clinical procedure manual-ref

UNITED CIIGMA Hospital

TABLE OF CONTENTS


TABLE OF CONTENTS

32C-1.1Acquisition of medicines

33C-2.1Inventory control

34C-3.1List of high risk medication

35C-5.1Medication administration

36C-7.1Management of adverse drug event

37C-10.1Handling of medical gases

38D-1.1Patients and familys rights and responsibilities

39D-1.2Citizens charter

40D-1.3Patients complaints and grievance handling

41D-2.1Obtaining consent

42D-2.1

List of situations where informed consent is required

43E-3.1Sterilization

44E-4.1Handling of biomedical waste

45F-2.1Patients satisfaction survey

46F-2.2Employee satisfaction survey

47F-2.3Medical Audit

48F-2.4Handling of Sentinel events

49H-1.1List of acts and laws applicable to the hospital

50I-4.1Employee grievance handling

51J-2.1Maintenance of medical records

Purpose: To carry out the registration of patients smoothly

Scope: OPD and Emergency registration

S. NO.STEPSRESPONSIBILITY

1. Registration is done for all patient requiring OPD and / or Emergency services. OPD and emergency in-charges shall be contacted for any clarification or in matter of conflictOPD and Emergency In-charges

For OPD

2. OPD registration shall be done on the basis of first come first servedRegistration staff

Ask following details from the patient / relative

1. Name

2. Age

3. Sex

4. Income

5. AddressRegistration staff

Check the referral slips if any for identifying the specialty. If referral slip is not available, patient shall be registered under General OPDRegistration staff

3. Enter the details in HMISRegistration staff

4. Take the print and handover to patientRegistration staff

5. Direct the patient towards concerned OPD consultation areaRegistration staff

For emergency

6. Emergency registration is done 24 hrs a day at AE WardHospital worker

7If patient is serious, he/she is directly sent to casualty bed or to doctor and one of the relative is asked to get the registration done. Registration should not delay emergency careCase writer, Medical Officer on duty, Staff nurse on duty

8For unidentified patients registration shall be done as unknown.Medical Officer, Staff nurse

9If on later date identity is confirmed the same shall be entered in registration detail through back entry.Staff Nurse on duty, Case writer

Purpose: To admit the patient requiring in-patient care


1. Admission can be through OPD or through Emergency. In case of conflict or further clarification, RESIDENT DOCTOR / Matron shall be contactedRESIDENT DOCTOR, Matron

2. Decision for admitting a patient is made by treating consultant. The reason for the admission is explained to the patient. Consultant

3. The admission along with the ward is recorded in OPD case paper / emergency case paperConsultant

4. All admissions are done from OPD case counter and from emergency registration counterCase writer

5. Enter all patient related details in admission module of HMISCase writer

6. Following details of patients attendant are entered in HMIS

Name

Address

In case of unidentified patients this step is not followedCase writer

7. 2 visitor passes are given to the patient / relative for free. If the patient / relative needs extra pass he / she is directed to the RESIDENT DOCTOR Office to collect the same Case writer

8. Patient is directed to the concerned ward. Need for stretcher / wheelchair / ward boy shall be identified and provided to the patient Case writer, OPD incharge

9. Staff nurse of the concerned ward shall check admission paper and case paper having doctors order for admission.Staff nurse on duty

10. A bed shall be arranged for the patient. If bed is not available Concerned doctor / Matron shall be contacted. Staff nurse on duty

11. Treatment as advised in inpatient case paper is startedStaff nurse

12. If patient is serious, he / she is assessed by Medical Officer before initiation of treatmentStaff nurse, Medical officer

13. Admission is recorded in admission bookStaff nurse

14. Diet form is filled and sent to kitchenStaff nurse

15. Specialist is sent information about the admission of patientStaff nurse

Purpose: To safely transfer the patient outside the facility


1. Patient shall be referred to GMKM College & Hospital, Salem if the treatment needs of patient doesnt match the scope of services provided by hospitalConsultant

2. Decision for transfer to other facility shall be taken by consultant and same shall be noted on OPD / IPD / Emergency case-paperDuty Doctor / Ward Medical Officer

3. In case of emergency, the concerned consultant is informed by the Medical Officer on dutyMedical officer on duty

4. Consultants advice is taken before transferring the patientMedical officer on duty

5. Oral and written consent of the patient is taken on the case paper. If the patient is not willing for transfer consent of patient relative is taken and continue the treatment.Medical officer on duty

6. In case of unidentified patients police is informed.Medical officer on duty

7. Treatment given and diagnosis is written on the case paperMedical officer on duty

8. Driver is informed to keep the ambulance readyStaff nurse on duty

9. Referral slip is given to the patient / relativeStaff nurse on duty

10. In case of unstable patient, a call is made in the concerned department at reference Hospital or any other hospital of patients choice handover the treatment slip to the ambulance driver / patient attender to be handed over to GMKMCH, Salem.Staff nurse

11. Emergency assistant accompanies the unstable patientEmergency assistant

12. This shall be cross-signed by RESIDENT DOCTOR for ambulance. If the patient is BPL same shall be recordedRESIDENT DOCTOR

13. If the patient is stable, he / she is transferred in a general ambulance with driver and cleanerMedical Officer / Consultant

14. If the patients condition is unstable, he should be stabilized in emergency before transferringMedical officer

15. If the patient is serious (as decided by doctor), an ambulance with critical care facility shall be arranged.Medical officer

16. Patient shall deposit the ambulance charge to the driver at the destination and collect the receipt for the same.Office

17. Duty medical officer shall arrange ambulance and driver to transfer the patientStaff Nurses

18. In case of conflict RESIDENT DOCTOR shall be contactedRESIDENT DOCTOR

A. Purpose: To follow a uniform protocol for clinical assessment and reassessment of patients requiring same type of healthcare in OPD, IPD and emergency

Read and follow the policy

The goal of the patient assessment function is to determine what kind of care is required to meet a patients initial needs as well as his or her needs as they change in response to care.

B. Initial assessment at General OPD:

Medical Officers or duty staff nurse initially screens each patient on following parameters.

History of illness

Height and weight if necessary

Temperature, Blood Pressure and Respiration

Allergies or any associated disease

Medical officer shall write the progress notes, investigation, prescribe treatment or refer to required specialty as per initial assessment. All these shall be documented and signed, named, dated and timed by medical officer

C. Assessment at specialty OPD

Each patient shall be assessed as per their disease process

Patients physical, psychological, social status and nutritional needs shall be assessed.

The assessment process for an infant, child, or adolescent patient shall be individualized.

Special needs of the patients who are receiving treatment for emotional or behavioral disorders have shall be addressed.

Special needs of patients who are possible victims of alleged or suspected abuse or neglect shall be addressed Based on assessments, treating physician shall document plan of care for the patient.

These records shall be signed, named, timed and dated by person who is entering in the record.

D. Assessment at Emergency

Medical officer on duty staff nurse authorized paramedical personnel shall assess all patients attending emergency. Same parameters as mentioned in General OPD should be assessed. In case of mass casualties triage shall be followed instead of assessment Specialist shall be called and required assessment made on discretion of casualty medical officer.E. Initial assessment of admitted patient

Initial assessment is done and documented in medical record of the patient for all admitted patient

The assessment shall be done by Medical Officer / duty staff nurse

The assessment shall include generic and individualized elements specific to patient age, diagnosis and condition.

Following elements shall be considered for assessment as per requirement. These are generic in nature

Reason for admission;

Physical status;

Cognitive status;

Psychosocial status;

Communication status;

Allergies;

Special precautions;

Pain;

Medication uses;

Substance abuse;

Domestic violence/neglect/abuse screening*

Communicable disease exposure;

Personal routines and self-care needs;

Nutritional screening;

Spiritual / cultural practices;

Advance Directives (adults 18 years);

Educational status;

Financial concerns;

Need for discharge planning;

Belongings inventory and disposition.

F. Additional assessment requirements for the infant, child, or adolescent patient

Emotional, cognitive, communication, educational, social, and daily activity needs;

Developmental age, length or height, and weight;

Head circumference (age: day 1 up to and including 24 months)

Effect of family or guardian on the patients condition;

Effect of the patients condition on the family or guardian;

Immunization status;

Weight (in kg);

Family or guardians expectations for involvement in the patients assessment, initial treatment, and continuing care;

Availability of appropriate child restraint device

G. Assessment of Obstetric and high-risk obstetric patients

(This includes pregnancies with Diabetes, HTN, Asthma, eclampsia, convulsions, multiple pregnancies, elder mother (>35 years), bad obstetric history (abortions etc)

The assessment shall include

Weight

Height

Routine lab investigations

BP

Hb

Blood group / RH Typing

Urine (routine & microbiological)

Months of pregnancy (regularly noted on each visit)

Tetanus injections

2-3 ultrasounds in whole period

H. Time frames for initial assessments

Initial clinical assessment shall be completed at the earliest as warranted by the situation, and documentation as per given time frame as follows

Emergency within 1 hour of registration

IPD within 24 hrs of admission.

