU067 Deep Vein Thrombosis and Pulmonary Embolism

in Adult Inpatients & Outpatients; diagnosis &

management of



Care : Respiratory

CPDI047 Domiciliary Ventilated Patients Accompanied by

Carers to Support 24hr Care; Admission of Adult


Dietetics

CPDI148 Part 4 Nutrition Support In Adults Part 4: Guidelines for

Parenteral Nutrition


Theatres

CPSU038 Theatre Safe Handling & Collection of Specimens


Theatres

DPSU003 Booking Emergencies in the Theatre Department -

Oldham & North Manchester sites only


Theatres

CPSU025 Handover from Recovery Staff to Ward Staff


Anaesthesia

CPDI164 Hypotension Postoperatively; Management of


Theatres

NCSU027 Theatre; Management of Elective Operating Lists


Theatres

NCPDI001 Spillage in the Operating Department; Management

of

Surgery Clinical Documents : Surgery DGSU004 Electro Surgery


Theatres

CPSU018 Laryngeal Masks

Surgery Clinical Documents : Nursing :

Renal Procedures

CPME056 Collective Renal Protocols for Managing

Intermittent Haemodiafiltration Treatment on Critical

Care Unit North Manchester General Hospital Site


Anaesthesia

DPGDI024 Anaesthesia; Minimum ages of paediatric patients

undergoing


Anaesthesia

CPSU083 Invasive Procedures; safety standards for


Anaesthesia

CPSU077 Lung Protective Ventilation & Treatment of Acute

Respiratory Distress Syndrome in Intensive Care



& Surgery

PGD300 PGD300 Administration of Oral Co-Codamol tablets

/ Soluble Tablets for adult patients undergoing

Lithotripsy treatment



& Surgery

PGD299 PGD299 Administration of Intramuscular

Gentamicin For adult patients undergoing

Lithotripsy treatment



& Surgery

PGD296 PGD296 for pre procedure administration of per

rectum diclofenac for adult patients undergoing

lithotripsy treatment



& Surgery

PGD295 PGD295 for pre procedure administration of oral

paracetamol tablets/soluble tablets for adult

patients undergoing lithotripsy treatment



CPDI210 Diabetic Charcot Neuroarthropathy; Management

of

Surgery Clinical Documents : Nursing CPDI044 Patient Observation Practice; Standard for


Care

EDC047 Organ Donation & Required Referral


Theatres

CPSU037 Peri-operative Drug Administration

Surgery Clinical Documents : Surgery CPSU082 Operating Theatre Department, Standard

Operating Practice in the


Care

CPDI065 Enteral Feeding Adults in Critical Care


Anaesthesia

CPSU086 Malignant Hyperthermia; Anaesthesia Emergency

Treatment and Management of Known Cases

Surgery Clinical Documents : Surgery NCSU004 Cancelled Operations


Urology

CPSU070 Supra Pubic Catheter; Insertion of

Surgery Clinical Documents : Surgery CPSU091 Thromboprophylaxis in Ambulatory trauma-

orthopaedic outpatients


Theatres

CPSU035 Endotracheal Tube in Recovery Unit - Adults only;

Removal of


Orthopaedics

CPSU095 Orthopaedic Ward (I5) North Manchester Care

Organisation Operational flow


Anaesthesia

CPDI165 Low Body Mass Index (BMI); Management of

Patients with a low BMI Requiring Surgery


Gastroenterology

CPDI231 High Output Stoma in Adults Patients

(Management of)

Women & Children Clinical Documents : Paediatrics CPWC045 Post-Op (Paediatric)

Women & Children Clinical Documents : Neonatal CPWC188 Parenteral Nutrition on the Neonatal Unit; Use of

Women & Children Clinical Documents : Paediatrics CPWC012 Sedation (Paediatric)

Women & Children Clinical Documents : Paediatrics CPWC033 Transfer (Paediatric)

Women & Children Clinical Documents : Paediatrics CPWC002 Sucrose (Paediatric)

Women & Children Clinical Documents : Neonatal CPWC088 Neonatal Unit; Admission to

Women & Children Clinical Documents : Paediatrics CPWC069 Mental Health (Paediatric)

