Screened out

Sept-Dec 2011:

The proposed relocation of dental services from Ballyowen Clinic to Beech Hall Health and Wellbeing Centre.

Catering services Belfast City Hospital

Cedar Lodge School

Proposed Relocation of Specialist Continence services from Ballyowen Clinic to the Beech Hall Health and Wellbeing Centre.

Proposed Relocation of Specialist Continence services from Whiterock Clinic to the Beech Hall Health and Wellbeing Centre.

Proposed Relocation of Specialist Continence services from Dundonald Clinic to the Arches Centre.

Policy for the Supply of discharge medications from wards when pharmacy is closed

Temporary closure of the Emergency Department (ED) at Belfast City Hospital (BCH) from 1st November, 2011.

Emergency Care Protocol – ‘Take Home’ Medication Supply from Emergency Department

Proposed Transfer of Intermediate Care from Grovetree House to Chestnut Grove.

Proposed Protocol to support Nurses within Emergency Care to Request specific X-rays.

Proposed relocation of footwear and orthotic services

Proposed Relocation of Specialist Continence services from Crumlin Clinic to the Carlisle Health and Wellbeing Centre.

Proposed relocation of Neurology Unit, Forster Green Hospital (FGH) to a new build at Musgrave Park Hospital (MPH).

The proposal for the relocation of dental services from Shankill Health Centre to Shankill Health and Well Being Centre.

Proposed BHSCT Spiritual Care Policy

Jan-March 2012:

Assistance Dogs Policy.

Corporate Security Policy

Belfast Trust Policy & Procedural Arrangements relating to Display Screen Equipment

Domestic Violence and Abuse in the Workplace Policy

Fire Safety Policy Statement & Procedural Arrangements

Restructuring of the Medical Illustration Service, development of Workforce Plan.

Safeguarding Children & Young People who are admitted to Adult Wards for care and Treatment.

Work Experience Placement Policy.

April-June 2012:

Being Open Policy

Centralise Audiology Services at the Royal Victoria Hospital but continue Services at the Mater and Belfast City Hospitals.

Standardisation of policy and procedures for crash call communications in the BHSCT

Relocation of Finaghy Continence Clinic to Beechall and Bradbury Health and Wellbeing Centres.

Fit Testing of Respiratory Protective Equipment (RPE) masks.

Management of Tuberculosis in BHSCT secondary care settings

Proposed relocation of the Unscheduled Care team from Windsor House to Woodstock Lodge.

Radiation Safety Policy

Rapid Tranquillisation Guideline for the immediate pharmacological management of violent and aggressive behaviour in adults and adolescent patients in the Belfast Health and Social Care Trust.

Relocation of Health visitors from Cherryvalley Health Centre to Dundonald Clinic

Proposal to relocate 2 Thoracic Outpatients clinics from Belfast City Hospital (BCH) to the Royal Victoria Hospital (RVH) site.

July-Sept 2012:

BHSCT IV Flushing Policy

Northern Ireland Cancer Trial Centre Team Guidelines

Relocation of Intensive Family Support Team (Eastside Project) from 46 Upper Newtownards Road to Dundonald Health and Wellbeing Centre.

Relocating the Regional Acute Eye Service from Level 8, Outpatients Centre, Royal Group of Hospitals to refurbished accommodation located off the Old Corridor, Royal Group of Hospitals

Oct-Dec 2012:

Potassium chloride concentrate and other strong potassium solution(s) policy

BHSCT Guidelines for Safe Warfarin Management

Belfast Trust Policy & Procedural Arrangements relating to the General Health & Safety Policy

Moving some Laboratory A&C staff from the standard working pattern

Review of Portering Service in Belfast City Hospital

Procedure for safeguarding child patients who attend Emergency Departments (ED)

Policy and guidance on the confidentiality and security of clinical information in the Belfast HSC Trust Occupational Health Service.

Policy on the access to data for organisations external to the Trust.

