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Worcestershire Key Documents
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Acute Kidney Injury

Access and delivery of interpreting services 

Patient accommodation pathway

Acute pain control for adult patients

Acute coronary syndrome (ACS) guideline (including the management of ST elevation and no ST elevation

Delivering same sex accomodation 

Adult patients going home with an altered airway - Guidelines for the care and training required for carer/patient prior to discharge from hospital

Admission to MIU following 999 call

Advance decisions (Living wills)

Policy for the use of NHS professionals temporary and external agency staff/Nursing and midwifery

Administration of antibiotics for surgical prophylaxisOESO

Managing children with airway obstruction/inhaled foreign body - protocol

Allergy skin prick testing

Recognition and treatment of alcohol abuse in acute hospital settings

Guidelines on the use of 'extended interval' aminoglycoside (gentamicin and tobramycin) therapy

The amber care bundle

Management of anaemia associated with chronic kidney disease 

Care pathway for patient controlled analgesia KTC

Antibiotic prescribing in the paediatric directorate

Worcestershire Secondary Care adult antibiotic Prescribing policy

Dental damage during anaesthesia

Local Anaesthetic block policy

Responsibility of the consultant anaesthetist on call 

Nurse led indocyanine green angiography

Guideline for the management of ankle injuries in the minor injury unit

Animal derived medical products - trust guideline for patients who do not wish to receive medicines containing animal extracts

Applications of mittens as a physical restraint for patients requiring naso-gastric feeding

Medical staff appraisal and revalidation policy

Assessment of ward patients (adults) who have fallen and sustained a head injury

Asceptic technique policy

Assessing Mental Capacity and complying with the Mental Capacity Act 2005 

Management of Asbestos

Assessment of ambulatory oxygen therapy guideline

Care pathway for patient controlled analgesia KTC

Cardiac rehabilitation policy

Care of pin site guideline

Car parking policy

Carers policy

Care of the skin

Care of skin in relation to Tissue Viability

Nurse led DC cardioversion guideline

Cancer patients who do not wish to pay privately for chemotherapy drugs not covered by the NHS

Worcester Acute Hospitals NHS local pathway for referral of all patients with a metastatic cancer of unknown origin/cancer of unknown primary

Guidelines for Holistic needs assessment of the patient with cancer

Carer's diary

Cellulitis Flowchart

Central venous access devices (CVAD) guideline for insertion and management

Chaperone policy

Nurse led removal of chest drain in adult patients  

Chest drain flushing in adult patients 

Guideline for the prevention and management of chemotherapy induced nausea and vomiting CINV in the patient being treated for malignent disease

Policy and procedures for adult intrathecal cytotoxic chemotherapy

Managing children with airway obstruction/inhaled foreign body - protocol

Chronic obstructive pulmonary disease

Worcestershire Chronic Kidney Disease (CKD) 

Guideline for the treatment of chronic heart failure caused by left ventricular systolic dysfunction

Insertion of a chest drain

Safe prescribing, handling and administration of chemotherapy drugs 

Guideline for the utilisation of scalp cooling devices for patients at risk of chemotherapy induced alopecia

Claims handling and policy and procedure

Cleaning policy

Cleaning, decontamination and validation of flexible endoscopes

Clinical Coding policy and procedure

Clinical record keeping policy

Clinical Diagnostic tests

Clinical Audit Policy

Clostridium Difficile infection (CDI) and prevention and spread

Guideline and Nursing care plan for post operative cell salvage Blood Transfusion in patients undergoing Total knee and Hip Arthroplasty using the Stryker Auto Transfusion System

Guideline for the use of continuous blood glucose monitoring system (CGMS Medtronic)

Nurse led 2 week wait clinic for suspected colorectal cancer patients

Code of conduct for employees in respect of confidentiality

Promotion of continence and management of incontinence in adults

Near to patient clinical equipment cleanliness and decontamination in the dialysis unit

Investigating incidents, complaints and claims policy  

Investigating incidents complaints and claims policy appendix 9 Divisional initial case review

Compliants and PALS policy and procedure

Guideline for conscious sedation practice in adult endoscopy

Concecssionary car parking tickets policy

Control of substances hazardous to health

Control of contracters policy

Consultant Medical Staff covering resident junior doctor shifts

Conduct, capability, Ill health and appeals policies and procedures for Medical and Dental staff

Consultants clinical excellence Awards policy

Confirmation of expected death in adults for registered nurses

Contrast echocardiography utilising nurse led introduction of 0.9% Sodium Chloride for diagnosis of PFO

Management of constipation in adults

Consent to examination/or treatment

Countywide Emergency surgery triage clinic  

Corporate records management policy and procedure 

Corporate records management policy and procedure appendix 12 records and retention disposal

Policy for managing the requirements of the Health and Social care act 2008 (Regulated activities) Regulations 2010 and the Care Quality Commission (CQC) (Registration) Regulations 2009

Critical Care Key Documents 

Critically ill children presenting to MIU

Creutzfeldt-jakob disease (CJD) and variant CJD (vCJD) - minimising the risk of transmission