I. Reassessments

Re-assessment shall be done throughout patients hospitalization by Medical Officers twice a day for emergencies and once a day for other IP cases. The frequency can be augmented based on the clinical condition.

All clinical re-assessments shall be recorded and signed with name, date and time duly endorsed in the medical record by the assessor.

The re-assessment shall faithfully reflect the patients clinical condition, response to treatment and inputs to plan further line of treatment or discharge.

In addition to clinical assessment patients shall also be reassessed daily for safety risks, e.g. potential for falls and skin breakdown.

Reassessments to determine patient response to care and progress in meeting identified outcome goals are documented at least every 24-hours on general care units, and at least every 12-hours in critical care units.

Reassessment is always done following a significant change in patient condition, a change in diagnosis, and at the time of unit transfer.


Policy No. A-7Type of document Work InstructionIssue Date:

Revision No:00

Document No. A-7.1Work instructions for Laboratory

Revision Date: -

Purpose: To effectively provide all clinical pathology services as required by the scope of clinical services of the hospital.

S.No.InstructionsResponsibility

1. To receive the samples along with the requisition forms and verify the particulars. Give Laboratory number and record in the departments register and in computer. Technician

2. Urine freshly voided specimen is preferred, When there is delay in testing/transporting, the sample should be refrigerated to prevent bacterial contamination

Routine examination includes both physical, chemical and microscopic examination

Physical examination volume, colour, specific gravity.

Chemical examination screening for presence of albumin, sugar, ketone bodies, bile pigments, bile salts and urobilinogen

Microscopic examination to look for epithelial cells RBC, pus cells, casts, crystals bacteria and foreign bodies.

To use multistix strips for all samples. Any abnormality detected is to be confirmed by conventional methods i.e. a. Proteins- heat acid test

Technician

3. Stool - fresh specimen is preferable

Routine analysis includes physical, chemical and microscopic examination i.e. colour, consistency, blood or mucous if present, pH, occult blood and microscopic examination for ova and cysts

In specific cases microscopic examination for ova and cysts is to be done by concentration techniques Technician

4. Semen analysis

Give following instructions for semen collection

3 day period of abstinence is recommended

To receive the sample as per instructions given in point one

To do the physical examination for colour, pH, liquefaction time, viscosity, volume,

To do the sperm count for motility and morphology

To Estimate fructose in case of infertility

Technician,

5. To enter all results in the register Technician

6. To verify the typed report with the register and initial the report in the lower right hand corner.Technician

7. To check the results and sign before dispatch.Sr.Lab Technician

8. To dispatch OPD, IPD and outside reports to the specific departments.Lab technician

9. To ensure minimum wastage in the department and all wastes are handled properly.Technician


Policy No. A-7Type of document Work InstructionIssue Date:

Revision No:00

Document No. A-7.2COLLECTION, IDENTIFICATION, HANDLING, SAFE DISPOSAL OF SPECIMENS

Revision Date: -

Purpose:

Sample shall be handled in a safe and secured manner in following ways:

Sample Collection.

Sample collection shall be carried out on 24 hours basis either in the sample collection room or in the laboratory

Sample Identification

Access No is generated in the software against every sample request from ward in the software

All samples will be labeled with the name, age, sex, OPD/IPD No and Access No of the patient

All samples will be accompanied by a written requisition for lab investigation

The lab reception receiving the samples will enter the details in register

Sample Handling

All samples will be handled as per the infection control guidelines

Universal precautions are to be observed while handling samples

Safe Transportation of Samples

All samples requiring transportation will be transported in vacutainer

All measures shall be taken for samples are not to be allowed to deteriorated

Necessary precautions are to be taken depending on prevailing environmental factors

Processing of Samples

Processing of samples is to be carried out as per the requirements of individual tests

Procedure for testing is to be standardized and necessary instructions issued to all concerned personnel

Samples will be processed without delay, and on priority for emergency cases.

Disposal of Specimens

Disposal is to be carried out in accordance with bio-medical waste handling rules.

Precautions in accordance with the hospital infection control manual are to be observed


Policy No. A-7Type of document - GuidelineIssue Date:

Revision No:00

Document No. A-7.3Reporting of Critical and Non-critical test results

Revision Date: -

A. Purpose:

To provide a protocol for notification of critical patient test results. Each department is responsible for ongoing assessments and to identify and implement a process, as needed, for the reporting of critical values.

B. Definitions:

Normal: A test result that is within the normal variation and does not require follow-up.

Non-Critical: A test result that is beyond the normal variation and that:

A. Is not what is expected due to the patients current medication and/or disease state

B. May require follow-up to ensure stability, resolution, or further evaluation and/or

C. May change the medical management of that patient.

Critical: Tests result beyond the normal variation with a high probability of a significant increase in morbidity and/or mortality in the foreseeable future and requires rapid communication of results for determination of intervention.

Read Back: The individual accepting the critical test result must record and then read back the critical test result, in its entirety, to the reporter at the time the result is given.

C. Communication Tools:

Electronic: Hospital Management Information System

Manual: Hand delivery or pick up to/by the testing area, patient care area or physician / nurse / ward staff.

Verbal: including verbal report in person or by telephone / intercom / pager

D. Order of Notification:

Ordering / Treating Physician / Staff nurse on duty / Casualty Medical Officer Each department reporting critical values must have in place a defined process, which documents the reporting of pre-approved critical values. E. Normal / Non Critical Test Results Reporting and Documentation

Laboratory

Results are reported in HMIS and also entered in patients records

Radiology

Results are reported in HMIS and also entered in patients records

Both the image(s) and report are archived, when applicable.

F. Critical Test Results Reporting and Documentation

Laboratory

1. When a critical result is identified, the Laboratory Technologist contacts the ordering physician or their assistant within 15 minutes of test readiness via a phone / intercom

2. For the patient who is no longer in the hospital or clinic, the Laboratory Technologist contacts the ordering physician or their assistant immediately after identification of critical result

3. If the ordering physician or their assistant is not reached within 15 minutes of test readiness, the Laboratory Technologist will follow the order of notification.

Radiology

1. When the radiologist identifies a critical test result, a verbal report is given to the ordering physician immediately in person or by phone.

2. If the ordering physician is not available, the radiologist immediately contacts their assistant and a verbal report is given in person / phone / intercom

3. If their assistant could not be reached, the radiologist will immediately follow the order of notification.

4. The result is reported in the HMIS

5. . The image(s) and the report are archived, when applicable.

G. System Failures

Clinical Laboratory

With any applicable communication system failure a hard copy of the critical result will be delivered to the ordering physician or their assistant. The

Laboratory Technologist will document the name and credentials of the person receiving the report with the time of delivery in HMIS.

Radiology

With any applicable communication system failure, the radiologist will give an in person verbal report to the ordering physician or their assistant.


Policy No. A-7Type of document - GuidelineIssue Date:

Revision No:00

Document No. A-7.4Lab Safety Programme

Revision Date: -

Purpose: Laboratory staff to carry out safe practices while working in laboratory. Laboratory shall conduct regular training on the safe practices in their departmental training programme. Non-adherence to these safe practices shall be recorded as non-conformity and appropriate corrective and preventive measures shall be taken

Following safe practices are documented for practicing in daily routine work of lab. Laboratory shall continuously identify other potential hazards and develop safe practices to prevent the same.

Procedure: 1. Standard practices for lab safetya. Only disposable blood collection devices will be used for collection of blood specimens.

b. Appropriate PPE shall be used for protection of patients, phlebotomists, laboratory technicians and other laboratory workers.

c. No recapping of used needles is allowed.

d. No mouth pipetting is allowed

e. Exterior of blood container shall be wiped for any trace of blood with appropriate disinfectant.

f. All specimens shall be labeled carefully.

g. MSDS shall be available for hazardous chemicals,

h. All fluids shall be discarded only after treatment with 1% sodium hypochlorite or freshly prepared solution of NaDCC (sodium dichloroisocynuarate, 140 ppm solution).

i. All laboratory workers will perform hand wash as per the appropriate indications.

j. All laboratory workers will be immunized with Hepatitis B vaccination.

2. Safety with blood borne pathogen

Potential hazard: All the laboratory employees are exposed to the risk from acquiring infections from blood borne pathogens while handling contaminated lab samples such as blood or other body fluids (i.e., cerebrospinal fluid, and semen).