Linen Services Hybrid Proposal (SLA)

Guidelines for Securing Patient/Client Records following a Serious Adverse Incident within Social and Primary Care

Belfast Health and Social Care Trust Skin Care Policy

Policy for the Safeguarding, movement and transportation of Patient/Client/Staff/Trust Records, files and other media between facilities and when using postal/courier services.

Jan-March 2013:

Restructuring of Administrative Support in Adoption Services, Due To the Withdrawal of Joint Funding by South Eastern Trust.

Policy and procedures for the application of paediatric orthopaedic splintage for Developmental Dysplasia of the Hip (DDH)

Discharge from Acute Inpatient Settings Policy

Proposal to re-arrange how domiciliary care services are provided in various Sheltered Accommodation schemes throughout the south & east of the City

Referral to GPs for arrangement of shared care for patients on enoxaparin

Policy for the Use of Procedural Sedation in the Emergency Department

Northern Ireland Clinical Pharmacy Standards

NI Injectable Medicines Guide Policy

Proposed Interim changes to the Patient Flow/Hospital at Night Service on the BCH Site

Competency based respiratory protocols for healthcare support workers in The Royal Belfast Hospital for Sick Children (RBHSC)

April-June 2013:

Pneumatic Tube Operational Guidelines Policy for BHSCT

Relocation of the Consultant Diabetic Retinopathy Clinic from BCH to RVH site

Belfast Trust Adult Protection Policy and Procedures 2013

Belfast Trust Smoke Free Policy

Interfacing with the Pharmaceutical Industry

Policy for the Management of Medical Gas Pipelines and Medical Gas Cylinders

Northern Ireland New Entrants Service Operational Protocol (NINES)

Mediation Policy

Review of Pilot model of service delivery at Cedar Lodge School following recommendation of an equality screening of the proposal in 2011

July - September 2013:

Management of accidental dural puncture during epidural insertion.  SG 133/09

Intramuscular and subcutaneous Diamorphine for analgesia in labour - supply and administration of by midwives.  SG 1909/12

Protocol for referral for chest x-ray by Community Child Health Nurses

BHSCT Outpatient Treatment Advice Note Policy

Work Life Balance Flexible Working Policies and Arrangements

Special Leave Policy

A practical guide for the acute management of haemorrhage, emergency surgery and overdose in patients receiving Rivaroxaban and Apixaban

A practical guide for the acute management of haemorrhage, emergency surgery and overdose in patients receiving Dabigatran

Equal Opportunities Policy

Guidance for the Management of Patients who become ill whilst receiving Radiotherapy or within 6 weeks of Radiotherapy

Thromboprophylaxis during pregnancy, labour, delivery and in the puerperium.  SG 145/09

October - December 2013

Policy on the Data Protection Act 1998 and the Protection of Personal Information

Management of Attendance Protocol

BHSCT Records Retention & Disposal Schedule

Policy for the safe use of oral Methotrexate in secondary care

Waste Policy

Maternity extremely preterm babies and other screenings

January - March 2014

Change in the provision of Transport for voluntary clubs in the evenings and weekends from overtime to single time rates.

BHSCT Policy & Procedural arrangements relating to the control of noise at work.

BHSCT Policy & Procedural arrangements relating to control of vibration at work regulations (NI) (2005)

Skin Care Policy for patients receiving radiotherapy

Environmental & Sustainability (incl Energy) Policy

April - June 2014

A zero tolerance approach to the prevention and management of aggression and violence towards staff in the workplace.

E-mail retention and archive policy

Cluster of policies from Maternity services - new and updated policies for Specialist Hospitals and Women's Services

Registration and verification screening

Medical Devices Policy

Decontamination of reusable invasive medical devices

July - September 2014

Policy and Procedural arrangements for the prevention and management of slips, trips and falls.

Manual Handling Screening

The Reporting of Injuries, Diseases and Dangerous Occurences Regulations (NI) 1997 (RIDDOR) Procedural Arrangments

October - December 2014

The Control of Substances hazardous to Health (COSHH) Trust Policy and Procedural Arrangements

Corneal Service Move from M.I.H. to R.V.H.

