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CONTENTS
TOPIC
i.
PAGE NO.
Abbreviations........................................................................................................................................5
1.0 INTRODUCTION.......................................................................................................................................7
1.11 CURRENT SCENARIO..............................................................................................................................7
1.12 STATISTICS...............................................................................................................................................7
1.13 LEGAL MANDATES................................................................................................................................8
1.14 NEED FOR STANDARDISATION OF ACCIDENT AND EMERGENCY SERVICES......................8
1.15 PROBLEMS IN ACCIDENT and EMERGENCY CARE DELIVERY IN INDIA AT THE
HEALTHCARE
FACILITY............................................................................................................................................................8
2.0 PURPOSE OF THE GUIDELINES............................................................................................................................8
3.0 OBJECTIVE OF THE GUIDELINES............................................................................................................................8
2.
3.
4.
5.
REASSESSMENT OF PATIENT..................................................................................................................52
6.
7.
REFERRAL OF PATIENTS.............................................................................................................................53
8.
9.
ABBREVIATIONS
A&ED
AIDS
APIC
BID
Brought In Dead
BPL
CCTV
CPR
Cardio-Pulmonary Resuscitation
CSSD
EMT
HAI
HBV
Hepatitis B Virus
HCV
Hepatitis C Virus
HR
Human Resource
HVAC
ICU
IPD
In-Patient Department
LAMA
LASA
MLC
NACO
OPD
Out-Patient Department
OT
Operation theatre
PEP
POP
Plaster of Paris
PPE
WHO
GUIDELINES ON
ACCIDENT & EMERGENCY DEPARTMENT
1.0
INTRODUCTION
Accident and Emergency services is a vital component of hospital services because injury is
always unexpected and unplanned and if not treated urgently can result in damage, deformity
and death.
The patients entering an emergency department can be saved only if they arrive at the right time,
at the right place, receives the right treatment and right resources.
The aspect of speed, accuracy and sympathy are important in the emergency department.
The major functions of an emergency department involve:
1) To treat unexpected patients with life threatening and routine conditions.
2) To provide services at all 365 days in a year.
3) To provide immediate, appropriate and life saving care.
4) To provide services in efficient and effective manner.
5) To be sensitive to emotional needs of the patients and their relatives
6) To liaise with courts and police in emergency.
7) To be ready for disaster and mass casualty.
1.1.2 STATISTICS
Emergency services is a broad term as such in clued trauma and non-trauma emergencies like poisoning,
burns, acute Myocardial Infarction etc. There are no state and National level statistics available on
incidence of emergency conditions. For trauma emergencies the National Health Profile of India 2009 lists
injury as the 3rd leading cause of death in India. Recent calculations by the Planning Commission of India
estimate the total societal cost of injury in India to be approx. 3% of Indias GDP. 1 Planning and
standardisation of emergency services is a vital step in order to decrease these cost implications.
Lack of accountability and monitoring mechanisms to ensure timely and optimal care.
2.0
PURPOSE
GUIDELINES
OF
Chapter -1
10
Chapter -1
1.0 INTRODUCTION
The department would accept all patients of all age groups (Adult
as well as paediatric) and they would receive emergency care and
referral as necessary.
1.2 GOALS
1) To provide priority care for individuals who require
immediate medical attention as per triage guidelines.
2) To provide rapid resuscitation, stabilisation and referral of
critically ill patients.
3) To provide necessary definitive medical care to stabilise an
emergency condition within discretion of the doctor doing
screening of patients.
4) To provide continuity in care through mechanisms for
admission, treatment, discharge and or referral to another
facility.
5) To ensure that all the patients coming to emergency are
assessed by qualified individuals.
11
SNO.
1
NAME OF ILLNESS
CARDIOVASCULAR SYSTEM
a) Chest Pain (Ischemic Heart Disease)
b) Acute Myocardial Infarction
c) Accelerated Hypertension
d) Congestive Cardiac Failure
e) Arrhythmias
GASTROINTESTINAL TRACT
a) Acute Cholecystitis
b) Acute Gastroenteritis with/without dehydration
c) Dysentery
d) Vomiting
e) Pain Abdomen
f) Ascitis
g) Haematamesis
h) Cirrhosis
i) Alcoholic Liver Disease (ALD)
DIABETIC COMPLICATIONS
a) Hypoglycaemia
b) Ketoacidosis
c) Diabetic Coma
d) Hyperglycaemia
Shock
Anaphylactic Reactions
12
Septicaemia
Snake Bite
Animal Bites
10
Insect Bites
11
Heat Stroke
12
13
14
NEUROLOGY
a) Cerebro-Vascular Accident (CVA)
b) Transient Ischemic Attack (TIA)
c) Vertigo
d) Headache
e) Spinal Injury
f) Encephalitis
g) Epilepsy
13
h) Meningitis
i) Febrile convulsions
15
HAEMATOLOGY
a) Severe Anaemia
b) Bleeding Disorder like Haemophilia, Thallasemia
16
COMMUNICABLE DISEASES
a) Cholera
b) Measles
c) Mumps
d) Chicken Pox
e) Diphtheria
f) Rabies
17
PSYCHIATRY
a) Anxiety disorders
b) Alcohol and Drug Abuse
c) Stress disorder
d) Depression
e) Acute Psychiatric Illness
18
NEPHROLOGY
a) Urinary Tract Infection (UTI)
b) Nephrotic Syndrome
c) Acute Nephritis
d) Diabetic Nephropathy
e) Hypertensive Nephropathy
f) Nephrolithiasis
g) Acute Renal Failure/Chronic Renal Failure
19
GENERAL SURGERY
a) Intestinal Obstruction
b) Burns
14
c) Cellulitis
d) Acute Abdomen
e) Acute Appendicitis
f) Acute Cholecystitis
g) Perforation
h) Assault Injuries
i) Haemorrhoids
j) Acute Urinary Obstruction
k) Liver Abscess
l) Benign/ Malignant Tumors- (Investigate and Decide further)
m) Road Traffic Accident
n) Head Injury (Not requiring Surgery)
o) BPH with Urinary Retention
20
OPTHALMOLOGY
a) Foreign Body
b) Injuries
21
A
NOSE
a) Epistaxis
b) Foreign body
THROAT
a) Tonsillitis/ Laryngitis
15
b) Quinsy
c) Malignant Larynx
d) Foreign Body Oesophagus
e) Foreign Body Bronchus
f) Malignancy of Larynx
22
ORTHOPEDICS
a) Osteomyelitis
b) Road Traffic Accident / Polytrauma
c) Fractures
d) Acute Gout
23
DENTAL SURGERY
a) Injuries -Trauma
b) Toothache
24
MLC CASES
a) Assault
b) Poisoning
c) Intoxication
d) Burns
e) Drowning
f) Suicidal Attempts
g) Vehicular/ Factory/ Unnatural Accident
h) Sexual Assault
i) Criminal Abortion
j) Unconscious patient
k) Cases referred from field as Medico-Legal
l) Brought Dead
m) Post Mortem
n) Any person brought by police for Medical Examination
o) Any other case not falling under the above categories but has legal
implications
16
Chapter -2
DESIGNING FOR ACCIDENT AND EMERGENCY
DEPARTMENT
(A & ED)
17
Chapter-2
A wrongly planned
emergency department
can ruin a hospitals
activities. A hospital
must be adequately
equipped to handle
emergencies
like
accidents,
involving
mass
causalities,
internal and external
disaster
extremely difficult
the emergency
personnel are
specifically trained.