Safe practices:

STANDARD PRECAUTIONS WILL BE STRICTLY ADHERED TO AS A SAFETY MEASURE.a. Wear appropriate PPE when exposure to blood or other potentially infectious body substance is anticipated.b. Gloves must be worn when hand contact with blood, mucous membranes, or non-intact skin is anticipated, or when handling contaminated items or surfaces

c. Hepatitis B vaccination for all laboratory employees

d. Access to the work area shall be strictly limited to authorized persons.

e. All activities involving other potentially infectious materials shall be conducted in biological safety cabinets or other physical-containment devices within the containment module. No work with these other potentially infectious materials shall be conducted on the open bench

3. Safety with tuberculosis:

Potential hazard: Exposure of laboratory employees to TB from working with specimens (e.g., acid fast bacilli smears) that may contain acid-fast bacilli (Mycobacterium tuberculosis). Specimens that may be potential sources of acid-fast bacilli (Mycobacterium spp.) are respiratory secretions (sputum, Bronchoalveolar lavage or endotracheal aspirates), aspirated pus, tissue, cerebrospinal fluid and other serous fluids, and urine.Safe practices:a. All culture or specimens suspected of containing TB bacilli must be manipulated in settings where specific engineering controls, administrative procedures, and appropriate personal work practices ensure containment of the organism and protection of the workers

b. The laboratory procedures involving chances of aerzole generation shall be performed in biological safety cabinet (class II). Such procedures include:

i. Pouring liquid cultures

ii. Using fixed-volume automatic pipettes

iii. Mixing liquid cultures with a pipette

iv. Preparing specimens and culture smears

v. Dropping and spilling tubes containing suspensions of acid-fast bacilli.

vi. Centrifugation and vortexing cell suspension.

4.Safety with chemicals

Potential hazard: Staff exposure to hazardous laboratory chemicals leading to burns or other adverse effects

Safe practices:a. MSDS shall be available on workplace for all hazardous chemicals

b. Chemicals shall be used as per manufacturers instructions for safetyc. Eating, drinking, and smoking are prohibited in areas where laboratory chemicals are present. Hands shall be thoroughly washed after working with chemicals. Storage, handling and consumption of food or beverages shall not occur in chemical storage areas, nor refrigerators, nor with glassware or utensils also used for laboratory operations

d. Each employee shall keep the work area clean and uncluttered. All chemicals and equipment shall be labeled with appropriate hazard warnings. At the completion of each work day or operation, the work area shall be cleaned

e. Mouth suction or pipetting or starting a siphon is prohibited.

f. Skin contact with all chemicals shall be avoided. Appropriate PPE will be used while handling hazardous chemicals. Employees shall wash exposed skin prior to leaving the laboratory

g. Additional specific precautions based on the toxicological characteristics of individual chemicals shall be implemented as deemed necessary by the lab supervisor

h. All glassware will be handled and stored to minimize breakage; all broken glassware will be immediately disposed of in the broken glass containers

5.Safety with chemical spills, releases and accidentsa. In Case of Fire: The first reaction shall be to evacuate the occupants of the building. Fire extinguishers are available in labs and are inspected annually. They may be used by trained personnel to fight small fires.b. In case of spills: Person not wearing personal protective devices shall remain away from spillage area. Spillage surface shall be cleaned with 1% sodium hypochlorite or sodium dichloroisocynuarate as per the spillage management guidelines of United Ciigma Hospital.6.Safety with formaldehyde exposure.

Potential hazard: Employee exposure to Formaldehyde. Formaldehyde can cause acute effects like Eye and respiratory irritation, severe abdominal pains, nausea, vomiting and possible loss of

Consciousness. Chronic effects of formaldehyde include laryngitis, bronchitis or bronchial pneumonia.

Safe practicesa. Use of appropriate PPE including goggles

b. If there is any possibility that an employee's eyes may be splashed with solutions containing 0.1 percent or greater formaldehyde, acceptable eyewash shall be done.

7.Safety with Xylene, concentrated acids or alkalies Exposure

Potential hazard: Employee exposure to hazardous chemicals such as Xylene concentrated acids or alkalies. This can cause acute effects like Eye and respiratory irritation, severe abdominal pains, nausea, vomiting and possible loss of consciousness. Chronic effects includes, skin burns, irritation laryngitis, bronchitis or bronchial pneumonia

Safe practicesa. Protective clothing should be worn to prevent any possibility of skin contact

b. In the event of a spill or leak, persons not wearing protective equipment and clothing should be restricted from contaminated areas until cleanup has been completed

8.Safety with needle stick and sharp injuries

Potential hazard: Employee exposure to blood borne pathogens from needle stick injuries or cuts from sharp objects when working with specimens, centrifuge tubes or overfilled sharps containers.

Safe practices:a. Use safer needle devices and needle less devices to decrease needle stick or other sharps exposures

b. Properly handle and dispose of needles and other sharps

c. Do not bend, recap, or remove contaminated needles and other sharps unless such an act is required by a specific procedure or has no feasible alternative

d. Do not shear or break contaminated sharps.

e. Have needle containers available near areas where needles may be found

f. Discard contaminated sharps immediately

g. Do not pick up broken glassware, such as capillary tubes directly with the hands

h. Dispose of regulated wastes including capillary tubes properly

i. Wear gloves when among other things, handling or touching contaminated items or surfaces, such as capillary tubesj. In case of needle stick or sharp injury, wound shall be washed with soap and water and blood shall be allowed to flow freely. Complete needle stick injury-reporting form and follow Hospital Needle Stick Injury protocol

Purpose:

To provide an identification system to insure that all hospital patients are properly identified prior to any care, treatment or services provided.

Exception: Patients unable to provide identifying information, who experience conditions requiring emergency care, will receive treatment prior to identification if such care and treatment is necessary to stabilize the patients condition.

Procedure:

1. An identification slip shall be prepared by the case writer and given to the patient / attender at the time admission. Identification slips are carried with admission paperwork to the respective ward and affixed at the point by the receiving personnel.

2. The identification slip shall show the IPD / OPD number, patients name, age and sex.

3. Initially, the identification slip shall be checked by the ward staff Nurse to ensure that it is legible and contains the correct information when the patient is admitted.

4. Prior to the administration of tests, treatments, medications, procedures or transfer, the healthcare professional providing the care is responsible for verifying the patients identity by utilizing two identifiers: patient name and patient medical record number. Staff shall verbally assess the patient to assure proper identification, the patients name and date of birth, and match the verbal confirmation to the written information on the identification.

5. If the identification slip is illegible, missing, or contains incorrect information, the test, treatment, medication, or procedures will not be done until the patient is properly identified.

6. Nursing is responsible for obtaining a new slip in the event that an identification band is illegible, missing, or contains incorrect information, obtaining a new band is from Patient Registration and Admissions.

7. The patient can return the identification slip before discharge. In the event of death, the identification slip shall remain on the patients body.

Purpose:

To provide appropriate means for the transporting of patients who must be sent to other designated areas for special tests, procedures or advanced care.

Procedure:

A. The treating physician shall take care of:

1. Writing an order for transportation

2. Designating what portion of patients medical record / clinical information is to be sent with the patient.

3. Scheduling the test or procedure to be performed

4. Ordering IV to be changed to IV lock prior to transfer

5. Paramedical / Attendant to accompany the patient

B. Nursing staff will be responsible for:

1. Making the necessary arrangements for transportation as follows

a. Identification information and ordering physician, location (unit, room and bed number)

b. Name of facility and department to which patient is to be

transported

c. Test or procedure to be performed

d. Date and time for scheduled test or procedure and

e. Mode of transport wheelchair / stretcher / ambulance / special requirements if any.

2. Notifying the concerned personnel where necessary

3. Patient shall be identified as per procedure for patient identification prior to transfer

4. Nursing staffs are responsible to change IV to IV lock prior to transfer.

C. Emergency department will be responsible for making the arrangements for external transportation from casualty.

Purpose: To effectively provide all radiology services as required by the scope of clinical services of the hospital.