Policy for the handling of spillage of cytotoxic drugs

Occupational Therapy for Profound Brain Injury Resulting in Prolonged Disorders of Consciousness (PDOC)

Identification of Orthostatic Hypertension

Intergrated care pathway for adult patient care after death

Managing intellectual property

Policy and procedure for the administration of injectable medicines

Policy and procedures for independent and supplementary prescribing

Care pathway for the management of initiation of insulin

Guideline for the use of intranasal Diamorphine

Inflation of expandable breast implants

Use and monitoring of intravenous unfractionated heparin (UFH) in adults

Policy and procedures for adult intrathecal cytotoxic chemotherapy

Promotion of continence and management of incontinence in adults

Induction policy

Ward closure due to infection procedure

Infection control and bed management guideline

Notifying known or suspected infection

Infection prevention and control protocol for seasonal influenza

Infection due to parasites

Infection control policy

Insertion and management of peripheral vascular devices

Innoculation incident protocol

Prevention of innoculation incidents policy

Information communication technology policy 

Worcestershire information sharing protocol

Information governance policy

Information governance strategy

Therapy intervention for median nerve lesions and neurapraxia

Information risk policy

Investigating incidents, complaints and claims policy

Investigating incidents complaints and claims policy appendix 9 Divisional initial case review

Incident reporting policy

Integrated Identity management (IIM) process policy 

Policy to identify all patients 

Access and delivery of interpreting services  

Failed intubation on obstetrics

Guideline for the management of Immune related Adverse Reactions following Immunotherapy Treatment

Inflammatory bowel disease referral/care pathway

Isolation policy

Occupational therapy assessment and treatment guideline for patients with traumatic spinal fractures

Occupational therapy assessment and treatment for patients with upper limb fractures

Operating on ENT patients - Children and young persons - Guideline 

Operational Guidelines for Occupational Therapy assessment and treatment of adults with traumatic head injury  

Guideline for the management of Adult opiate dependent patients in the acute hospital setting

Oral anticoagulants

Outpatients and inpatients waiting times and patient access policy

Oral care guidelines

Out of hours emergency feeding starter regime (including risk reduction for re-feeding syndrome)

Operational escalation policy for monitoring cancer 14/31/62 day targets

Operational guideline for Cancer services

Obstetrics Key documents

Optimising care at end of life  

Ongoing care of a renal dialysis catheter

Oppurtunist Mycobacteria

Being open and candid following a patient safety incident or complaint policy

Pre and post operative occupational therapy assessment and treatment guideline for patients with total HIP replacement and HIP resurfacing

Joint Ophthalmology and Microbiology Microbial Keratitis guideline

Occupational therapy assessment and treatment guideline for patients with lower limb fractures

Occupational Therapy for Profound Brain Injury Resulting in Prolonged Disorders of Consciousness (PDOC)

Management of Organisational Change policy

Guideline for the prescribing, monitoring and administration of Oxygen in Adults

Paediatric Key Document page

Paediatric perioperative and recovery unit guidelines

Paediatric resuscitation, stabilisation, retreival and transfer

Patient slips, trips and falls policy

Patient Transfer policy

Patient accommodation pathway

Acute pain control for adult patients

Safekeeping of patients property and valuables policy

N-Acetylcysteine Dosing guidelines for paracetamol overdosing in adults

Parenteral nutrition guidelines

Compliants and PALS policy and procedure

Infection due to parasites

Pest control policy

Performance management policy

Personal development review (PDR) policy

- Appendix 1 PDR 1

-Appendix 2 PDR 2

-Appendix 3 PDR 3

Percutaneous endoscopic gastrostomy guideline - Adults

Physiotherapy  

Care of pin site guideline

Pleural effusion

Guideline for the procedure of pleurodesis with talc slurry

Pneumatic tube policy

Management of pneumonia acquired in the community

Post percutaneous coronary intervention (PCI) Clinic Guideline

Point of care testing policy

Therapy intervention post fasciectomy for the correct of dupuytren's disease 

Policy and procedures for independent and supplementary prescribing

Guideline for pre-operative preparation of elderly hip fracture

Privacy and dignity policy

Procurement Policy

Private patients administration policy

Safe operation and working on pressure systems (Excludes MPGS)

Prevention of innoculation incidents policy

Worcestershire Secondary Care adult antibiotic Prescribing policy

Safe prescribing, handling and administration of chemotherapy drugs 

Procedure for managing incremental pay progression  

Protocol for the management of extended spectrum beta-lactamase (ESBL) producing organisms, and also vancomycin (glycopeptide) resistant enterococci (VRE) protocol for their management and prevention of spread

Pressure ulcer management and prevention  

Promoting rest and sleep at night

Preceptorship policy for Nurses, Midwives, Allied health professionals and health care scientists

Promotion of continence and management of incontinence in adults

Prenatal diagnosis of vasa previa

Pre and post operative occupational therapy regime for total shoulder replacement, shoulder resurfacing and Hemi shoulder replacement

Prevention and control of Blood borne virus (BBV) infections in the Haemodialysis unit  