The scope of services being provided by an Emergency Department
is a major determinant of the level of staffing, resources and
physical design required.
Key considerations for planning A&ED include safety and security,
provision of amenities, access, patient expectations, and evolving
good practices.
18
The emergency department is a core clinical unit of a hospital. Its function is to receive patients, conduct
effective triage, stabilize and provide emergency management to patients who present with a wide
variety of critical, urgent and semi urgent conditions. The emergency department also provides for
proper reception and management of patients who are victims of a disaster as part of its role in the
disaster plan of that region. In addition to standard treatment areas, some additional specifically designed
areas may be required to fulfill special roles, such as:
Administration
Staff amenities
Storage areas
Entrance/Reception/Triage area
Resuscitation area
Acute Treatment area
Consultation area
Workstations of Staff
Amenities
19
AMBULANCE
BAY
AMBULANCE
TRIAGE
RESUSCITATION
OBSERVATION
SUPPORT
CIRCULATION
From
Main
Entry
CAR
PARK
TRIAGE
CLERICAL
RECEPTION
SUPPORT
WAITING
OPTIONAL INTEGRATION
X-RAY
STAFF
STATION
WORK BAY
OBSERVATION
ACUTE
OBSERVATION
OPERATING
UNIT/
INTENSIVE
CARE/
IMAGING/
INPATIENT
UNITS/
MORTUARY
SUPPORT
The main aggregation of clinical staff over 24 hours will be at the staff station in the Acute
Treatment/Resuscitation area.
Therefore it should be the focus around which the other clinical are as are grouped.
The Entrance/Reception/Triage area is the area in which an emergency patient initially
presents.
The Administration area should be accessible to the clinical areas but should not impair
the clinical function of the department.
The support areas are best arranged around the periphery of the department.
20
Ready Access
Access
Ambulance
Inpatient Wards
Medical Imaging
Operating Rooms
Pharmacy
Laboratory
Outpatients
Blood bank
Mortuary
Pathology/Transfusion Services
Medical records
Remarks
A &ED design should allow rapid access to every space with a minimum
of cross traffic.
There should be close proximity between the Resuscitation area, Acute
Treatment areas for non-ambulant patients and treatment areas for
ambulant patients, as staff may require to rush from one place to
another.
Visitor and patient access to all areas should not traverse through
clinical areas.
Due consideration should be given to protection of privacy, whilst
recognizing the need for observation of patients by staff.
Radiological, imaging, laboratory and other diagnostic services as per
scope of hospital must be available within a reasonable period of time
for individuals who require these services.
Appropriate signs consistent with the applicable regulations and laws
should indicate the direction of the A&ED from major thoroughfares
along with broad outline of services available.
Adequate provisions for the safety of the A&ED staff, patients, and
visitors must be designed and implemented.
The emergency department should be clearly identified from all
entrances.
The emergency department should be located on the ground floor for
ease of access.
It should be close to public transport.
Adequate bilingual signage should be available to ensure ease of way
finding.
Illuminated signage is required for some signs to ensure visibility at
night. The use of graphic and character display (Eg. a white cross on a
red background with the word EMERGENCY is recommended.
Car parking should be close to the entrance, well lit and available
exclusively for patients, their relatives and staff.
Undercover parking should be available for appropriate number of
ambulances. This will be determined by case load.
Constructed in compliance with fire regulations
21
2.2.5 Lighting
In the Acute Treatment area there should be at least 7.8 feet (2.4
meters) of clear floor space between beds. The minimum length
should be 10 feet (3 meters).
It is essential that a high standard focused examination light is
available in all treatment areas.
Each examination light should have a power output of 30,000 lux,
illuminate a field size of at least 150mm and be of robust construction.
Clinical care areas should have exposure to daylight wherever possible
to minimize patient and staff disorientation.
Designed so as to minimize the transmission of sound between
adjacent treatment areas
2.2.8 Physiological
Monitors
Each Acute Treatment area bed should have access to a physiological monitor
which should include a minimum of:
ECG
Non Invasive Blood Pressure (NIBP)
Temperature
SpO2
2.2.9 Cabling
2.2.11 Doors
All doors through which patients may pass must be of sufficient size to
accommodate a full hospital bed.
2.2.12 Corridors
2.2.13 Air
Conditioning
22
2.2.14 Information/
Communications
Support
2.2.15 Patient
Facilities
Call
2.2.16 Hand
Washing Facilities
2.2.17 Emergency
Power
2.2.19 Floor
Covering
The floor covering in all patient care areas and corridors should have the
following characteristics
Non slip surface
Impermeable to water, body fluids
Durable
Easy to clean
A wall clock should be visible in all clinical areas and waiting areas.
Time clocks are desirable in the resuscitation, procedure and plaster
rooms.
Times displayed in all areas and on computers must be synchronized.