S. No.InstructionResponsibility

1. To give clear-cut instructions for pre-requisite for carrying out the procedure (e.g. empty stomach/full stomach, empty bladder/full bladder, purgative/no purgative) and the cost of the procedure if applicable.Radiographer

2. To give clear instructions to patients who require contrast (oral/rectal/I/V) so that they are physically and mentally prepared.Radiographer

3. To receive the investigation form for x-ray.Technician / Radiographer

4. To enter all the required details in register Radiographer

5. To position the patient as per the requirement.Radiographer

6. To load the film in the cassette.Technician / Radiographer

7. To adjust control panel as per the requirement.Radiographer

8. To expose the film.Radiographer

9. Standing behind the lead screen for radiation safety. If a relative has to be present, make sure that they use a lead apron for radiation safety. Technician / Radiographer

10. To process exposed film in the dark room / automatic film processor.Technician / Radiographer

11. Ensuring that the exhaust fan is on for minimum exposure to fumes.Technician

12. To store the used fixer in a separate container and marked Hazardous Waste. Incharge /Technicians

13. Collecting all waste films for disposal to waste contractor. Incharge / Technicians

14. To inform the Housekeeping personnel. Whenever a used fixer container becomes full or sufficient waste films have accumulated so that it can be disposed off to an authorized waste contractor.Incharge

15. To write and sign the report after analyzing the radiographs (where applicable).Radiologist / M.O i/c

16. To enter the particulars in the dispatch register and obtain signature of the person receiving the reports.Technician/ Radiographer

17. To perform emergency radiography after working hours and portable x-rays in wards / operation theatre.Technician

18. To ensure minimum wastage in the department and ensure all wastes are handled properly Radiologist

19. To ensure that every one gives maximum productivity / customer satisfaction and implements hospital service rules, policies, dress code, systems, office orders, circulars, minutes of various meetings or any joint decisions.The radiology department staff / incharge / radiologist

Purpose: To refer the patient to another department requiring interdepartmental / inter-speciality services for continuity of services.


1If the patient required another departmental services, he / she is referred to the departmentReferring Consultant

2The reason for referring is written down on the case paperReferring Consultant

3If the patient is serious or requires emergency care, the referring doctor shall stabilized first and refer to the concern department / consultantReferring consultant

4If the patient is serious or requires emergency care, the referred department / consultant is informed by phone or other meansReferring consultant

5Proper transportation facilities is provided to the patient Staff nurse and Ward Attendant

6The patient should be accompanied or guided to the referred departmentStaff nurse and Ward Attendant

7Patient transportation, if required shall be done as per document no. A 10.2 (Transportation of patient (internal and external))

Purpose: To stream line the process of discharging patients from hospital

Process owner: Treating physician

Scope: All patient discharges of inpatient, observation patients, daycare patients, patients undergoing transfer to another external facility, DAMA and absconded patients. Patients death in hospital will also be reflected in the discharges.


1The treating physician will decide on patients readiness for discharge / transfer for advance treatment. Patients who request discharge against medical advice are also considered.

If the patient leaves without intimation or informing the ward staff, it shall be recorded on patients medical record as patient absconded and considered to be discharged.

Patient death in hospital is to be reflected in discharge procedureTreating physician

2If the patient is not fully recovered, patient shall be advice to stay in the hospital till recovered. If still unwilling to remain, request to be obtain in writing from patient / family member / attendant / guardianTreating Physician

3Absconded MLC patients are to be intimated to RESIDENT DOCTOR and COO and a report to be made to the local policeTreating physician / RESIDENT DOCTOR

4After the decision to discharge a patient is made, the discharge summary (as per guideline) should be given at the time of dischargeTreating physician

5Discharge shall be recorded in a register, which shall include patients identity, discharge diagnosis, date and time of discharge, ward / unit, special remarks if any. Staff nurse

7Discharge advice, medication, follow up and other necessary instructions shall be given to the patient at the time of handing over the discharge cardStaff nurse

8Patient feedback / satisfaction survey proforma to be completed and collected at the time of dischargeStaff nurse

9Special transportation arrangements if necessary shall be madeStaff nurse / Family member

10Endorse Death / DAMA / Absconded / Medico-legal case on patients medical record where necessaryStaff nurse

11Patients Indoor case paper is to be sent to Medical Records Department as scheduled and record maintainedStaff nurse / MRD in charge

Discharge summary shall be made for all discharged / DAMA patients. In case of patients death, death summary shall be prepared.

The instructions in discharge summary shall be in a manner that the patient / family member can easily understand.

Use of medical terms and jargons shall be avoided to the extent possible

Discharge summary shall comprise the following components.

1. Reason for admission, significant findings, diagnosis, condition at the time of discharge

2. Information regarding investigation results, any procedure performed, medication and other treatment given

3. Follow up advice, medications, any other instructions in an understandable manner

4. Instructions about when and how to obtain urgent care are to be incorporated

5. In death cases the summary is to include cause of death

6. The discharge diagnosis is made available in the discharge summary.

All the patients and their families visiting the hospital have the following rights, which are respected by every staff member of the hospital. Patients and families may bring to the notice of the RESIDENT DOCTOR any instance of violation or perceived violation of these rights.

Respect for dignity and privacy of patients

All patients and their family are entitled to due respect for personal dignity, and suitable privacy for patients undergoing examination, certain procedures, and treatment.

Protection from physical abuse or neglect

Utmost care is to be taken that patients are not harmed because of neglect or physical abuse. This is to address areas like physical security, assault, and use of criminal force, harassment, adequacy of equipment safety, unnecessary use of restraint, manhandling, and such illustrative situations.

Special care shall be taken while dealing with the vulnerable group of patients such as the elderly, paediatric, neonate, women, mentally challenged, deaf, dumb, blind, and the physically handicapped. (Refer Document No. B - 9.1, regarding care of vulnerable patients).Confidentiality of information regarding patients

All information in respect of patients is ideally kept confidential except in instances where disclosure is required by law. Families also may be denied disclosure of some kinds of information unless consented to by the patient. This will not apply to minors, and individuals who are incapable of exercising rational decision-making. Only those personnel have the right to access patient information, who are involved in the care of the patient or specifically authorised by the hospital.

Patients right for refusal of treatment

The patient has the right to refuse treatment. Exceptions to this are made in case of minors or those cases where the patient is incapable of exercising judgment and appreciation of the consequences of their actions. Other exceptions are in cases where the law restricts this right. (See gazette notification for patient rights also)

Informed consent

Patients and family rights includes right to be informed and provide consent before anaesthesia, blood and blood products transfusion, any invasive high risk procedure or treatment (Refer policy no. D- 2 also).

This includes information and consent before any research protocol is initiated.

Voicing a complaint

Patient, family or guardian has the right to voice their complaints. Complaints are to be communicated through their treating physician or RESIDENT DOCTOR in the prescribed manner preferably in writing. Complaints can be placed in the complaint and suggestion box, or endorsed in the complaint and suggestion register. A suggestion and complaint book has been kept in the reception and with the office of the RESIDENT DOCTOR. A Complaint and Suggestion box has been placed in the same locations. Those desirous of sending such communications by post may address their complaints and suggestions to the Office of the COO, whose address is as follows:

To The COO

UNITED CIIGMAX Hospital,.

abcdefgh

Information on expected cost of treatment

The patient and their family / guardian have the right to receive reliable information on the expected cost of treatment, will be available in the RESIDENT DOCTORs office.

Right to know their treatment details:

Patients, and families where minors and incapacitated patients are concerned, have the right to know their treatment details.

Access to Emergency Services

If patients have severe pain, injury, illness, that convinces them that they are faced with an emergency medical situation, they have the right to receive screening and stabilization at the available emergency service in the hospital, regardless of capacity to pay.

Participation in Treatment Decisions

Patients have the right to know the various options for treatment available and to participate in making decisions about their care. Parents, guardians, family members, or other individuals that they designate, can represent them, if they so desire.

Patients right to information and education about their healthcare needs

Patients have a right to be educated about the following in a language and format that they can understand

Safe and effective use of medicines, and their potential side effects.

Diet and nutrition requirements

Immunization

Their specific disease process, complications, and prevention strategies.

Prevention of infections, where applicable

USERS RESPONSIBILITIES

Users of the hospital are entitled to demand adherence of all concerned to the charter principle as indicated above and bring any shortcomings or deficiencies to the notice of appropriate authorities

Users should appreciate the various constraints under which the hospital is functioning and ensure its smooth functioning without inconveniencing other patients and visitors

They should help the hospital authorities in keeping the hospital and surroundings clean and in proper sanitary condition.

Provide useful feedback and constructive suggestions regarding the quality and extent of service available at the hospital.

Refrain from misusing the facilities available or demanding an undue favour from staff or officials.

Name of the Hospital: UNITED CIIGMAXX Hospital, yyyyyyy Dist.

Address:

Telephone No.:

1. Preamble

This charter is an expression of commitment and resolve of this hospital to provide to its patients information about the services that are available, the quality and standards of service that they may expect, as also the machinery and procedure available for redressal of their grievances and complaint.