Guideline for the prescribing, monitoring and administration of Oxygen in Adults

Policy and procedures for independent and supplementary prescribing

Pre-Op Assessment Key Document page

Pseudonymisation policy 

Suspected pulmonary embolism  

Radiotherapy Skin reactions

Radiology Key Documents Page

Therapy intervention for radial nerve lesions

Recognition and treatment of alcohol abuse in acute hospital settings

Releasing removed body parts (human tissue) to the patient

Registration with Professional regulatory bodies policy

Retirement gift policy 

Responsibility of the consultant anaesthetist on call 

Renal education and support for patients in LCC guideline (nursing)  

Renal clinic:CKD and low clearance guidelines worcester

Care pathway renal biopsy ultrasound

Research governance policy

Resuscitation Key Documents Page 

Reducing Venous Thromboembolism (VTE) Risk in Adult Patients

Paediatric resuscitation, stabilisation, retreival and transfer

Applications of mittens as a physical restraint for patients requiring naso-gastric feeding

Clinical record keeping policy

Corporate records management policy and procedure 

Corporate records management policy and procedure appendix 12 records and retention disposal

Medical staff appraisal and revalidation policy

Restrictive interventions for adult patients

Recruitment and selection policy

- Appendix 1 - Recruitment and selection procedure

-Appendix 2 - Recruitment and selection guidance

-Appendix 3 - Vacancy review checklist

-Appendix 4 - Guidance on creating a job description and template job description

-Appendix 5 - Guidance on person specifications and template person specification/interview assessment form

-Appendix 6 - Advertisement request template

-Appendix 7 - Invitation to interview template

-Appendix 8 - Letter requesting a reference

-Appendix 8a - Excutive director reference

-Appendix 9 - Guidance on interview arrangements and techniques

-Appendix 10 - Conditional offer letter

-Appendix 11 - Pre employment checks

-Appendix 12 - Unconditional offer letter

-Appendix 13 - New starter checklist

-Appendix 13a - New starter checklist director and equivalent

-Appendix 14 - Departmental induction checklist


-Appendix 15 - Right to work in the UK checklist

-Appendix 16 - DBS decision tree

-Appendix 17 - Guidance to assist managers in the disclosure and barring process

-Appendix 18 - Trust disclosure and barring service declaration

-Appendix 19 - Information for applicants

-Appendix 20 - Workplace health questionnaire

-Appendix 21 - Night workers health assessement form

-Appendix 22 -  Fit and proper persons

-Appendix 23 - Fit and proper person declaration

Guideline for the management of patients with regular narrow complex tachyarrythmia

Guideline for the management of re-feeding syndrome

Therapy intervention with repair extensor-tendon zone V-VII 

Risk assessment procedure

Risk Management strategy 

Routine 20 week scan

Management of Natural and rubber latex allergy

Safeguarding Key Documents page 

Safe haven policy

Safekeeping of patients property and valuables policy

Safe operation and working on pressure systems (Excludes MPGS)

Safe prescribing, handling and administration of chemotherapy drugs 

Delivering same sex accomodation

Managing Safety alerts policy

Routine 20 week scan

Guideline for the utilisation of scalp cooling devices for patients at risk of chemotherapy induced alopecia

Security strategy

Security policy

Policy for the secondment to professional training for Nurses, Midwives and Allied health professionals

Guideline for conscious sedation practice in adult endoscopy  

Sensory stimulation guideline

Seasonal clinical management: Quick reference guide for staff - 2017/2018

Care of the skin

Care of skin in relation to Tissue Viability

Sepsis Key Documents Page

Guideline for the management of suspected Neurtopenic sepsis induced by cytotoxic therapy  

Hospital staff for the contol of Meningococcal Meningitis/Septicaemia and other forms

Severe acute respiratory syndrome (SARS) avian influenza and other severe viral respiratory infections

Management of severe Anaesthetic toxicity

Pre and post operative occupational therapy regime for total shoulder replacement, shoulder resurfacing and Hemi shoulder replacement

Management of adult patients with sickle cell disease

Sickness, absence, Health and wellbeing policy

Patient slips, trips and falls policy

Slips, trips and falls policy for staff, visitors and contractors 

Promoting rest and sleep at night

Smoke free environment policy

Policy for the handling of spillage of cytotoxic drugs

Speech and Language Therapy Functional Assessment of Voice and swallowing using Flexible Nasendoscopy - Policy

Guidelines for medicines management following bariatric surgery

Substance misuse policy

Supporting Staff involved in traumatic/stressful incidents, complaints and claims (all staff)

Supporting people with disabilities when accessing acute hospital services

Subject access request policy

Suspected pulmonary embolism  

Administration of antibiotics for surgical prophylaxisOESO

SUDIC - Investigation of sudden and unexpected deaths in children under 18 years

Standards of business conduct - Incorporating Hospitality, Gifts and sponsorship

Starting salaries procedure

Staff expenses policy

Study and Professional (external duties) leave policy for consultants and SAS medical and dental staff

Study leave policy for non-medical staff

Stress at work policy

Guidelines on the use of St Mark's solution in patients with a short bowel

Syringe pumps guideline

Appendix 1 - The Wessex Head Injury Matrix (WHIM)

Appendix 2 - Sensory Intervention response table

Page last updated: 02 October 2018