Information Services Relocation from Grovetree Annex, Grosvenor Road to Knockbracken Site

Relocate Grove Podiatry service to either Carlisle or Shankill HWC

Diabetic Eye Clinic Move from RVH to MIH

Proposal to redirect funding into priority area within Mental Health as commissioned by the Local Commissioning Group and to terminate contract with Community/Voluntary Organisation for provision of Step 1 Drug and Alcohol Services and seek expressions of interest fro provision of Step 2 services in the Stepped Care Model

Induction Policy and Management Guidelines

Harassment Policy

BCH Direct

Policy for Processing Requests for Access to Patient/Client and Personal Records

Faxing Policy

Policy on the access to data for organisations external to the Trust

Procedure on the use of ligature cutters

Review of Spoons Restaurant

On-call Radiology Service 

January - March 2015

Policy & Procedural arrangements for the prevention and management of slips, trips and falls

Policy and Procedural arrangements relating to driving for work

Use of restrictive interventions for Adult & Children's Services

Integrated Elective Access Protocol  -  Guidance for Staff

Social Media Policy

BHSCT Lockdown/Control Access Framework

BHSCT Communication Strategy in the event of a significant or adverse incident affecting service provision

Belfast Trust Policy & Procedural arrangements relating to Display Screen Equipment

Plenum -  Victoria Pharmaceuticals - options for managing restricted space on ground floor

Belfast Health & Social Care Trust Manual Handling Policy and Procedural arrangements

BHSCT Nurse Facilitated Discharge (NFD)

Commission and Provision of Domiciliary Care Services

Review of Supporting People funded Warden services at Ardavon Sheltered Dwelling

Policy and Procedural arrangements for staff requiring Prescription Safety Spectacles

Reducing risks associated with over sampling of patients

April - June 2015

Proposal to re-arrange how domiciliary care services are provided in various Sheltered Accommodation schemes throughout the south & east of the City.

Medicines Procurement Efficiency Plan 2015 2016

To reduce the funding provided by Belfast Trust to the Shopmobility service at the Royal Hospitals by 3%

Trust Decommissioning Policy

Better adherence to regional and NICE guidance for analgesia

VDCP- aggregation of telecomms services

Review of Telecoms services provided to General Practitioners

Review of Communication Directorate’s Goods and Services Expenditure

Reduction in the use of Goods and Services and consumable products - Environmental Cleanliness

Review of Waste Services

Reduction in the use of Goods & Services and consumable products - corporate nursing

Protocol For The Recruitment And Employment Of Staff Under The Requirements Of The Safeguarding Vulnerable Groups (NI) Order (SVGO) 2007 And Vetting And Barring Scheme, As Amended By The Protection Of Freedoms Act 2012

Estates Rationalisation Project

Modernisation of ICT Workforce

Targeted reductions in discretionary spend, targeting printing & stationery, books & publications, training, learning & development, courses and conferences, records storage, waste- both general and clinical, and travel & subsistence

Re-tender exercise providing procurement savings for cochlear implants

July - September 2015:

First Aid at Work Policy

Cash savings from enhanced procurement processes and greater standardisation within the ordering of prosthesis

BHSCT Community Controlled Drugs Policy

Policy for the acceptance and use of kidneys for transplantation from locally deceased cardiac death donors

The control of substances hazardous to health (COSHH) Trust Policy & Procedural Arrangements

 October - December 2015:

Lithium Policy

Statutory and Mandatory Training Policy

Guidelines for Practitioners regarding the transition between Paediatric Community Epilepsy Services and Adult Epilepsy Services

Decontamination of Endoscopes, ToE probes and related equipment (ToE, trans-rectal, trans-vaginal and related equipment)

Policy on the data protection act 1998 and the protection of personal information (update of existing policy)

Recommendations for dental management of patients with LQTS

Macular - creating additional space at the Macular Service in order to improve and maximise the service further

School of Dentistry Referral Guidelines for:  Oral Surgery, Oral Medicine, Restorative Dentistry, Paediatric Dentistry, Special Care Dentistry, Orthodontics