2. Hours of work

Out Patient Department

Registration 8.30am 12.00am

OPD consultation 8.30am 12.00

Administrative office

Weekdays: 9.45 am 5.45pmLunch break: 12.45pm 1.45pmClosed on Sundays and gazetted holidaysCasuality / Emergency department : Open throughout 24 hours on all days

Medical officer

: Available throughout 24 hours on all days

Duty doctor

: Casualty / emergency will have a minimum of one duty doctor available for 24 hrs.

Specialist services

Weekdays: 8.30am 12.00pm

Emergency : 24Hrs (On call)

Closed on Sundays and hospital holidays (As per government holidays)

3. Scope of services

The Hospital shall provide following services: -General SpecialtyRelated Additional Services

Time

Remarks

General Examination

OPD- Morning and Evening as per Schedule

Emergency Examination and admission round the clock all 365 days through Casualty Department

General MedicineBasic Cardiology

Diabetes Care

OPD- Daily Morning

IPD- Daily

ICCU facility available. Cases for interventional cardiology referred to higher centre. 2 D Echo facility available on fixed day.

Obstetrics & Gynecology High-risk Pregnancy

Family Welfare servicesOPD- On designated days

IPD- Daily

General SurgeryBurns Cases

OPD- On designated days

IPD- Daily

Laparoscopy surgery facility

PediatricsWell baby clinic

Neonatology

Immunization ServicesOPD- On designated days

IPD- Daily

Complicated neonatal and pediatric surgery cases referred to higher level

Orthopedics

Physiotherapy


IPD- Daily

Joint Replacement surgery facility

ENT Surgery


IPD- Daily

Ophthalmology

Facility for Intra Ocular Lens Implant with Phaco Emulsification


IPD- Daily

Dermatology

Sexually Transmitted Diseases Clinic

Cryodermabrasion

OPD- Daily Morning and Evening

Indoor as and when necessary

Dental services

Basic Dental services available

OPD- Daily Morning and Evening

Anesthesia services

Pain Clinic on fixed day

As per OT Schedule

Pathology Laboratory

Hematology

Pathology

Bio Chemistry

Investigations as per schedule during OPD hours

Investigations not available in OPD are referred to Government Hospital, or Private Lab as per patients choice

Critical investigations available round the clock 365 days

Radiology

X- Rays

Sonography Examination

CT Scan

Routine investigations done during OPD hours Emergency Investigations done round the clock 365 days

Investigational procedures like IVP, Barium Meal and follow up done only after consultation of Radiologist depending on workload.

Integrated Counseling and Testing Centre (for HIV/AIDS)

Prevention of parent to child services also available

HIV and STD testing facility available during routine OPD hours

Positive people network given supportOthers

Certificate (Medical fitness, Disability certificate, Health Certificates, Age certificate)

Emergency Medical Response

4 Other facilities

a. The list of doctors on duty, names of Medical Officer, RESIDENT DOCTOR/COO, along with their location is displayed / available at receptionb. Wheelchairs and stretchers are available on request at the gate / reception for facility of patients who are not in a position to walk

c. A location map is on display at the main waiting area for easy access to various departments by patients

d. Every staff in this hospital can be identified by their uniform.

e. Information regarding the fees and other payments if any to be made for use of various facilities / diagnostic and other machines and equipment and / or for specialists fees / medicines etc.are also displayed / available at the reception

f. Adequate safe drinking water and toilet facilities are available for the convenience of the public.

g. Adequate display boards are available at different locations for guidance of visitors and outpatients

h. Ambulance / Mortuary vans are available for use on payment as per rules throughout 24 hrs.

i. Laboratory is available in the hospital premises at ground floor, for various tests.

j. Public telephone booth is available at Ground floor.

k. Tea Stall is available at ground floor for catering to visitors and outpatients during normal working hours

l. There is a standby generator to cater to emergency and critical areas in case of general breakdown of electricity.

m. A pharmacy is located at OPD and Emergency which is open 24 hours a day

5. Service standard

This hospital has

Doctors : 31

Nurses : 41

Beds : 265

5.1 Standards of service and adequate degree of patient care can be provided to the extent proper and workable ratio between doctor to patient, nurse to patient and beds to patients are maintained, as per available manpower. Consistent with this every possible effort will be made by this hospital:

a. To provide access to hospital and professional medical care to all patients who visit the hospital

b. To prescribe a workable maximum waiting time for outpatients, before they are attended to by a qualified doctor and / or specialists and continuously strive to improve upon it

c. To ensure that all equipment in the hospital are maintained efficiently in proper working order

d. To ensure availability of beds and operation theatres facilities as freely as possible

e. To ensure treatment of emergency cases with utmost promptitude and attention

5.2 Every outpatient seeking treatment at the hospital will be registered and issued a case paper for recording various details of the symptoms, diagnosis and treatment being provided.

5.3 The patients and families rights are in consonance to accreditation standards and are documented separately in this charter

5.4 All patients and visitors to the hospital will receive courteous and prompt attention from the staff and officials of the hospital in the use of its various services

5.5 Reliability and promptness of diagnostic investigation results is ensured and whenever possible such reports will be made available.

5.5 Operation theatre is maintained on a regular basis to ensure that they are serviceable all the time and every effort will be made to keep the hospital and its surroundings, clean, infection-free and hygienic.

5.6 A regular system of obtaining feedback from the users is in place through exit interviews and periodic surveys. The inputs from these are continuously used for improving the service standards

5.7 The hospital has necessary equipments required for provision of service mentioned in scope of services and system to ensure proper maintenance and working of various equipments.

5.8 If any equipment is out of order, information regarding the same shall be displayed suitable indicating the alternate arrangements, if any, as also the likely date of recommissioning the equipment after repairs and replacement.

5.9 When things go wrong or fail, appropriate action is taken on those responsible for such failures and action taken to rectify the deficiencies. Complainants will also be informed of the action taken, if requested

5.10 In case of likely persistence of the deficiency, the reasons for the delay in rectifying the deficiency and the time taken for rectifying the same will be displayed prominently for the information of the public.

5.11 Special directions are given to the non-medical staff to deal with the patients and public courteously. Any breach in this regard when brought to the notice of the hospital authorities shall be dealt with appropriately.

5.12 Hospital encourages the patients and the public to inform the authorities when things go wrong. Suggestion / complaint boxes and registers are provided at the reception, RESIDENT DOCTOR office, Matron office and administrator

5.13 Hospital follows all policies, processes, programmes, committee meetings, regulatory guidelines which has been prepared to meet the standards of accreditation as set by NABH

6. Grievance / Complaint / Redressal

As given in patient rights.

7. Patient and Familys Rights

All the patients and their families visiting the hospital have the following rights, which are respected by every staff member of the hospital. Patients and families may bring to the notice of the RESIDENT DOCTOR any instance of violation or perceived violation of these rights.

7.1 Respect for dignity and privacy of patients

All patients and their family are entitled to due respect for personal dignity, and suitable privacy for patients undergoing examination, certain procedures, and treatment.

7.2 Protection from physical abuse or neglect

Utmost care is to be taken that patients are not harmed because of neglect or physical abuse. This is to address areas like physical security, assault, and use of criminal force, harassment, adequacy of equipment safety, unnecessary use of restraint, manhandling, and such illustrative situations.

Special care shall be taken while dealing with the vulnerable group of patients such as the elderly, paediatric, neonate, women, mentally challenged, deaf, dumb, blind, and the physically handicapped.7.3 Confidentiality of information regarding patients

All information in respect of patients is ideally kept confidential except in instances where disclosure is required by law. Families also may be denied disclosure of some kinds of information unless consent obtained from the patient. This will not apply to minors, and individuals who are incapable of exercising rational decision-making. Only those personnel have the right to access patient information, who are involved in the care of the patient or specifically authorised by the hospital.

7.4 Right for refusal of treatment

The patient has the right to refuse treatment. Exceptions to this are made in case of minors or those cases where the patient is incapable of exercising judgment and appreciation of the consequences of their actions. Other exceptions are in cases where the law restricts this right.

7.5 Informed consent

Patients and family rights includes right to be informed and provide consent before anaesthesia, blood and blood products transfusion, any invasive high risk procedure or treatment

This includes information and consent before any research protocol is initiated.

7.6 Voicing a complaint

Patient, family or guardian has the right to voice their complaints. Complaints are to be communicated through their treating physician or RESIDENT DOCTOR in the prescribed manner preferably in writing. Complaints can be placed in the complaint and suggestion box, or endorsed in the complaint and suggestion register. A suggestion and complaint book has been kept in the reception and with the office of the RESIDENT DOCTOR. A Complaint and Suggestion box has been placed in the same locations. Those desirous of sending such communications by post may address their complaints and suggestions to the Office of the COO, whose address is as follows

To The COO

XXXX Hospital, YYYY Dist.l.