Women & Children Clinical Documents : Neonatal CPWC176 Inhaled Nitric Oxide for Persistent Pulmonary

Hypertension of the Newborn; use of

Women & Children Clinical Documents : Neonatal CPWC032 Neonatal Stabilisation & Transfer

Women & Children Clinical Documents : Neonatal CPWC034 Neonatal Abstinence Syndrome; Management of

the Infant of a Mother who has misused substances

during pregnancy

Women & Children Clinical Documents : Neonatal CPWC199 Sepsis; Management of Asymptomatic Neonates at

risk of Early Onset Sepsis

Women & Children Clinical Documents : Neonatal CPWC191 Umbilical Line Insertion

Women & Children Clinical Documents : Neonatal CPWC183 Very Low Birth Weight Infant; Feeding

Women & Children Clinical Documents : Neonatal CPWC086 Attendance at Deliveries

Women & Children Clinical Documents : Maternity

Services : Labour

CPWC066 Induction and Augmentation of Labour


Services : Operational

DPWC017 Maternity Escalation, Divert & Closure


Services : Antenatal

CPWC156 HIV in Pregnancy

Women & Children Clinical Documents :

Gynaecology

CPWC010 Fetal Tissue up to 24 Completed Weeks Gestation;

Sensitive Disposal of

Women & Children Clinical Documents : Patient

Group Directions : Women and

Children's

PGD147 PGD147 Etonogestrel 68mg subdermal implant –

Nexplanon ® Subdermal Contraceptive Implant

postnatal contraception for teenagers



Children's

PGD149 PGD149 for routine antibiotic prophylaxis against

Group B Streptococcus (GBS) for GBS positive

women in labour



Children's

PGD155 PGD155 Pre Operative Ranitidine in Maternity



Children's

PGD224 PGD224 Codeine Phosphate for Pain Relief in

Early Labour

Women & Children Clinical Documents : Neonatal CPWC067 Golden Hour - Resuscitation & Early Care of

Preterm Infants 29+0 Weeks Gestation & Below



DPWC013 Safe Staffing Levels & the Responsibilities of

Consultant Obstetricians on Labour Ward;

Governing



CPWC187 Cervical Cerclage; Insertion of



CPWC055 Maternal Death; Guideline for Practitioners in the

Event of a



CPWC169 Syphilis in Pregnancy and the Neonatal Period;

Management of



CPWC147 Reduced Fetal Movements


Services : Obstetric

Emergencies

CPWC064 Placenta Praevia and Suspected Placenta Accreta;

Management of



CPWC025 Down's Syndrome, Trisomy 13 & 18 Screening in

Pennine Acute Maternity Services

Women & Children Clinical Documents : Neonatal CPWC205 Neonatal Death; Management of



CPWC180 Maternity Care Pathway & Operational Policy



CPWC042 Home Birth



DPWC006 Infant Abduction; Suspected or Actual

Women & Children Clinical Documents : Neonatal CPWC175 Therapeutic Hypothermia for Neonatal Hypoxic

Ischaemic Encephalopathy (HIE)

Women & Children Clinical Documents : Neonatal CPWC145 Neonatal Jaundice; Management of



CPWC159 Genital Tract Sepsis in Obstetrics; Management of

Women & Children Clinical Documents : Neonatal CPWC202 Gastro-oesophageal reflux in Neonates and

Preterm infants


Services : Postnatal

Care/Neonatal Care

CPWC201 Investigation of babies of mothers with thyroid

disease


Services : LSCS & Obstetric

Anaesthesia

CPWC027 Referral to Anaesthetist in Pregnancy



Children's

PGD242 PGD242 for the Supply & Administration of

Inactivated Influenza Vaccine to Pregnant Women



Care/Neonatal Care

CPWC110 Newborn (ENB); Performing the Physical

Examination of the

Women & Children Clinical Documents : Neonatal CPWC184 High flow nasal cannula (HFNC) for respiratory

support (Optiflow® or Vapotherm Precision Flow®)

on Neonatal Intensive Care Unit

Women & Children Clinical Documents : Paediatrics CPWC195 Paediatric Diabetes Operational Policy

Women & Children Clinical Documents : Paediatrics CPWC068 Diabetes - Ketoacidosis (Paediatric)