Reorganisation of Nuclear Medicine Scanning Services currently provided from RVH Level 1 imaging centre and BCH Cancer Centre and Tower Block

January - March 2016:

EDRMS -  Electronic Data Records Management System (HR Records)

Policy for Sharing Learning

Strategic Plan for the Modernisation of Acute Outpatients Admin

Special Leave Policy

April - June 2016:

General Health & Safety Policy

July - September 2016:

Guidance for prescribing and monitoring of high dose antipsychotics in Mental Health Service

Serious Adverse Incident Procedure

Carers' Strategy (BHSCT) 2016-2019

Injectable Medicines Code

Risk Register Production and Management Guidance

October  -  December 2016:

Protocol for the administration of immunisations by registered healthcare professionals.

Policy on the accommodation of assistance dogs.

Infant Feeding Policy (Health Visiting) BHSCT.

2nd phase of the temporary reorganisation of Laboratory Out of Hours (OOH) service resulting in a one site OOH service in the RVH Kelvin Laboratory.

BHSCT Policy & Procedural arrangements relating to working at height.

January - March 2017:

Move of Condition Management Programme Base from Glendinning House to Knockbracken Healthcare Park

To change the dispensing of Etanercept from MPH Pharmacy to a Homecare Model

Relocation of the paediatric chronic pain clinic from Belfast City Hospital (BCH) to Beech Hall Health & Wellbeing Centre (HWBC)

Routine antenatal Anti-D prophylaxis and management for RhD negative women

Guidelines for empirical antibiotic prescribing in hospitalized adults

Controlled Drugs Policy  -  Inpatient Areas

ENP Protocol on requesting CT for scaphoid injuries Dec 2016 Draft 2

Insertion and maintenance of central venous catheters

Manual Hyperinflation of Adult Patients in Critical Care

Upgrade of current Office suite to 2016 and upgrade of Lync to Skype for Business

VCDP Wireless LAN Pilot RVH

Oral hygiene for infants and children in the Paediatric Intensive Care Unit (PICU)

Guideline on the use of Cuffed Endotracheal Tubes in Paediatric Intensive Care (PICU), Royal Belfast Hospital for Sick Children (RBHSC)

Fraud Policy Statement

Cardiac Monitoring  -  The Management of patients being monitored with Standalone Cardiac Monitors (SACM)

Discharge from Adult Critical Care Services

ICT Security Policy

Belfast Health & Social Care Trust Rapid Tranquilisation Guideline for the Pharmacological Management of Violent and Aggressive Behaviour in Adults, Children and Young People in Inpatient Units

ICT Policy

Management of the 3rd stage of labour following vaginal birth.  Guideline for Obstetricians and Midwives.

Abdominal Compartment Syndrome  -  Measurement Guidance

Guidelines for the use of High Flow Nasal Cannula in the Paediatric Intensive Care Unit, Royal Belfast Hospital for Sick Children

Management of adult patients receiving subcutaneous fluids within a community setting

Supply of medicines as prescription only medicines (POMs) exemptions  -  (Podiatry BHSCT)

Hand Hygiene

Radiation Safety Policy

The management of patients treated with Clozapine who smoke and are admitted to inpatient units following the implementation of the hospital smoke free policy

Operational Policy for Ambulatory Care Centre (ACC)

Guidelines for teaching staff and parents how to clean a breast pump

Guideline for bathing a baby in the Regional Neonatal Unit (RNU), Royal Jubilee Maternity Service (RJMS)

Nurse Led Botox Clinic

Policy and procedure for the intravenous (IV) administration of medication via a Central Venous Access Device (CVAD) using the McKinley T34 Ambulatory Syringe Pump in the care of children

April - June 2017:

Guidance for the regional mortality and morbidity process

Nurse led treatment and discharge at triage  -  Operational Protocol Emergency Service

Speculum examination by Midwives

BHSCT Loading Dose Policy

Guidelines for management of steroid induced hyperglycaemia for adult patients

Management of umbilical cord prolapse by medical/midwifery staff

Investigation and management of fetal hydrops

Guidelines re the maternal and neonatal transfer/referral from Mater midwifery led unit