23
Consultation
Area
Specialities
Women &
Child Health
AMBULANCE
TRIAGE
Acute &
Sub-acute
Assessment
RESUSCITATION &
TRAUMA
Short Stay
Unit
IMAGING
SERVICES
Inpatient Wards
HOME
2.3.1
Area
Entrance
2.3.2
Reception
24
2.3.3
Triage
There may be need for triage when a school bus accident or a large pileup of cars on a highway results in too many injured people for too few
ambulances or EMTs.
The first interaction with the patient happens at the Triage.
The term "Triage" refers to a sorting of injured or sick people according to
their need for emergency medical attention.
It is used to determine priority for who gets care first.
Triage may be performed by anyone from emergency medical technicians
(EMTs) to emergency room gatekeepers.
The most common triaging system is the 4 level systems:
Treatment
Patient and visitor exit routes out of the emergency department should be
clearly sign posted from within the emergency department.
Area
General Requirements
The department should be accessed preferably by two
separate entrances; one for ambulance patients and the other
for walk-in patients.
It is recommended that each entrance area contains a
separate foyer.
Both entrances should direct the patient flow towards the
Reception/Triage area.
The Reception/Triage area should have clear vision to both
the waiting room and the ambulance entrance.
The reception/triage area should be designed to cater for the
easy access of wheelchair bound or otherwise disabled
patients.
The area should be designed with due consideration for the
safety of staff.
Access to treatment areas from reception/ triage should be
restricted by the use of security doors.
There should be direct communication between the
Reception/Triage area and the Nursing Station in the Acute
Treatment/Observation area.
Equipment
The Reception/Clerical office should have access to the following
equipment Computer terminals
Telephones
Photocopier
Computer printers
Storage space for stationery and medical records
Switches/ Sockets
The Triage area should have access to the following equipment:
2.4.3Resuscitation
Room/ Bay
Area
Resuscitation area may be further divided into separate bays
26
General Requirements
The Resuscitation area should be easily accessible from the
ambulance entrance and separate from patient circulation
areas.
It must be easily accessible from the staff station in the Acute
Treatment/Observation area.
The Resuscitation area should have a full range of vitals
monitoring and resuscitation equipment.
The Resuscitation area should preferably have solid partitions
between it and other areas.
Sufficient area should be there to fit a specialized resuscitation
bed.
Space to ensure 360 access to all parts of the patient for
procedures.
Space for equipment, monitors, storage and disposal facilities.
Circulation space to allow movement of staff and equipment.
Appropriate lighting, equipment to hang IV fluids etc.
Maximum possible visual and auditory privacy for the
occupants of the room and other patients and relatives.
Equipment
Each Resuscitation bed space should be equipped with:
Wall mounted BP apparatus
Fully equipped crash cart
Defibrillator/ AEDs
Sockets
Vitals monitor with facility for ECG, NIBP, SpO2 ,
temperature
An operating room light
IV stand
Wall clock
Infusion pumps
Drugs cupboard
The following should be immediately accessible:
Intravenous access trolleys
Urinary catheterization tray
Airway management tray (including
equipment)
Pediatric resuscitation equipment
surgical
airway
27
2.4.4
Area
Area
Each treatment area must be at least 12 m2 (130 ft2) in area.
Areas such as procedure and plaster rooms are not considered
as treatment areas nor are observation unit beds for admitted
patients.
Minimum recommended space between centers of two
adjoining beds is 2.4 meters. (8 ft).
General Requirements
It is divided into number of small units and each unit
treatment area has the following requirements:
Area to fit a standard mobile bed.
Storage space for essential equipment, E.g. Oxygen masks.
Space for equipment, monitors, storage and disposal facilities.
Appropriate lighting, equipment to hang IV fluids etc.
Circulation space to allow movement of staff and equipment
around the work area.
If possible there should be a separate paediatric area/beds for
the treatment of children.
All of these beds must be situated to enable direct observation
from the Nursing Station.
If possible a separate dedicated area/ room should be present
for examination of MLC cases.
3.3.5
Area
Consultation
3.3.6
Plaster Room
Equipment
The following equipment are required:
Storage for plaster bandages
X-Ray viewing panel
Monitoring equipment (NIBP, SpO2, ECG) including access
to resuscitation equipment
Nitrous oxide delivery system or storage space for a
portable nitrous oxide delivery system
Plaster trolley
Sink and drain with a plaster trap
Work bench
3.3.7
Procedure Room
General Requirements
It should be directly accessible from A&ED.
It should have Area to fit a standard mobile patient trolley.
Storage space for essential equipment and dressing material
Eg. Oxygen masks, Ryles tube, PPE etc.
Space for dressing trolleys.
Space for disposal facilities.
Equipment
Minimal equipment include:
Operating theatre light suspended from the ceiling
X-Ray viewing box
Monitoring equipment: NIBP, SpO2, ECG with access to
resuscitation equipment.
3.3.8
Nursing Station
The Staff Station in the Acute Treatment area will be the major
staff area within the department.
Area
The staff station(s) must be at least 10m2 (108 ft2) in size or
1m2 (10 ft2) /1000 yearly attendances, whichever is larger.
General Requirements
The station should provide an uninterrupted view of patients
and the floor may be raised to achieve this aim.
It should be centrally located and constructed in such a
fashion to ensure that confidential information can be
conveyed without breach of privacy.
An enclosed area is recommended for this reason and also to
provide security of staff, information and privacy.
Equipment
The following equipment and fittings should be accessible:
29
Intercom
Direct line telephone for incoming Ambulance/Police use
only
Computer terminal
Medicine cupboards
Emergency and patient call display
Alarm
Valuables storage space
Storage for stationery
Writing and work benches
General Requirement
Patients may be kept in this Unit for diagnosis, treatment,
investigation or for medical stabilization.
The length of stay in the Unit is generally between 4 and 24
hours, although some patients may require longer stays.
The Unit may also be situated separately to the Emergency
Unit, although functionally linked. According to the service
plan, dedicated beds for short stay are separately
designated and staffed.
The number of beds required will be influenced by the
function and type of patient in the unit.
Some of the beds should be capable of physiological
monitoring similar to an acute treatment area.
There should be a separate nursing station of an
appropriate size.
Hospital beds and not trolleys must be provided.
30
Toilets
Public Telephones
Health literature
3.3.12 CLINICAL
SUPPORT AREAS
General Requirement
The location of an office for security personnel near the
entrance should be considered.