Women & Children Clinical Documents : Neonatal CPWC189 Fluconazole prophylaxis to Prevent Systemic

Fungal Infections in Extremely Low Birth Weight

(ELBW) Infants

Women & Children Clinical Documents : Neonatal EDT024 Neonatal Unit Antibiotics



Children's

PGD146 PGD146 Misoprostol for postpartum haemorrhage

& uterine atony


Services : Medicines

CPWC137 Remifentanil Patient Controlled Analgesia (PCA)

during labour; Use of



CPWC179 Women from 16+o weeks pregnant to 28 days

postnatal presenting at the Emergency Department

or Urgent Care Centre; Management of


Services : Transfer

CPWC087 Maternity Outliers



Children's

PGD137 PGD137 Local Anaesthetic Cream (Paediatric)



CPWC204 Diabetes; Management of Pregnant Women with

Type 1 and Type 2 Diabetes


Services : Obstetric Medical

Conditions

CPWC107 Gestational Diabetes; Management of



CPWC031 Stop Smoking support for women; Carbon

monoxide monitoring and



Anaesthesia

CPWC133 Epidural Analgesia in Labour including the

management of dural tap



Children's

PGD306 PGD 306 Ibuprofen 400mg tablets for Gynae pain,

Administration of



Children's

PGD307 PGD307 Administration of Co-dydramol 10/500mg

tabs for Gynae related pain



Children's

PGD098 PGD098 Insertion of Mirena Intrauterine System

(Levonorgestrel IUS)


Services : Medicines

CPWC130 Midwives Exemption List;



Care/Neonatal Care

CPWC094 Hepatitis B and Hepatitis C; management of

positive screen in Mothers and babies

Women & Children Clinical Documents : Neonatal CPWC111 Low Cord Ph in a Term Neonate; Management of



CPWC157 Amniocentesis Guideline

Women & Children Clinical Documents : Neonatal CPWC211 Oxygen administration on Neonatal Unit

Women & Children Clinical Documents : Paediatrics CPWC017 Palivizumab (Paediatric)



Emergencies

CPWC140 Cord Prolapse; Management of



Care/Neonatal Care

CPWC126 Newborn Bloodspot



CPWC072 Antenatal Screening & Management of Results



CPWC083 Maternity management of women with a raised

Body Mass Index. Guideline for,



CPWC160 Young Pregnant Women, Care Pathway for

Women & Children Clinical Documents : Neonatal CPWC181 Neonatal Cannulation & Venepuncture



Conditions

CPWC041 Haemoglobinopathy Screening



Children's

PGD072 PGD072 Ranitidine in Labour



Children's

PGD148 PGD148 Cabergoline following fetal loss, stillbirth or

neonatal death



Children's

PGD157 PGD157 Prostaglandin slow release PGE2 Pessary

(PROPESS) 10mg or Dinoprostone (Prostin E2)

3mg tablet for the induction of low risk, post term

labour



Children's

PGD246 PGD246 Local Anaesthetic for use in

Colposcopy/Hysteroscopy procedures



Care/Neonatal Care

CPWC109 Tongue Tie in Neonates (Frenulotomy); Division of



Conditions

CPWC030 Epilepsy; Management of pregnancy & puerperium

in women with



CPWC039 Pregnant Women who are using Drugs &/or

Alcohol


Gynaecology

CPWC197 Laparoscopic hysterectomy on a 23 hour ward



Care/Neonatal Care

CPWC162 Cup Feeding the Neonate



Care/Neonatal Care

CPWC048 Formula Milk Feeding; Guideline for



CPWC127 Antenatal & Postnatal Mental Health Pathway



Conditions

CPWC150 Thrombocytopenia in Pregnancy


Gynaecology

CPWC177 Gynaecology pathway Emergency

Department/Urgent Care (including pregnancies

under 16 weeks gestation)

Women & Children Clinical Documents : Neonatal CPWC003 Neonates at Risk of Hypoglycaemia or with

Neonatal Hypoglycaemia; Management of

Women & Children Clinical Documents : Paediatrics CPWC206 Sepsis (Paediatrics) Recognition & Management of

suspected



Care/Neonatal Care

CPWC053 Breastfeeding



DPWC007 MEWS - Standards for maternal observations in

practice (including maternity early warning score &

maternal sepsis screening tool)

