Policies A to Z

All of our policies and procedures at DBTH

Please note: To search for a policy, press the ‘CTRL’ key and ‘F’ together. Then type in the name of the policy or keyword to find the relevant document.

We are working on creating a fully searchable policy database, please bear with us while we work on this. In the meantime, please press ‘CTRL’ and ‘F’ together.

Health and Safety

Employment and Work Life Balance

Information, Communication and Technology

Finance

Risk Management

Facilities

Procurement

  • CORP/PROC 2 v.6 – Supplier and Manufacturer Representative Policy
  • CORP/PROC 3 v.6 – Selection and Procurement of Medical and Surgical Products Policy
  • CORP/PROC 4 v.6 – Medical Devices Management Policy
  • CORP/PROC 6 v.3 – Condemnation and Disposal of Trust Assets
  • CORP/PROC 8 v.1 – (Procurement Policy) Policy and Guidance for the Procurement of Goods, Services and Works

Records Management

Communication and General

Infection, Prevention and Control

  • PAT/IC 2 v.6 – Asplenic Patients Policy – Management of Patients with Absent or Dysfunctional Spleen
  • PAT/IC 4 v.5 – Variant Creutzfeldt-Jakob Disease (vCJD) and Transmissible Spongiform Encephalopathy Agents (TSE): Minimising the Risks of Transmission
  • PAT/IC 5 v.7  – Hand Hygiene
  • PAT/IC 6 v.9 – MRSA Screening and Management of Patients with MRSA
  • PAT/IC 7 v.7 – Scabies – Guidance on Management
  • PAT/IC 8 v.8 – Sharps Policy – Safe Use and Disposal
  • PAT/IC 10 v.9 – Management of Respiratory Type Viruses
  • PAT/IC 11 v.6 – Pathology Specimens – Collection and Handling of Pathology Specimens
  • PAT/IC 12 v.6 – Meningococcal Infections – Management of Cases and Contacts
  • PAT/IC 14 v.7 – Management  of Sharps Injuries and Blood and Body Fluid Exposure Incidents
  • PAT/IC 15 v.6 – Chickenpox/Shingles Management Policy
  • PAT/IC 16 v.8 – Isolation Policy
  • PAT/IC 17 v.6 – Management of Patients with Glycopeptide Resistant Enterococci
  • PAT/IC 18 v.6 – Spillage of Blood and Other Body Fluids
  • PAT/IC 19 v.7 – Standard Infection Prevention and Control Precautions Policy
  • PAT/IC 20 v.7 – Management and Control of Incident/Outbreak of Infection
  • PAT/IC 21 v.6– Laundry Policy – Bagging Procedure for Linen
  • PAT/IC 22 v.4 – Kitchen Hygiene and Refrigerator Monitoring Policy for Wards and Clinical Areas
  • PAT/IC 23 v.6 – Tuberculosis – Care of the Patient with smear negative/positive Pulmonary Tuberculosis in Hospital
  • PAT/IC 24 v.7 – Cleaning and Disinfection of Ward-based Equipment
  • PAT/IC 26 v.5 Clostridioides difficile Infection (CDI) Policy
  • PAT/IC 27 v.5 – Gastroenteritis Minor Outbreak Policy (Diarrhoea and Vomiting)
  • PAT/IC 28 v.5 – Multi-Resistant Gram-Negative Bacteria Prevention and Control Policy
  • PAT/IC 31 v.4 – Surveillance Policy
  • PAT/IC 32 v.5 – Hazard Group 4 Viral Haemorrhagic Fevers
  • PAT/IC 33 v.1 – Animals on Trust Premises (Including Pets As Therapy)
  • To access the Trust Antibiotic Formulary please click here