Guidelines for the management of obesity in pregnancy, during labour and post natal

Guideline for the prevention and the management of 3rd and 4th degree perineal tears by medical and midwifery staff

Guideline for the management of shoulder dystocia

Administration of Remifentanil Patient Controlled Analgesia in labour

Foundation Year 1 Induction Handbook  -  how to prescribe medicines safely in BHSCT

Community Nursing Patient Specific Direction PSD to administer medication and medicine administration recording charts

Blood Transfusion  -  appropriate use of fresh frozen plasma and Cryoprecipitate

Immunoglobulin therapy in BHSCT

ED Emergency Care Protocol:  Requests for Information from PSNI Operational Protocol for Emergency Service only

RBHSC Paediatric Intensive Care Unit Difficult Airway Guideline

Looked After Children Carepathway Model

Emergency Oxygen Policy

Policy for the use of oral or enteral syringes in the safer measurement and administration of liquid medicines via oral and other enteral routes

Policy for the use of procedural sedation in Emergency Department

Wound Management  -  principles of caring for patients with an open wound

Temporary transfer of top-ups from RVH to BCH and Mater Pharmacy Departments to facilitate refurbishment of RVH Pharmacy

Out of Hours Chemotherapy Policy RBHSC

BCH Pharmacy Patient Services Team:  proposed change to organizational structure and job roles and consultation process

BHSCT Outpatient Treatment Advice Note Policy

Employers Procedures for external beam radiotherapy and sealed source brachytherapy

Urinary Tract Infection UTI in children  -  management and referral

Policy for the authorization of a Chemotherapy regimen not included in the accepted list of regimens

July to 8 November 2017 report:

Infection Control during construction, renovation and maintenance

Interfacing with the pharmaceutical industry

Policy on supporting breast feeding employees

Medical Devices Policy

Management of medical devices - procedures and guidelines

Policy for nurse to request radiological examination for testicular cancer patients

The management of patients at risk of self harm or actual self harm in acute settings (other than mental health)

Policy for implementing one to one staffing in nursing and residential care to promote management of behavioural disturbances in people with dementia / delirium.

Guidelines for the care of central venous access devices

Weighing of infants, children and young people in RBHSC

NI Alcohol use disorders care pathway - management in the acute hospital setting

Policy for the management of paediatric haematology / oncology patients using telephone triage service

Guideline for the management of home birth

BHSCT Policy relating to the prevention and management of Latex sensitisation (revision 3)

Policy for nurses to request radiological examination for patients attending the Joint Lung @ Belvoir Park Suite, Cancer Centre, BCH

High Flow Nasal Oxygen HFNO use and management for inpatients

Local guidance for facilitating visits by children to mental health & learning disability inpatient residential facilities

Policy for safe administration of intrathecal cytotoxic chemotherapy

Employers procedures for diagnostic and therapeutic uses of unsealed radioactive materials

Guidelines for cleansing hubs/needleless device of intravascular catheters and access devices of intravenous fluid bags

Guideline for the administration of Human Albumin to a baby in the regional neonatal unit.

Skin care policy for adult patients receiving radiotherapy

Setting a prescribed number of classes available for people affected by cancer (Yoga, Tai Chi, Pilates and classes to be changed to 12 classes at each level)

BHSCT Policy and procedural arrangements relating to the management of stress, health and wellbeing

 Policy for transferring a patient from PICU to MRI

BHSCT policy and procedural arrangements relating to control of vibration at work regulations NI (2005)

Procedure for the insertion and irrigation of a Replogle tube in a baby with an oesophageal atresia and or a transoesophageal fistula in RNU.

Protocol for nurse led fluorescein and indocyanine green angiography

Guideline for the management of an inverted uterus

Administration of intramuscular intravenous and oral Vitamin K to a neonate in RJMS

Preparation for the insertion of a urinary catheter in a neonate and the management of a neonate with a urinary catheter in RNU RJMS

Homecare Medicine Policy

Lymphoma Nurse led clinic protocols