Women & Children Clinical Documents : Paediatrics CPWC081 Diabetes - Hypoglycaemia (Paediatrics)

Women & Children Clinical Documents : Paediatrics CPWC078 Diabetes - new diagnosis (Paediatrics)



Emergencies

CPWC044 Primary Postpartum Haemorrhage; Management of



Emergencies

CPWC092 Shoulder Dystocia


Services : Labour

CPWC073 Pre labour Rupture of Membranes at Term;

Management of women with



Conditions

CPWC062 Thromboembolic Disease in Pregnancy & the

Puerperium: Acute Management of



CPWC139 Small for Gestational Age Singleton Pregnancy;

Investigations and Management of


Gynaecology

CPWC190 Gestational Trophoblastic Disease; Diagnosis and

Management of



CPWC131 Bladder Care; Intrapartum & Post Partum


Services : Labour

CPWC136 Meconium Stained Liquor Antenatally & in Labour;

Management of


Services : Labour

CPWC061 Birthing Pool During Labour & Delivery; Use of the



CPWC051 Anti-D Prophylaxis in Pregnancy & Following Birth


Services : Labour

CPWC040 Fetal Monitoring in Labour including Fetal Blood

Sampling



Anaesthesia

CPWC106 Thromboprophylaxis in Obstetrics



CPWC074 Antenatal Care



Anaesthesia

CPWC085 Caesarean Section

Women & Children Clinical Documents : Neonatal CPWC193 Neonatal Cranial Ultrasound; Screening



CPWC208 Aromatherapy use in Maternity Care



CPWC070 Early Gestational Sac (EGS) Pregnancy of

Unknown Location (PUL) and Suspected /

Confirmed Ectopic Pregnancy; Management of


Services : Transfer

DPWC004 Transfer & Handover of Care Between

Professionals in the Maternity Services



CPWC213 Midwives caring for close relatives and friends

during pregnancy and labour guideline


Gynaecology

CPWC143 Colposcopy Standards & Guidelines

Women & Children Clinical Documents : Neonatal CPDI026 Blood and Blood Components on the Neonatal

Unit; Use of


Services

CPWC216 Placental Investigations and disposal


Gynaecology

CPWC006 Miscarriage: Confirmed Non Viable Intrauterine

Pregnancy in the First Trimester

Women & Children Clinical Documents : Paediatrics CPWC023 CPAP (Paediatric)

Women & Children Clinical Documents : Neonatal CPWC014 Neonatal Injuries; Management of



CPWC215 Antenatal CTG's (Interpretation and Management

of)



Emergencies

CPWC091 Antepartum Haemorrhage not including Placenta

Praevia; Management of

Women & Children Clinical Documents : Neonatal CPWC148 Intravenous Fluids & Medicines in the Neonate;

Commencement, Maintenance, & Removal of



Care/Neonatal Care

CPWC089 Co-Sleeping & Parent and Infant Bed-Sharing


Services : Labour

CPWC029 Vaginal Birth After Caesarean Section



Care/Neonatal Care

CPWC138 Newborn Infant; Immediate Routine Care of the

Term


Gynaecology

CPWC009 Nausea & Vomiting in Pregnancy up to 16 weeks

Gestation; Management of


Services : Birth Centre

CPWC128 Birth Centre Operational Guidelines: Pennine Acute

Trust



Care/Neonatal Care

CPWC065 Candida Albicans (Thrush) in the Breastfeeding

Mother & her Baby; Management of

Women & Children Clinical Documents : Medicine

Management

EDT016 Antibiotic (Paediatrics)


Services : Fetal Loss/Death

EXWC002 Part 1 Pregnancy Loss: North West Second Trimester

Pregnancy Loss ICP



EXWC002 Part 2 Pregnancy Loss: North West Second Trimester

Pregnancy Loss Guideline


Services : Labour

CPWC217 Intrapartum acupuncture provision by midwives



Care/Neonatal Care

CPWC108 Postnatal Care

Women & Children Clinical Documents : Neonatal CPWC198 Neonate; Exchange Transfusion in