Address:7.7 Information on expected cost of treatment

The patient and their family / guardian have the right to receive reliable information on the expected cost of treatment will be made available in the RESIDENT DOCTORs office.

7.8 Right to know their treatment details:

Patients, and families where minors and incapacitated patients are concerned, have the right to know their treatment details.

7.9 Access to Emergency Services

If patients have severe pain, injury, illness, that convinces them that they are faced with an emergency medical situation, they have the right to receive screening and stabilization at the available emergency service in the hospital, regardless of capacity to pay.

7.10 Participation in Treatment Decisions

Patients have the right to know the various options for treatment available and to participate in making decisions about their care. Parents, guardians, family members, or other individuals that they designate, can represent them, if they so desire.

7.11 Patients right to information and education about their healthcare needs

Patients have a right to be educated about the following in a language and format that they can understand

Safe and effective use of medicines, and their potential side effects.

Diet and nutrition requirements

Immunization

Their specific disease process, complications, and prevention strategies.

Prevention of infections, where applicable

8. Responsibilities of users

8.1 Users of the hospital are entitled to demand adherence of all concerned to the charter principle as indicated above and bring any shortcomings or deficiencies to the notice of appropriate authorities

8.2 Users should appreciate the various constraints under which the hospital is functioning and ensure its smooth functioning without inconveniencing other patients and visitors

8.3 They should help the hospital authorities in keeping the hospital and surroundings clean and in proper sanitary condition.

8.4 Provide useful feedback and constructive suggestions regarding the quality and extent of service available at the hospital.

8.5 Refrain from misusing the facilities available or demanding an undue favour from staff or officials

9. Suggestion for improvement

Any suggestion for improvement of this charter document will be most welcome and may be addressed to COO /RESIDENT DOCTOR

Purpose: To have a system of receiving, reviewing and taking appropriate action on patient complaint and grievances

Patients and families have a right to voice a complaint and seek redressal of the same.

A complaint and suggestion box shall be provided in the general area and should be labeled appropriately.

Patient and family can also voice complaint directly to RESIDENT DOCTOR office.

In this case the complaint / grievance shall be documented.

Along with the complaint and suggestion box 6 registers shall be maintained and kept at following places

1. General OPD

2. Main reception counter

3. Accident & Emergency ward

4. Matron

5. RESIDENT DOCTORRESIDENT DOCTOR of the hospital shall be in charge of receiving patient grievances, complaints, and suggestions for redressal.

On receipt of complaint person in charge shall;

Provide the aggrieved person with a written response for his / her complaint, along with the action taken, and an application number which may be used as reference by the applicant.

Contact the concerned health service provider and remedy the situation, when possible; and

Provide to the aggrieved person, printed information in Tamil on all the remedies available to him / her, including the right to file an application for a grievance at the district court

The person in-charge shall submit the register of complaints along with action taken to the state monitoring committee at the end of each month through the RESIDENT DOCTOR and COO.

Policy No. D - 2 - Consent

Consent shall be obtained from patients and family for informed decision making about their care. Consent is of two types, viz. general, and informed.

Consent is to be given by

By the patient, unless he or she is a minor.

If patient is incapable of informed decision making, consent shall be obtained from next of kin / parent / guardian, as per law of the land.

In case of unidentified patient in unconscious condition, treating doctor shall take a decision in life saving circumstances. Permission will be sought from COO / RESIDENT DOCTOR for surgery

In case the patient incapable of independent decision-making is a prisoner, the consent shall be taken from the Jail Superintendent.

General consent is to be taken when the patient enters the hospital to avail of the services as an inpatient, daycare, observation and detention, specified investigations and procedures as mentioned in the document.

Scope of general consent is communicated to the patients and / or the family members.

Informed consent is obtained as above in situations, which are listed in the document. This shall include information on risks, benefits, alternatives, which will perform the requisite procedure. The consent shall be taken as per the documented procedure and communicated in a language that the patient / family can understand.

Purpose: To have a uniform and appropriate methodology for obtaining consent for medical treatment from patient or family

Scope: General and special consent


1. General consent for treatment shall be taken at the time of admission on admission paper and should be attached in medical recordStaff nurse

2. Informed and special consent shall be taken by treating physician for the situations listed in document D-2.2Treating physician

3. Take into account, patients psychological features, culture, and educational level while obtaining consent.Treating physician

4. Provide following information to take informed consent

Procedure to be performed with reason

During the course of operation/procedure, unforeseen conditions may be revealed or encountered which necessitate surgical or other emergency procedures in addition to or different from those contemplated at the time of initial diagnosis

Use of anaesthesia and of which type

Nature and purpose of the operation and / or procedures, the necessity, thereof, the possible alternative methods, treatment, prognosis, risk involved and possibility of complicationTreating physician

5. Take consent that patient is not suffering from Hypertension/Diabetes/Bleeding disorders/heart diseases, allergies, drug reaction or similar other conditions

Treating physician

6. If photographing or televising of the operation / procedure has to be done, for the purpose of medical, scientific or educational purpose, consent has to be taken for that accountTreating physician

7. The consent shall be taken on consent form which shall contain

Signature/thumb impression of patient,

Signature, names and address of the witness

(In case patient incapable of independent decision making) Signature / thumb impression of guardian (as per policy) with name and relationship with patient

Signature of doctor incharge with name and designation

Date and time of signing the consentTreating physician

8. In case if the consent is taken on plain paper (in medical record), it should contain items mentioned in S.No. 4 (in written) in addition to those mentioned in S. No. 7Treating physician

Informed consent from the patient / family is required whenever patient is undergoing any of the following procedures

1. Transfusion of blood or any other blood product

2. Ascites tapping / Abdominal paracentesis

3. Thoracentesis

4. Direct Laryngoscopy / Bronchoscopy / Cystoscopy / Colonoscopy / Sigmoidoscopy

5. Bone marrow biopsy / aspiration

6. Fine needle aspiration cytological studies (FNAC)

7. CT guided or US guided FNAC

8. CT scan with contrast

9. Lumbar puncture

10. Any surgical procedure

11. Foleys catheterization

12. Nasogastric tube insertion

13. Intubation

14. Immuno therapy, intravenous or sub-cutaneous

15. Abdominal, pleural or pericardial drainage and drainage tube insertion

16. Central line placement

17. For restraining the patient

If patient is not aware of the diagnosis or is incapacitated, the lead caregiver signs the consent.

In emergency situation doctor on duty can sign the consent or give verbal affirmation for any procedure.

Purpose: To streamline the system of attending the patients in emergency

Primary responsibility: Medical Officer on duty in casualty

Sl noProcedural stepsResponsibility

1. Receive Patient on stretcherWard boy and Brother

2. Call the doctor Nurses

3. Immediately check

L. I. S. A : Life Threatening

Impression

Stabilize Cervical Spine

Doctor /Staff Nurse

4. Air Way : Suction

Head Tilt Chin Lift /

Jaw Thrust Maneuver

Oral Airway

Assess for Advance Air Way Management Definitive Air Way.Doctor /Staff Nurse

5. Breathing : IPASS-O2

I : Inspection

P: Palpate

A: Auscultation

O: Oxygen

(1) Do you see any sign of inadequate respiration?

(2) Is the rate and quality of breathing adequate to sustain life?

(3) Is the patient complaining of difficulty breathing?

(4) Quickly palpate the chest for unstable segments, repetition (trauma), and equal expansion of the chest

(5) If the patient is responsive and breathing < 8 or >24, administer oxygen using a None Rebreather Mask (NRM) at 15 lts/minute

(6) If the patient is unresponsive and breathing is adequate, administer oxygen using a NRB at 15 lts/minute

(7) If the patient is unresponsive and breathing is inadequate, administer oxygen using a Bag Valve Mask (BVM).Doctor /Staff Nurse

6. Circulation: VCRS

Check: Natural Voids

Carotid Artery

Radial artery

Skin: Color Temperature, Condition

Manage For Shock

Take Two Large bore IV Lines when needed

Doctor /Staff Nurse

7Admit the patient

Decision Making:

If expert opinion is delayed for more than 20 Minutes for any reason then critical decision is taken by Medical officer to transport patient immediately by Rapid Transport to Advance Trauma Centre.