This room should be so positioned as to enable direct
visualization of the waiting room, triage and reception areas
with immediate access to these areas being essential.
Remote monitoring of other areas in the department by CCTV
should also occur from this area.
1 Clean Utility
This should be of sufficient size for the storage of clean and sterile
supplies.
2 Dirty Utility/Disposal Room
Access should be available from all clinical areas.
There should be sufficient space to house the following:
Stainless steel bench with sink and drainer
Storage space for soiled linen
3 Equipment/Store Room
This is used for the storage of equipment (Eg. IV stands) and
disposable medical supplies for the department. There should be
sufficient space to store. The total area of dedicated store rooms
must be at least 2.2m2 (24 sq ft) /1000 yearly attendances.
31
Janitors Room
It should have a basin, water facility for washing and
adequate space for keeping mops, broom and reagents.
The flooring should be non slippery and stain resistant.
7 Patient toilets
In an Emergency Unit the following Patient Toilet facilities will be
required, (separate Male and Female):
Up to eight treatment beds- 2 patient toilets, one each for
male/ female.
Between nine to twenty treatment beds-4 patient toilets,
two each for male/ female.
Between 21 to 40 treatment beds-6 patient toilets, 3 each
for male/ female.
At least two of the above toilets to be assessable for
wheelchair, one each for male /female
3.3.13 STAFF
FACILITIES
1.
Staff Room
At least two rooms should be provided within the
department one for doctors and other for staff nurses to
enable staff to distress during rest periods.
There should be appropriate table and seating
arrangements.
It should be located away from patient care areas and
have access to natural lighting and appropriate floor and
wall coverings.
The staff room should be based upon the number of staff
working at any one time and their anticipated needs, and
as an initial guide, this should be at least 0.8m2 (9 sq ft)
/1000 yearly attendances, which can be adjusted
depending on staff numbers.
Staff should have access to independent toilets. Staff
lockers should be available.
32
3.3.14 SECURITY
33
Chapter -3
MANPOWER REQUIREMENTS FOR ACCIDENT AND
EMERGENCY DEPARTMENT
34
Chapter -3
1.3 (a)
PRINCIPLES OF A range of methods exists that enables staffing to be
APPROACHES TO PLANNING planned.
NURSE STAFFING
The principles to planning staffing rely on quantifying the volume of nursing care to be
provided on the basis of :
The size of population,
Mix of patients, and
Type of service - and
Relating it to the activities undertaken by different members of the team.
Good quality data (HR, quality and outcomes) is therefore the cornerstone of effective
staff planning and review.
Staffing decisions cannot be made effectively without having good quality data on the
following parameters
35
Patient mix
(acuity/dependency)
and service demands
Current staffing
(sanctioned/vacant
posts)
Factors that
impinge on daily
staffing levels
(absence,
vacancies,
turnover)
Evidence of the
effectiveness of
staffing - quality
patient outcomes
1.3 (b)
APPROACHES TO There are two broad types of approach to workforce
planning: top-down and bottom-up. While they can be
PLANNING OF WORKFORCE
used in isolation of one another, they are best considered
as complementary approaches.
TOP-DOWN PLANNING
BOTTOM-UP METHODS
36
1.4
CHALLENGES
IN It is necessary to provide staff to cover a workload higher
DECIDING STAFFING LEVELS than the average number of visits keeping in view the
critical nature of patients coming to A&ED.
FOR A&ED
It is necessary to provide staff to cover a workload higher than the average number of visits
keeping in view the critical nature of patients coming to A&ED. This results in some standby or
idle time of the staff. Despite this idle time, staff cannot be reassigned to other areas and pulled
back when patients arrive. Matching the peak patient volumes to peak staffing pattern is a
challenging task.
Volume varies significantly from day to day and also during the 24 hours. Often the highest
volumes occur during odd hours and on weekends and holidays when alternative sources of care
are closed, Eg., doctors offices and clinics. While the total number of visit may be higher on
weekends, the number of admitted patients does not go up at the same rate, and may not
increase because the acuity is lower on weekends.
The distribution of patients by shift is somewhat dependent on where the hospital is located. An
inner city hospital may have more patients admitted on the night shift as compared to a
suburban hospital.
Type of patients coming to A&ED department varies depending upon location of hospital in the
city as well as the region of state in which hospital is located. For Eg. hospitals close to national
highways may have more accident cases. Hospitals closer to medical colleges may be catering to
lesser number of patients and less acute cases.
Other significant factors impacting the staffing standard are the percentage of patients admitted
rather than treated and released, and whether or not the ED staff is responsible for selected
activities. The admitted percentage can range from less than 10% to almost 25% of all patients.
SNO
Supervisory
personnel
like
Resident Medical Officer or
Emergency In charge-
Medical Officers
REMARKS
37
So for a workload of
< 75 patients/ 24 hrs = 1 MO / shift ( Total
3 MO during 24 hours)
Staff Nurses
For a workload of
< 50 patients/24 hrs = 1 OTA and or
dresser/ shift (Total 3OTA/Dresser during
24 hours) for dressings, splint application and
suturing of minor injuries.
38
night shift.
b) Registration Clerk-
d) Lab technician-
for
e) Security staff-
For a workload of
f)
Group D staff-
For a workload of
g) Housekeeping staff-
For a workload of
39
Chapter-4
STANDARD CONCEPTS RELATED TO ACCIDENT
AND EMERGENCY DEPARTMENT
AND
QUALITY INDICATORS FOR A&ED OF HOSPITAL
40
Chapter: 4
The rst hour after injury largely determines a criticallyinjured persons chances for survival, it is also known as
the Golden Time.
It is the time period which can range from a few minutes to a few hours, i.e. not necessarily one
hour, but the amount of time which follows a traumatic injury sustained; during which there is
highest likelihood that prompt medical treatment will prevent death.
During this time period, the possibility of saving ones life is the highest through emergency
medical treatment. Special trauma centres and many other emergency medical services are
designed just because of this reason and to make sure that the injured person is properly treated
in the case.
Death following Trauma generally occurs due to a shock. Major causes include internal bleeding
leading to haemorrhage shock. It is crucial to provide proper and instant medical help to
someone in dire need of it. If the injury can be treated on time, the blood flow controlled and
blood pressure restored in that course of time, a life can be saved.