Services : Labour

CPWC052 Labour & Birth



EXWC001 Part 2 Stillbirth; (Greater Manchester, Lancashire & South

Cumbria Strategic Clinical Networks)



EXWC001 Part 1 Stillbirth: Intrauterine Fetal Death > or = 24+0

weeks gestation (Greater Manchester, Lancashire

& South Cumbria Strategic Clinical Networks)


Services : Labour

CPWC043 Perineal Suturing Including 3rd & 4th Degree Tears

Women & Children Clinical Documents : Paediatrics CPWC079 Diabetes fasting or Surgery (Paediatric)



Conditions

CPWC161 Hypertensive Disorders in Antenatal Day Unit;

Management of



Emergencies

CPWC134 Breech Presentation including External Cephalic

Version


Services : Labour

CPWC049 Assisted Vaginal Delivery



CPWC214 Large for gestational age, Guideline for



Conditions

CPWC060 Cholestasis; Management of Obstetric


Services : Labour

CPWC063 Multiple Pregnancy & Birth; Management of


Services : Labour

CPWC071 Group B Streptococcus in Pregnancy & Labour;

Management of



Care/Neonatal Care

CPWC038 Weighing Babies whilst in Midwifery Care



Emergencies

CPWC090 Severe Pre-Eclampsia and Eclampsia; In-patient

Management of



CPWC218 Maternity Triage (referral to and management of)

Women & Children Clinical Documents : Paediatrics CPWC152 NG Tube (Paediatric & Neonatal)


Services : Labour

CPWC084 Preterm Labour & Extremely Preterm Labour &

Birth, including preterm Prelabour rupture of

membranes; Management of

Women & Children Clinical Documents : Paediatrics CPWC035 MANCHEWS (Paediatric)



CPWC212 Midwife Ultrasonography

Women & Children Clinical Documents : Paediatrics CPWC210 Paediatric Pain Management

Workforce & OD Non Clinical Documents :


OD

EDH016 Training Events; Learning & Organisational

Development Policy for Application & Attendance at


Finance

EDF008 Travel Expenses (AFC Staff Only); Payment of



EDE039 Mobile Phone Procurement including

Telecommunication Devices



EDE038 Mobile Phone



Resources

EDH004 Equal Opportunities in Employment



Resources

EDH039 Disclosure & Barring Service (previously CRB)



Resources

MCH HR018 Toil/Flexitime (Community Services North)



Resources

MCH HR017 Term Time & Annualised Hours (Community

Services North)



Resources

MCH HR011 Job Share (Community Services North)



Resources

MCH HR008 Equal Opportunities (Community Services North)



Resources

EDH066 Transfer of Undertakings (Protection of

Employment)



Resources

EDH071 Agency Worker Regulations - Guidance for

Managers



Resources

EDH056 Leavers Process: Managers Guidance



Resources

MCH NO REF Professional Registration (Community Services

North)



Resources

EDH040 Recruitment; International



Resources

EDH018 Partnership Working Agreement including Trade

Union Recognition, Time off for Trade Union Duties

& Activities and Facilities for Trade Union

Representatives


Workforce & OD : Occupational

Health

PGD174 PGD174 Best Practice for the administration and

supply of Truvada and Raltegravir tablets for HIV

post exposure prophylaxis



Health

CPDI071 Tuberculosis; Staff



OD

EDH054 Learning & Assessment in Practice; Standards to

Support



OD

EDH069 Learning & Organisational Development Quality

Assurance



Resources

EDH077 European Working Time Directive compliance;

reporting & monitoring on



Health

EDC001 Hepatitis B and C in the Health Care Worker



Resources

EDH065 Inclement Weather/Major disruption to travel links



Resources

EDH012 Absence - Career Grade Medical & Dental Staff



Resources

EDH042 Temporary Staff (Including Locum

Doctors/Consultants); Use of

Workforce & OD Clinical Documents :


EDM009 Private Care Whilst Receiving NHS Treatment;