Call AmbulanceDoctor

8CHECK FOR CUPS:

Critical

Unstable

Potentially Unstable

StableDoctor /Staff Nurse

9Exam:

Rapid Physical Examination

DCAP BTLS:

D: Deformities

C: Contusions

A: Abrasions

P: Penetration / Puncture

B: Burns

T: Tenderness

L: Lacerations

S: Swelling

HeadNeckChestAbdomenGroinExtremities

Doctor /Staff Nurse

10Take Full Set of Vital Signs

Blood pressure

Pulse

Respiration

Skin: Temperature,

Pupil

Doctor /Staff Nurse

11FIVE:

F: Focused Exam

I: Initial Assessment

V: Vital Signs:

Every 1 hour for Unstable patient

Twice a day for Stable Patient

As & when situation required it will be done

Every 15 Minutes in Stable Patient

E: Evaluate Intervention /Treatment

Doctor /Staff Nurse

12.If time permit do detailed physical examinationDoctor /Staff Nurse

Purpose: To follow a uniform guideline to handle cases of road traffic accident or trauma

Sl No.ACTIVITYRESPONSIBILITY

1. Receive Patient on stretcherServant / Brother

2. Call doctor over telephoneNurses

3. Immediately check

L. I. S. A : Life Threatening

Stabilize C Spine

Impression

AVPU

Doctor/Staff Nurse

4. Air Way:

Suction

Head Tilt Chin Lift /

Jaw Thrust Maneuver

Oral Airway

Assess for Advance Air Way Management Definitive Air Way.Doctor /Staff Nurse

5. Breathing: IPASS-O2

I : Inspection

P: Palpate

A: Auscultation

S: Seal Holes

S: Stabilize (Flail Chest)

O: Oxygen Check Devices

and Adequacy Doctor /Staff Nurse

6. Circulation: VCRS

Check: Natural Voids

Carotid Artery

Radial artery

Skin: Color Temperature, Condition

Manage For Shock

Take One Large bore IV Lines, another if necessary

Doctor /Staff Nurse

7. Admit the patientDecision Making:

If expert opinion is delayed for more than 10 Minutes for any reason then critical decision is taken by Medical officer to transport patient immediately by Rapid Transport to Advance Trauma Centre.

Call AmbulanceDoctor

8. CHECK FOR CUPS:

Critical

Unstable

Potentially Unstable

StableDoctor /Staff Nurse

9. Examination:

Rapid Physical Examination

DCAP BTLS:

D: Deformities

C: Contusions

A: Abrasions

P: Penetration / Puncture

B: Burns

T: Tenderness

L: Lacerations

S: Swelling

HeadNeckChestAbdomenGroinExtremities

Doctors/Staff Nurses

10. Take Full Set of Vital Signs

Blood pressure

Pulse

Respiration

Skin : Temperature

Pupil

Doctor /Staff Nurse

11. FIVE:

F: Focused Exam

I: Initial Assessment

V: Vital Signs:

Every 1 hour for Unstable patient

Twice a day for Stable Patient

As & when situation required it will be done

E: Evaluate Intervention /Treatment

Doctor / Staff Nurse

12. If time permit do detailed physical examinationDoctor /Staff Nurse

13. Get SAMPLE history from attendant

S: Signs & Symptoms

A: Allergies

M: Medication

P: Pertinent to past history

L: Last Oral Intake

E: Events Leading To Injury / EventDoctor /Staff Nurse

Purpose: To properly handle poisonous cases


1All cases of poisoning including snakes bite are registered under MLCDuty Doctor

2Keep the patient in stretcher and scrap properly with soap and water in case of cutaneous exposureStaff nurse

3Patient is dressed with hospital uniform Staff nurse

4Proper history of the patient has to be taken to find out whether it is inhalation type or ingestion type of poisoningDoctor

5If possible the patient / relatives should bring the culprit toxic substance or similar compoundPatient relatives

6According to signs and syndromes treatment is started to stabilize the patientDoctor

7Accordingly treatment can be done by regular monitoring of the patientDoctor

Purpose: To provide emergency medical care to cases of burn injury


1All major burns cases shall be registered under MLCDuty Doctor/ COO

2Emergency aids are given and admitted in burns wardDuty Doctor

3Clean water bath of the patientStaff nurse / Nursing Assistants

4Applied normal salineStaff nurse / Nursing Assistants

5Clean the body with sterilized gauze pieceStaff nurse / Nursing Assistants

6Apply vaseline with silver sulphadiazine cream to the sterilized gauze and dressing is doneStaff nurse / Nursing Assistants

7Put the patient on the sterilized bed (used cradle if the patient is old or not able to walk or move)Hospital worker

8Antibiotic injections, pain injections, etc are givenStaff nurse

95%DNS / IV fluids are given to the patientStaff nurse

10Patient who is not able to take food is given continuous IV fluids as per doctors advice Staff nurse

114 important aspects of burnt cases are cleanliness, dressing, proper nutrition and sterilization Staff nurse / Nursing Assistants

12 Further treatment by doctorsConsultant

Purpose: To properly identify patients and provide the care as per needs in mass casualty or disaster

Triage: Triage is the process of sorting patients based on their need for immediate medical treatment as compared to their chance of benefiting from such care. Triage is done in the emergency service department, when faced with mass casualties and limited medical resources, which must be allocated to maximize the number of survivors.


1All paramedical staff, emergency medical staff are involved in triaging of patients Controlling officer of mass casualty

2Colour tags are used for triaging of patients

Red > Alive, Required Emergency Care

Yellow > Alive, Does Not Required Emergency Care

Green > Injured but can wait longer with first aid

Black > DeathParamedical / all involved

3Patients with red tag are shifted to the emergency department / hospitals and given emergency medical care and further treatmentsParamedical / all involved

4Patients with yellow and green tag are given first aid on the spot and if required shifted to hospitalParamedical / all involved

5Patients with black tag are shifted to mortuary for post mortem Paramedical / all involved

6 All the cases are registered under MLC and police are informedParamedical / all involved

Purpose: To handle MLC properly for legal aspects


1. All cases of medico-legal importance are registered as MLC and marked as MLC. This shall be decided by COODuty Doctor

2. All MLC shall be treated free of cost for first 24 hours RESIDENT DOCTOR

3. Police is informed which is available round the clock the hospitalCOO

4. Medical records for MLCs are maintained separatelyMRD Incharge

5. MLC records are kept in different shelves MRD Incharge

6. MLC records are submitted to concerned records keeper after patient is dischargedStaff Nurse

Purpose: To take immediate action in case of medical emergency situation for patient / staff / visitor, to ensure that required urgent medical care / resuscitation activities is provided on time.

Procedure:

S. No.Procedural stepsResponsibility

1. The team is identified for the day and consists of the following:

1. MO on duty

2. 1 staff nurse on duty

3. 1 Hospital worker on duty from emergency / casualty

4. An anesthetist is on call to assist in difficult intubation and for post intubation management

RESIDENT DOCTOR

2. The name of the team members and shifts shall be published in advance for information and preparedness of all concerned. RESIDENT DOCTOR

3. A code blue medical emergency shall be anticipated if patient is unresponsive, meaning he is not breathing or his heart has stopped beating, or both, in which case near by medical / nursing personnel shall be summoned immediately First responder

4. First responder / medical / nursing /paramedical personnel shall check the responsiveness by speaking loudly to the casualty, and trying to rouse them by shaking his shoulder.

If there is no response send / call for help as the patient is being treated.First responder

5. Institute CPR / BLS (Refer guidelines document No. B 6.2)paramedical / Nursing / medical professional on the spot

6Code blue team members, whosoever on duty shall immediately reach the specified location (within 1 minute) and manage the emergency situation as per necessary (Refer Document No. B-6.2)Code blue team

7All resuscitation efforts are recorded in patients medical records with summary of procedure/s, pharmacologic interventions, length of intervention, and outcome clearly recorded.Code blue team in charge

8The medical audit committee will review all such resuscitation records and provide analysis of each event, for corrective and preventive measures, if anyMedical audit committee

Basic Life Support

Resource reference: American Heart Association guidelines on CPR, BLS and ALS

Basic Life Support (BLS) establishes a clear airway followed by assisted ventilation and support of the circulation, all without the aid of specialised equipment.

When approaching a patient who appears to have suffered a cardiac arrest the rescuer should check that there are no hazards to him before proceeding to treat the patient. Although this rarely arises in hospital, patients may suffer a cardiac arrest due to electric shocks or toxic substances. In these situations the rescuer may be in considerable danger, and must ensure that any hazard is taken account of and eliminated as a risk.

Checking responsiveness is best done by speaking loudly to the casualty, and trying to rouse them by shaking a shoulder. If there is no response send for help as the patient is being treated.

Opening the airway - this is normally done by simply extending the head and performing a chin lift. In some patients a jaw thrust will be required along with the insertion of an oropharyngeal airway. False teeth that are loose or other debris within the airway should be removed.