In case of heart and chest injuries, the patient can get a stroke easily and during that time the
theory behind Golden Hour comes into real-time practice.
Since the patient is in a state of shock, a well trained medical practitioner can provide the help
they need and that can be vital in saving their life.
CONCEPT 2. TRIAGE
1.1GOALS OF TRIAGE
a.
b.
c.
d.
41
e.
Category 2
Urgent (Yellow)
Category 3
Minimal (Green)
Category4
Expectant (Black)
Patients in Green
Category should be sent
to Consultation Area
Patients in Red
Category should be
sent to the
Resuscitation Area
CONCEPT 3.REVERSE TRIAGE This concept is used to provide extra patient beds during
public health emergency.
Sometimes the less wounded are treated in preference to the more severely wounded. This may
arise in a situation such as disaster situations where medical resources are limited in order to
conserve resources for those likely to survive but requiring advanced medical care.
This method evaluates inpatients to see which ones can be safely discharged to free up beds for
other patients in more immediate need of medical care.
Patients who have only a slight chance of experiencing an adverse event within four days of
leaving the hospital may be discharged to free bed space. A&ED staff can provide a daily initial
reverse triage score for patients being admitted, even if a disaster is not imminent.
42
Total monthly
admissions:Total number of
patients admitted through
emergency in a month.
Number of patients
Referred in from periphery
with details of referring
institute along with reason for
referral.
Number of patients
Referred out to other
hospital with details of
referring institute along with
reason for referral.
Time to Treatment
43
Time to treatment
This indicator applies to all patients coming to emergency. It shows the time taken
from arrival to seeing a doctor and nurse who will start the treatment for the
patients condition.
Time to shifting
Patient satisfaction
surveys
Time to shifting
This indicator shows the number of patients shifted to respective wards within 8 hours of
admission out of total admissions.
44
Medication Errors
A medication error is any preventable event that may cause or lead to inappropriate
medication use or harm to a patient, like Errors in the prescribing, transcribing,
dispensing, administering, and monitoring of medications, Wrong drug, wrong
strength, or wrong dose errors, Wrong patient etc.
All the cases of medication error should be reported and analysed.
Adverse Events
An adverse effect is a harmful and undesired effect resulting from a medication or
other intervention such as surgery.
All the cases of adverse events should be reported and analysed.
Near Miss
A near miss is an unplanned event that did not result in injury, Illness, or damage,
but had the potential to do so.
Errors that did not result in patient harm, but could have, can be categorized as near
misses.
All the cases of near miss should be reported and analysed.
Audits
In addition to above indicators medical record audit/ death audit/ prescription
audit should be routinely conducted on sampling basis.
Total Number of
Emergency Cases
per thousand
population
Total Number of
Trips per
ambulance
Total number of
trauma cases
treated per 1000
Emergency cases
Total number of
poisoning cases
treated per 1000
emergency cases
Total number of
Cardiac cases
treated per 1000
emergency cases
Total number of
Obstetric Cases
treated per 1000
emergency cases
Total number of
resuscitation
done per 1000
population .
Proportion of
patients attended
at Night
45
Response time of
Ambulance
Death Rate
Average Turnaround
time: Average time a
patient stays at the
emergency
observation bed
LAMA Rate
Proportion of Patient
referred by State
owned 102
ambulance per 1000
referral cases
Absconding Rate
46
Chapter -5
STANDARD PROTOCOLS FOR EMERGENCY
DEPARTMENT
47
Chapter- 5
3.
4.
5.
Reassessment of patient
6.
7.
Referral of patients
8.
9.
48
In case of critical patients, they are immediately directed to the consultation area and
registration is done afterwards at the emergency registration counter.
All critical patients coming to emergency are registered at emergency registration counter.
During OPD working hours if a non critical patient walks into emergency he is directed to go
to concerned OPD after registration at the general OPD registration counter of the hospital,
whereas during odd hours and holidays all patients walking into hospital are registered at
the emergency registration counter except in those hospitals where evening OPD is
functional.
For referred in patients same is mentioned on the OPD card along with details of facility
from where referred and reason for referral. Referral slip if available is retained in hospital
record.
In addition to OPD number, all the medico-legal cases are separately identified by a
centralised MLC number. MLC number is provided either manually at the registration
counter or generated by computer.
Police information is sent for all the medico legal cases by the doctor on duty.
All unidentified patients are registered as medico legal cases and the information regarding
this is sent to police and once the patient is identified, information is updated in the records.
After doctors assessment a provisional or actual diagnosis is entered on the OPD card by
concerned doctor both for MLC and non MLC cases.
2.2 IN PATIENT REGISTRATION:
Responsibility: Registration clerk
Identification bands are provided to all the patients at the time of admission with the
help of which he/she is identified during his/her stay irrespective of the condition
(conscious /unconscious).
Different types of coding is followed to avoid any error that is
50
All the patients admitted under a particular speciality are examined by a specialist
within 12 hours of admission.
Patient assessment is recorded as per IPD assessment form attached as annexure-.
All the patient records are dated, timed, named and signed by the concerned person.
51
5. REASSESSMENT OF PATIENT
Purpose:
To monitor clinical progress of patient and to modify care of plan as and when required.
Responsibility:
Doctor on duty, staff nurse, concerned specialist
5.1OUT PATIENT REASSESSMENT:
All the critical patients are kept under observation in the observation area/room.
These patients are reassessed by the doctor on duty every 30 minutes or as and when
required.
All the non critical patients are reassessed every 4 hours or as and when required.
Decision to refer is taken in consultation with the specialist, however in life threatening
conditions the doctor on duty can refer the patient on his own and then inform the
concerned specialist.
5.2IN-PATIENT REASSESSMENT:
All the admitted patients are reassessed by doctor on duty at least twice during each
shift or more frequently if the patient is critical.
All the parameters are assessed as mentioned in reassessment form ( Attached as
annexure-II)
7.REFERRAL OF PATIENTS
7.1REFERRED IN
Purpose:
To ensure that all the patients being referred to hospital from periphery and other institutes are
promptly treated if services required are within scope of the hospital.
Responsibility:
Doctor on duty, staff nurse on duty
Procedure:
All the patients referred from periphery and other institutes are promptly treated at the
hospital if the services required are within scope of A&ED of hospital.