Patients who want to pay for Additional



OD

EDH024 Induction and Mandatory Training



Health

PGD168 PGD168 Administration of BCG vaccine



Health

PGD172 PGD172 Administration of Varicella Zoster (VZ)

vaccine



Health

PGD179 PGD179 Administration of Hepatitis B vaccine



Health

PGD177 PGD177 Administration of Measles/Mumps &

Rubella (MMR) Vaccine



Health

PGD176 PGD176 Supply of Mupirocin Nasal Ointment



Health

PGD175 PGD175 Supply of Naseptin Nasal Ointment



Health

PGD173 PGD173 Best Practice Guide for administration of

Tuberculin Purified Protein Derivative (PPD) BP 2

TU per 0.1ml



Health

PGD170 PGD170 Supply of Chlorhexidine Gluconate

Mouthwash



Health

PGD167 PGD167 Administration of Diphtheria/Tetanus/Polio

vaccine



Health

PGD166 PGD166 Administration of Hepatitis A Vaccine

Workforce & OD Clinical Documents : Patient

Group Directions : Occupational

Health

PGD297 PGD297 Administration of Typhoid Vaccine –

Typhim Vi (POM)



Health

PGD292 PGD292 Administration of Bexero Meningococcal

Group B vaccine (POM)



Health

PGD248 PGD248 Supply of Chlorhexidine (Hibiscrub) Skin

Cleanser



Health

PGD245 PGD245 for the Administration of Influenza Vaccine



Health

CPDI018 Needlesticks, Sharps, Accidental Inoculation

Workforce & OD Non Clinical Documents : IM&T

Documents

EDI016 Information and Data Quality Assurance Policy


Documents

EDI007 Barcodes – Deployment and Use


Documents

EDI006 Barcoding


Documents

EDI018 Information Management & Technology 2015 -

2018

Workforce & OD Clinical Documents :

Resuscitation

EDC039 Unified Do Not Attempt Cardiopulmonary

Resuscitation (DNACPR) Adult



Resources

EDH049 Job Banding



Resources

EDH009 JLNC Constitution



Resources

EDI008 Registrations Authority Operating Procedures


Documents

EDI017 Information and Data Quality Assurance Strategy



OD

CPDI082 Intravenous Medicines; Training & Assessment

Requirements for Staff Preparing & Administering



Resources

EDH061 Job Plan Mediation and Appeals Policy and

Procedure for Consultants, SAS Doctors and

Dentists


Workforce & OD : Equality &

Human Rights

EDH041 Equality & Human Rights Strategy



Health

EDH080 Workplace Physical Activity Guidelines



Resources

EDH028 Special Leave


Documents

EDI001 Information Governance



Health

EDH034 Staff Immunisation and Vaccination



Resources

EDH010 Handling Concerns about Medical Staff Policy (Ill

Health, Capability, Conduct and Remediation)



OD

EDH032 Bariatric



OD

EDH021 Moving and Handling



Resources

EDH003 Grievance Policy & procedure



Resources

EDH002 Conduct and Disciplinary



Resources

EDH055 Conduct & Disciplinary Procedure Guideline



Resources

EDH073 Revalidation & Appraisal for Non-Trainee Medical

Staff



OD

EDH067 Appraisal; Values based appraisal & personal

development review



Resources

EDH078 Shared Parental Leave Policy



Resources

EDH005 Dignity at Work



EDG001 Police Disclosure of Information & Clinical Samples



EDH013 Whistleblowing



Resources

EDH050 Flexible Working/Work Life Balance



Resources

EDH047 Retirement



Resources

EDH030 Holiday Leave



Resources

EDH014 Maternity, Paternity & Adoption Leave

(Incorporating the Administrative Guidelines & the

Breast Feeding at Work Guidelines)



Resources

EDH007 Organisational Change; (incorporating

Redeployment Guidance, Protection of Pay &

Conditions of Service & Redundancy)



Resources

EDH052 Alcohol, Drug & Other Substance Misuse at Work



Resources

EDH063 Capability Procedure



Resources

EDH031 Capability



Resources

EDH027 Attendance Management



Resources

EDH083 Removal and relocation



Human Rights

EDH081 Accessible Information & Communication for

Service Users



Resources

EDH084 Remote & Homeworking



Human Rights

EDH062 Equality Impact Assessment



Resources

NCAHR001(18) Employment Checks (Management of)