Treatments and investigations

  • PAT/T 1 v.5 – Trust Policy for the Referral of Imaging Examinations by Qualified Non-Medical Healthcare Professionals
  • PAT/T 2 v.6 – Blood Transfusion Policy
  • PAT/T 3 v.3 – Pressure Ulcer Policy – Tissue Viability Top Ten
  • PAT/T 7 v.3 – Wound Management Policy
  • PAT/T 8 v.7 – Specimen and Request Form Labelling Policy
  • PAT/T 12 v.6 – Leg Ulcer Management Policy, including bandaging
  • PAT/T 16 v.5 – Percutaneous Endoscopic Gastrostomy (PEG)/Enteral Tube Care Policy
  • PAT/T 17 v.5 – Nasogastric Tube Management and Care
  • PAT/T 20 v.5– Tracheostomy Adult Care Policy (Guidelines for Best Practice)
  • PAT/T 21 v.3 – Drug Misuse Management in the Acute Hospital Setting – Guidelines
  • PAT/T 25 v.4 – Alcohol Issues in the Acute General Hospital Setting (Guidelines and Management)
  • PAT/T 29 v.2 – Chest Drains – Guidelines for the Insertion and Management in Adults
  • PAT/T 33 v.4 – Physiological Observations and prevention of deterioration in the acutely ill adult
  • PAT/T 37 v.5 – Non Obstetric Emergency Care for Pregnant and Postpartum Women
  • PAT/T 38 v.4 – Failsafe Alert for Radiological Findings (Communication Protocol)
  • PAT/T 43 v.2 – Nutrition and Hydration Policy for Adults in Hospital
  • PAT/T 44 v.3 – Venous Thromboembolism (VTE) Prevention and Treatment of VTE in Patients Admitted to Hospital  Note: PAT/T 46 v.2 combined within this document
  • PAT/T 47 v.4 – Adjustable Gastric Band Management Practice Guidelines
  • PAT/T 48 v.3 – Prevention of Contrast Induced Nephropathy (CIN) Guidelines in Adults
  • PAT/T 49 v.3 – In Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus
  • PAT/T 55 v.3 – Deactivation of Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronisation Therapy (CRT) Devices Procedure (adults and young people aged 16 years and over)
  • PAT/T 56 v.1 – Paracentesis for Malignant Ascites Procedure
  • PAT/T 57 v.3 – Diabetes Care at the End of Life
  • PAT/T 60 v.2 –  Care after Death and Bereavement Policy:  Operational policy for staff to follow in the event of a patient death
  • PAT/T 61 v.3 – Telephoned Pathology Results
  • PAT/T 62 v.2 – Rapid Response to Unexpected Child Deaths and Child Deaths Function Standard Operating Procedure
  • PAT/T 64 v.2 [Amended 17 Dec 2018] – Female Genital Mutilation: Identification, Reporting and Management
  • PAT/T 65 v.3 – End of Life:  Guidelines for the Management of Patients in last hours/days of life
  • PAT/T 66 v.2 – Parenteral Nutrition Policy
  • PAT/T 68 v.1 – Faecal Microbiota Transplantation Policy – Use of FMT in the management of Clostridium difficile infection
  • PAT/T 69 v.2 – Nasal Retention Device Policy
  • PAT/T 70 v.1 – Pre-operative Management of Diabetes in Adults – (this policy is withdrawn until further review)
  • PAT/T 71 v.1 – High Output Stoma Policy
  • PAT/T 73 v.1 – Vascular Access Device Policy – (combines PAT/T 23 v.5 – Central Venous Access Devices (CVADs) Care and Management and PAT/T 45 v.3 – Peripheral Venous Cannula (PVC) Management Guidelines)

Emergency Care

Medicines Management

  • PAT/MM 1 A v.10   – Safe and Secure Handling of MEDICINES POLICY Part A
  • PAT/MM 1 B v.7 – Safe and Secure Handling of MEDICINES POLICY – Part B – Controlled Drugs
  • PAT/MM 4 v.4 – Unlicensed Medicines Policy
  • PAT/MM 5 v.5 – Injectable Medicines Policy
  • PAT/MM 6 v.3 – Paediatric Acute Pain Policy – Assessment and management of pain in children and young people
  • PAT/MM 7 v.2 – Patient Controlled Analgesia (PCA)
  • PAT/MM 9 v.4 – Self-Administration of Medicines Policy
  • PAT/MM 11 v.2 – Non-Medical Prescribing Policy

Patient Safety

Patient Administration

  • PAT/PA 1 v 9 (amended June 2019) – Referral to Hospital Access Policy
  • PAT/PA 2 v.7 – Consent to Examination or Treatment Policy
  • PAT/PA 3 v.5 – Discharge of Patients from Hospital Policy
  • PAT/PA 5 v.3 – Communicating Delays in Trust Outpatient Areas
  • PAT/PA 6 v.3 – Arrangements for the Provision of Care to Individuals who are Violent or Abusive (Age 18 or Over)
  • PAT/PA 8 v.4 – Adult Organ Donation Policy – Departments of Critical Care
  • PAT/PA 9 v.6 – Children and Young People – Guidance for Care in Hospital
  • PAT/PA 10 v.3 – Concordat for the Care of Prisoners Admitted to DBTH
  • PAT/PA 12 v.4 – Patient Property and Valuables
  • PAT/PA 14 v.4 – Photography and Video Policy: to Govern Clinical and Non-clinical Recordings
  • PAT/PA 15 v.6 – Cancer Services – ‘Key Worker’ Policy
  • PAT/PA 19 v.6 – Mental Capacity Act 2005 Policy and Guidance, including Deprivation of Liberty Safeguards (DoLS)
  • PAT/PA 24 v.4 – Transfer of Patients and their Records
  • PAT/PA 27 v.2 – Advance Decision to Refuse Treatment (ADRT) Policy
  • PAT/PA 28 v.2 – Privacy and Dignity Policy
  • PAT/PA 31 v.4 – Handover Policy
  • PAT/PA 33 v.4 – Clinical Site Management Team Operational Policy
  • PAT/PA 34 v.2 – Interpretation and Translation Services Policy
  • PAT/PA 37 v.1 – Bassetlaw@ Operational Policy

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