If the services required are not in the scope of hospital then these patients/ attendants are
explained the same and also guided about the alternatives. The protocol for referred out
patient is followed.
All the referred in patients are registered in the hospital and their record is maintained
separately as per format provided in annexure.
7.2REFERRAL OUT
Purpose:
Patients who do not match scope of the services of the hospital are referred to higher centre without
unnecessary delay.
Responsibility:
Doctor on duty, concerned specialist
Procedure:
Once doctor on duty decides that the patient requires referral to higher centre for further
treatment he/she contacts the concerned specialist on telephone or through a written call. If
required specialist doctor visits the patient and assess condition of patient and then take the
decision to refer the patient.
If the patient is critical and any delay in treatment may endanger life of patient, he/she is
referred by doctor on duty.
If the patients condition is unstable, he should be stabilized in the emergency department
before referring out.
Doctor on duty ensures availability of bed in the hospital where patient is being referred.
In case of non-availability of beds alternatives are explained to the relatives of the patient and
decision is made accordingly.
EMT accompanies the patient in case of critical patient.
Fully filled referral card is provided to the patient at the time of referral with details like
reason for referral, investigations done if any.(Attached as annexure-I)
Ambulance used is fully equipped with resuscitation equipment and with trained staff who has
training in BLS.
Entry is made in the refer-out register.
53
Procedure:
Discharge process is discussed with patient and family.
The concerned doctor, discharging the patient documents the discharge instructions in the file at
the time of discharge.
Discharge summary is prepared on a standardised format and signed by the concerned doctor.
The discharge summary contains :
Diagnosis
Brief progress notes
Significant findings
Investigations results
Procedures performed (if any)
Condition at the time of discharge
Discharge medications and follow up instructions
Instructions about when and how to contact in case of emergency
The doctor on duty/ specialist discusses the consequences and risk to the patient and
relatives. The patient, relatives, concerned doctor and the nurse on duty sign the consent
for discharge against medical advice.
A discharge summary is handed over to the patient/relative with the medical advice and it is
mentioned on the discharge card that patient is being discharged against medical advice.
8.2 ABSCONDED PATIENT:
Purpose:
To provide guidelines to be followed in case the patient absconds from hospital without
informing concerned staff.
Responsibility:
Doctor on duty, concerned specialist, staff nurse
Procedure:
If a patient absconds from hospital without informing any concerned staff member
54
then this information is mentioned in the patient record.
In medico legal cases information is sent to police about absconded patients.
The Category-I patients are referred to Resuscitation Room. Patients are managed as per the
resuscitation protocol.
9.2 OBSERVATION ROOM CARE
The Category-II patients are referred to Observation Room.
Purpose:
To Provide a standardised protocol to be followed in case of critical patients kept under
observation in observation area and to ensure that all the equipments in the observation area
are functional at all times.
Responsibility:
Doctor on Duty, Nurse on Duty
Procedure:
Initial Assessment of the patient is done as per the initial assessment protocols already
described.
The doctor on duty reassesses the patient every 30 minutes or more frequently as per
patients condition.
Decision is taken to admit, shift, discharge or refer the patient within four hours.
The staff nurse on duty also monitors the patient as per doctors instructions.
All the investigations (Laboratory, Radiology, etc.) are done as soon as possible and reports
are made available on priority.
Doctors and nurses follow ethical code of conduct and universal precautions.
Proper written handover of patients is done as the shift changes.
Drugs and equipments are checked and monitored at the start of every shift.
Hygiene and sanitation is maintained at all times. Infection control and waste management
protocols are strictly followed. (Attached as annexure-V)
55
Procedure:
The privacy of the patient should be ensured first.
The doctor on duty examines the patient and prepares medico legal report in computerized
format. In case doctor is unable to provide computerised report immediately, manual report is
provided to the patient and computerised report is provided within one week.
The police authorities are intimated giving brief details of the case in a written format.
The reporting time and date is also mentioned in the police information.
MLC police information form is filled in duplicate and one copy is handed over to the police
person and one copy is retained in the hospital record.
Receiving is taken from police person who receives the information.
Wherever required various specimens are collected, sealed and handed over to the police
authorities after sealing the same. A receipt of the items sealed and handed over to the police is
taken. Patient case file is stamped as medico-legal case.
* For more details refer to Haryana medico legal manual
56
Patients are advised to leave all valuables at home or send them home upon admission to the
hospital; this includes jewellery , cash etc. That would be considered a loss if misplaced
If attendant is not available the nurse on duty keeps the valuables under lock and key. They are
not kept at patient bedside
Patient is informed to take care of their belongings that they bring along such as mobile etc.
57
Chapter -6
DISASTER MANAGEMENT
58
Chapter-6
DISASTER MANAGEMENT
Disaster is a Situation or
event which overwhelms
1.0 DEFINITION
external assistance.
59
Disaster management committee (Details related to the committee are given below)
A documented Disaster Management Plan
Emergency /disaster alert codes
Fully equipped Ambulance with first aid equipment.
Flexible space and beds should be ensured to accommodate patients and relatives.
Medico-legal responsibilities should be defined.
Procedure to ensure availability of drugs i.e. Emergency kit / Disaster kit and other supplies
(Example Antibiotics, ORS, IV fluids, Analgesics, Disinfectants etc.) at the casualty department.
Operation Theatre to be kept ready for an emergency.
Job card should be assigned to each staff member explaining the exact role of that person during
disaster.
All staff instructed that on receipt of warning they should immediately report to the hospital
without any delay
Mobilisation of disaster management team members and other ancillary staff.
Names and contact numbers of the staff and their position according to the plan (list of
emergency contact number, adjoining hospitals, fire brigade, Police station.)
Training and mock drill.
3.1 LINES OF AUTHORITY: The following persons, in the order listed, would be in charge:
1.
Medical Superintendent
2.
3.
4.
Matron.
5.
6.
60
Functions are assigned to members and the members prepare and update the disaster
management plan.
Code activation,
Major decisions to be taken during disaster
Manage disaster management events
Supervise training and mock drills
1.
A siren/ public address system is available and working in the emergency department to
Casualty medical officer will inform casualty- in- charge who is head of disaster management
committee, who in turn will inform medical superintendent and hospital administrator.
3.
4.