Assisted ventilation should be provided if the patient is not breathing. It may be provided using expired air ventilation (mouth to mouth, mouth to nose, using a Laerdel pocket mask) or by using a self inflating bags, usually with supplemental oxygen. Oxygen should be added to self-inflating bag, using a reservoir on the inlet side of the bag. Adequacy of ventilation is judged by each breath producing adequate movement of the chest on inspiration. In general tidal volumes of 400 - 500mls are optimal.

Chest compressions (previously known as cardiac massage) are used whenever a central pulse (carotid) is absent. The technique creates positive pressure within the chest and forces blood out of the chest during the compression phase. Due to the valves within the venous system and the heart, most of the blood flows forward through the arteries. When the chest recoils to its normal position blood returns to the chest from the venous side of the circulation. A small amount of flow is produced by direct compression of the heart between the sternum and the spine. During chest compressions approximately 25% of the normal cardiac output is produced.

Current guidelines advise that 15 chest compressions are carried out for each ventilation when two rescuers are available. In the event of only one rescuer, 1 ventilation should follow 30 compressions. The overall rate of chest compressions should be 100/minute.

When starting chest compressions:

Get the patient on a firm surface

Feel the xiphisternum, and measure 2 fingerbreadths up on the sternum without moving your fingers, place the heel of the second hand on the sternum. Put both hands together and depress the sternum 4-5cm in an adult.

Keep your elbows straight, and ensure that all the pressure is directed through the sternum and not through the ribs. To perform chest compressions adequately, it is necessary to be above the patient. Stand on a platform if necessary.

During a cardiac arrest change the person performing chest compressions regularly, as it is tiring when performed properly.

The rescuer performing chest compressions should count out loud "1,2,3,4,5", and the rescuer ventilating the patient should count the number of cycles completed.

Early BLS has been shown to improve outcome, particularly when access to advanced airway management and defibrillation is likely to be delayed. Although the barely adequate level of oxygen delivery achieved during BLS may be regarded as a holding measure, it is of great importance and will occasionally reverse the primary cause of the cardiac arrest and restore some circulation preventing the rhythm degenerating into a systole.

Advanced Life Support

Advanced Life Support refers to the use of specialised techniques, in an attempt to rapidly restore an effective rhythm to the heart. The most important components of the advanced life support techniques are direct current defibrillation and efficient BLS.

General Management Principles for Cardiac Arrest

1. Establish the safety of the victim and potential rescuer.

2. Confirm the diagnosis of an arrest

3. Send for help

4. Establish Basic Life Support

5. Aim for early and frequent defibrillation if indicated, with regular doses of adrenaline and CPR.

6. If there is doubt about the rhythm, no ECG monitor is available, treat adults as being in VF.

7. Except for defibrillation, chest compressions should not be interrupted for more than 10 seconds to allow invasive procedures or advanced airway management.

8. Administer drugs intravenously whenever possible. Use a 20-50ml 0.9% saline flush with the peripheral route.

9. Consider and treat any underlying causes

10. Consider anti arrhythmic drugs and sodium bicarbonate

ADMISSION AND DISCHARGE CRITERIA

Criteria for admission to ICU

Mechanical support of organ function

Respiratory ventilation / CPAP

Renal haemofiltration / haemodialysis

Cardiac blood transfusion

Hepatic blood transfusion

Neurological intracranial pressure monitoring

Patient requiring support of 2 or more organ system even when this does not include the respiratory system

Potentially reversible patient condition

Circumstances in which emergency treatment already carried out (e.g. intubation and ventilation) even when there is no realistic prospect of survival

Patient requiring 1:1 nursing care

Criteria for discharge from ICU

Patient no longer requiring organ system support

Reversal of initial condition for which patient admitted to ICU

In case of bed shortage relatively stable patient shifted to HDU / wards

Purpose: To identify sound infection control practices used in the intensive care setting to reduce or control nosocomial transmission of infectious organisms.

I. General Practices:

A. A conscious-careful attitude must be incorporated into each patient care practice in these high-risk areas to reduce the risk of nosocomial colonization or infection.

B. While entering the ICU either

1. The general footwear shall be removed and only the approved footwear shall be used inside or

2. the footwear shall be covered by shoe-cover

C. Handwashing is the single most important practice to reduce the nosocomial infection risk. All individuals in the intensive care setting should practice hand hygiene appropriate to the task as given below. Alcohol based hand rubs shall be used before gloving for performing any invasive procedure on the patient. DO NOT use alcohol when the presence of spores (c. difficile, anthrax etc.) is known or suspected. In such cases wash hands vigorously with soap and water.

Guidelines for hand wash: Soap and Water Before beginning work and before going home.

Before direct patient contact.

Before and after eating.

After washroom (toilet).

Before caring for neutropenic or severely immune suppressed patients.

After contact with a patients intact skin (eg taking BP, lifting a patient).

After contact with inanimate objects, including medical equipment in the immediate vicinity of the patient.

After removing gloves.

Whenever hands are visibly soiled.

Whenever hands are contaminated.

When contact with Bacillus anthracis, c. difficile, or other spores is known or suspected.

After hand decontamination with any product, always allow the skin to dry before donning gloves.

D. Fumigation: Complete fumigation shall be done in the whole Intensive care setting per month.

II. Isolation / barrier nursing practicesA. The barrier nursing practice shall be followed for the patient care. Patients shall be assessed individually to determine any infection that would require additional isolation precautions.

B. Personal Protective Equipment is available to all the staff in the Intensive care for the appropriate use. Standard precaution shall be followed for same

III. Intravascular Device Related InfectionsA. Surveillancei. Palpate the catheter insertion site for tenderness daily through the intact dressing.

ii. Visually inspect the catheter insertion site if the patient develops tenderness at the insertion site, fever without obvious source, or symptoms of local of bloodstream infection.

iii. In patients who have large bulky dressings that prevent palpation or direct visualization of the catheter insertion site, remove the dressing (wearing gloves) and visually inspect the catheter site at least daily. If loose, damp or soiled, the dressing may need changing more frequently.

iv. The time and date of catheter insertion shall be noted down.

B. Barrier Precautions During Catheter Insertion and Carei. Wear clean gloves when inserting a peripheral venous or arterial catheter

ii. Wear maximum barrier protection, including sterile gowns, gloves, mask, and cap and use a large sterile drape when inserting a central line (arterial or venous).

C. Selection of Catheter Insertion Sitei. In adults patients, use an upper extremity site in preference to one on a lower extremity for catheter insertion. Transfer a catheter inserted in a lower extremity site to an upper extremity site as soon as the latter is available.

ii. In paediatric patients, insert catheters into a scalp, hand or foot site in preference to a leg, arm or antecubital fossa site.

iii. Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk for nontunneled central line placements.

iv. Place catheters used for Hemodialysis and pheresis in a jugular or femoral vein rather than a subclavian vein to avoid stenosis if catheter access is needed.

v. Weigh the risk and benefits of placing a device at a recommended site to reduce infectious complications against the risk of mechanical complications (e.g. pneumothorax, subclavian artery puncture, air embolism, catheter misplacement).

vi. Do not routinely use cut-down procedures as a method to insert catheters.

D. Catheter Site CareD.1 Cutaneous Antisepsis

i. Although the surface area for prepping is dependent on the size of the extremity, in adult patients, an area 2 to 4 inches in diameter is generally accepted for central lines.

ii. Cleanse the skin with chlorhexidene or chloraprep as first choice because of its residual effects; second choice, povidone iodine swab.70% alcohol may be used to prep for peripheral catheters.

iii. Chlorhexidine cannot be used on children less than two months of age.

iv. Do not palpate the insertion site after the skin has been cleansed with the antiseptic.

v. Do not routinely apply topical antimicrobial ointment to the insertion site.

D.2 Cathter site dressing

i. Use either sterile gauze or a semipermable transparent dressing to cover the catheter site.

ii. Tegaderm is the only transparent dressing approved for use with intravascular devices.

iii. The use of the biopatch at the insertion under a transparent dressing will reduce bacterial colonization rate.

iv. The first change of the dressing shall take place after 24hr. The second change shall take place after 48 hrs after the first change. Afterwards, change catheter site dressings every 72 hours routinely or before or when they become damp, soiled or loose.

v. Replace catheter site dressing when the device is removed or replaced Change dressings more frequently in diaphoretic patients.

vi. Avoid touch contamination of the catheter insertion when replacing the dressings.

E. Replacement of Catheteri. In adults replace short peripheral venous catheters and rotate peripheral venous sites every 48-96 hours to minimize the risk of phlebitis. Remove and replace when signs and symptoms of infections are present, i.e. warmth, tenderness, erythema or tenderness at the insertion site. ii. Leave peripheral venous catheters in pl

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