Various department Heads will notify their key personnel depending on extent of disaster
and need.
5.
6.
A Command Centre will be set up at the PMO/MSs office to handle and coordinate all
internal communications. All department heads will report to this office and call as many of
their employees as needed.
7.
Hospital administrator will assign a clerical staff who will answer all telephone calls from
this station. .
8.
The class IV/ Security Guard will be assigned to the telephone operator to deliver messages,
obtain casualty count from triage, etc.
9.
The class IV/Security Guard will be assigned to act as a runner to all departments to advise
them of the type of disaster and number of victims and extent of injuries when this
information is available.
Reception centre:
For moderate load: Present casualty OPD will function as reception area.
For heavy load: Main hall of OPD will function as reception area.
Police and security persons on duty will act as traffic controllers.
II.
61
One physician
One anaesthetist
Two sisters
One sweeper
The responsibilities of first aid centre will beQuickly sorting out causalities into:
Priority 1: Needing immediate resuscitation
Priority 2: Needing Immediate surgery
Priority 3: Needing first aid and possible surgery
Priority 4: Needing only first aid.
ACTIONS:
Priority 1 will be attended to in casualty department and if needed will be sent
to I.C.U.
Priority 2 will be transferred immediately to OT.
Priority 3 will be given first aid and admitted if beds are available or
transferred to other hospital.
Priority 4 will be given first aid and discharged home.
III.
1.
Morgue Facilities:
Patients brought in dead (BID) will be tagged with a black Disaster Tag. Their personal
belongings will be secured in plastic bags and stored along with dead body with ID Labels.
2.
Bodies will be stored in a designated place by Security with care and respect. Security
Personnel will remain with bodies until removed by proper authority.
3.
After bodies have been identified, the information will be filled on the Disaster Tag and
Medical Records will be updated.
4.
The bodies and their belongings will be handed over to the relatives after proper
identification in presence of representatives from the police department. Bodies which
remain unclaimed will be handed over to the police after following the required procedures.
All the activities to be supervised by forensic expert or designated person.
5.
All staff must be trained to be sensitive while preserving and handing over bodies/
belongings.
62
IV.
A hospital staff member will update and counsel the family members.
A list of the visitor's names in association with the patient they are inquiring about
will be kept. Volunteers may be needed to escort visitors within the facility.
V.
Telephone lines:
Telephone lines will be made available for outgoing and incoming calls.
The hospital
2.
3.
4.
Extra supplies will be obtained from store or through purchasing personnel under
supervision of store- in- charge. Separate room will be earmarked for this purpose
2.
Outside supplies will be ordered by the store- in-charges and brought into the hospital.
Large paper or plastic bags will be made available in the treatment Areas and the storeroom for
patient's clothing and valuables.
2.
All the bags will be labelled with patients name and C.R. number as far as possible. A staff nurse
will be assigned for this purpose.
A communication centre for giving information to the press and relatives will be set up in PMO
office. All the press releases will be handled by hospital administrator or designated person.
Appoint triage coordinator and medical coordinator for ward, casualty and O.T.
Will assign an M.O. to go to site if required, along with mobile medical team.
63
B. Hospital Administrator:
In a major disaster will do the following functions:
1.
Check with local authorities to verify the disaster and obtain additional information.
2.
3.
Ask for help from local police and volunteer organizations as deemed necessary.
4.
C. Nursing In charge:
1.
Is responsible for determining the extent of the disaster, whether it is a "major" or a "minor"
disaster. If it is a major disaster, then the PMO/ MS and Matron will be notified (if not present
at time of disaster).
2.
Will attempt to find adequate numbers of nursing personnel. Have them keep a list of those
notified.
3.
Will be responsible for making available prearranged admission ward and as many beds as
possible by discharging the categories of patients as explained above.
.
D. Department head or designee will call in their own personnel as needed after having
reported to the Command Centre.
E. Admitting office
1.
2.
3.
Assign an admissions person to aid with discharge of hospital patients from the wards, if
requested by Medical Team.
The Department in charge or designee will call in their own personnel as needed after
reporting to Command Centre.
2.
I. Maintenance
1.
Department head or designee will call in their own personnel as needed after reporting to
Command Centre.
64
2.
3.
All doors should be locked immediately except in case of fire. Doors to Emergency
Department and front lobby to be kept open. Prevent entrance of extra persons/ relatives
and security is reinforced.
Department head or designee will call in their own personnel as needed after reporting to
Command Centre.
2.
Be available to help clean receiving area, and clean rooms between cases in treatment areas.
3.
4.
Supervisor or Nurse will supervise Operating Room and call all needed personnel after
reporting to Command Centre.
2.
3.
4.
Notify anaesthetists who will maintain adequate anaesthesia and drug supplies.
L. Medical Imaging
1. The department head or designee will find out the number of patients involved and any other
pertinent information from the Command Centre.
2. The department head or designee will be responsible for calling in any and all personnel
needed to sufficiently handle the patient load.
M. Laboratory
1.
Department Head or designee will call in their own personnel as needed after reporting to
Command Centre.
2.
3.
Have arrangements made to obtain additional equipment and supplies from area agencies.
N. Pharmacy
1.
2.
Have list of drug suppliers that can provide emergency supplies quickly
3.
4.
Pharmacy remains open and has a runner to deliver needed medicines to areas.
65
O. Security
1.
2.
P. Ambulances:
All the ambulances will be kept well equipped and shall be available at casualty department along
with drivers.
Q. Engineering and maintenance department:
Engineers will make sure that water and electricity is made available without interruption.
66
Chapter-7
INFECTION CONTROL PRACTICES FOR EMERGENCY
DEPARTMENT
67
Chapter-7
1.0 STATISTICS
INFECTIONS
OF
HOSPITAL
ACQUIRED
A
nosocomial
/
Hospital
Acquired
infection is defined as
an infection acquired
in hospital by a
patient who was
admitted
for
a
reason other than
that infection.
Also an infection
occurring in a patient
in hospital or other
health care facility in
whom the infection
was not present or
incubating at the time
of admission can be
classified as HAI.
68
The structural aspects will be covered in other section in detail. However, few important points are given
below:
The surfaces, be it floor, walls or work surfaces, should be such that they do not
encourage the accumulation of dust and are easily cleanable/ washable.
Adequate space should be there between the beds in patient care areas to reduce
chances of cross infections.
Properly constructed & maintained isolation facilities for infectious diseases as well as
for immune-compromised patients will result in reduced morbidity & mortality from
primary disease as well as HAI.
HVAC system which are properly designed and regularly maintained would reduce the
burden of infection in healthcare settings.
Keeping two or more patients on one bed greatly increases chances of Infections.
S No.
Type of Infection
4Prevention
Prominent features
Discharge, Abscess and Spreading
Cellulitis at the site of operation within one month of operation.
Symptoms like burning pain while micturition, frequency of
micturition,
Page 1, 4
69
Respiratory infection
Some of the important processes which can go a long way to decrease the burden of HAI are listed below:
1.34
INFECTION
COMMITTEE
HOSPITAL
CONTROL
To review and approve a yearly programme of activity for surveillance and prevention.
To Institute appropriate control measures when there is considered to be a danger to patients
or personnel.
To provide suggestions and provisions of resources like manpower, materials, logistics, training,
monitoring and reporting about infection control activities and services.
To review epidemiological surveillance data and identify areas for intervention.
To ensure appropriate staff training in infection control and safety.
To review and provide input into investigation of epidemics.
The committee can form a subcommittee for day to day functioning which can be designated as infection
control team.
1.34
INFECTION
TEAM
HOSPITAL
CONTROL
70
To prepare the yearly work plan for review by the infection control committee and
administration.
71
Implementing and maintaining hygiene, consistent with hospital policies and good nursing
practices in the emergency department.
Implementing and monitoring aseptic techniques, including hand washing and use of isolation
precautions in the emergency department.
Reporting promptly to the attending physician any evidence of infection in patients in the
emergency department.
Limiting patient exposure to infections from visitors, hospital staff, other patients, or equipment
used for diagnosis or treatment in the emergency department.
Maintaining a safe and adequate supply of emergency equipment, drugs and patient care
supplies.
Participating in training of personnel of the emergency department.
Ensure that bed linen is clean and regularly changed.
1.35
INFECTION recommended instructions and practices for patient care, is
an important tool.
CONTROL MANUAL
The manual should be developed and updated by the infection
control team, with review and approval by the committee. It
must be made readily available for patient care staff, and
updated in a timely fashion.
72
The components of the Infection Control Manual include various components including
sterilisation and disinfection policies, role of hospital acquired infections in the hospital, role of infection
control tea, outbreak protocol etc.
2.0 TRAINING
2.1 TRAINING
REQUIREMENTS OF
EMERGENCY STAFF
FOR INFECTION
CONTROL
3.1 RISK FROM BLOOD from blood born diseases since risk of exposure is more in an
BORNE DISEASES
emergency care setting. Risk of infection varies according to
the type of exposure.
73
SHARP SAFETY
b) HAND WASHING:
Hand washing is the single most important procedure for preventing infection. Contaminated
hands are frequently implicated as a means of transmission of nosocomial outbreaks in acute
care settings.
The consistent application of soap and water or alcohol-based waterless hand sanitizer is the
best way for emergency staff to protect their
families, colleagues, patients, and themselves
from dangerous diseases.
Washing with soap and water should be used for the first and last hand-wash of the shift,
when hands are visibly soiled and after every five applications of alcohol-based waterless
hand sanitizer.
The mechanical action of washing, rinsing and drying is the most important contributor to
the removal of transient bacteria that might be present.
Alcohol based hand rubs can be used when hands are NOT visibly soiled because the
effectiveness of alcohol is inhibited by the presence of organic material.
Health care workers are frequent hand washers and time should be taken to use
moisturizers to prevent the skin from becoming dry and cracked. Skin that is dry, cracked or
suffering from rashes can be a portal of entry for disease. Healthy, intact skin is an effective
barrier to infection.
74
Care should also be taken to ensure non-intact skin is covered while at work. If non-intact
skin is on the hands, two pairs of medical gloves should be worn as additional protection.
c)
SHARPS SAFETY:
According to the Association for Professionals in Infection Control (APIC) the most frequent
cause of blood-borne infection in healthcare settings is through needle stick injuries.
There are an estimated 600,000 needle stick injuries to health care workers each year in the
United States; but the exact number is not known as injuries often go unreported.
In order to help prevent needle stick injuries it is imperative to have an effective sharps
safety system in place.
Average risk of acquiring infection after needle stick injury:
Occupational risk of transmission is of HIV infection following needle stick injury from an
HIV-positive patient is 0.2% to 0.4% per injury and about 0.3% when the patient is infected
with HIV. The probability of HBV infection by needle sticks injury range from 1.9% to 40%
per injury and is 3% when the patient is infected with HCV.
75
Blood
Semen
Vaginal secretions
Cerebrospinal fluid
Synovial, pleural, peritoneal, pericardial fluid
Amniotic fluid
Other body fluids contaminated
with blood
Tears
sweat
Urine
faeces
saliva
If a needle stick injury occurs: Do not sqeeze blood from the wound and wash site with soap
and water, alcohol based, waterless hand sanitizer and/or an antiseptic swab as soon as
possible.
Staff must report the injury to their supervisor/ Staff Nurse on duty and then,report to
the doctor on emergency duty. The doctor on emergency duty is available for advice on
risk assessment, counselling and need for post exposure prophylaxis (PEP).
The first dose of PEP should be administered preferably within 2 hours but not later than
48 hours of exposure and the risk evaluated as soon as possible. If the risk is insignificant,
PEP could be discontinued, if already commenced
In all cases an accident/ incident record form should be completed within 24 hours by the
SN on duty.
76
High Risk
probable contact with blood,
splashing,
uncontrolled
bleeding
EXAMPLES
PROTECTIVE BARRIERS
Injections
Minor wound dressing
Insertion or removal of
intravenous cannula
Handling of laboratory
Specimens
Large open wounds
Dressing
Venipuncture ,spills of blood
Vaginal examination
Major
surgical
procedures and other minor
surgical procedures
Gloves
Water-proof Gown or Apron
Eye wear
Mask
Immediately wash the wound and surrounding skin with water and soap, and rinse. Do not
scrub.
For mouth:
77
Donts
Do not panic
Do not put the pricked finger in mouth
Do not squeeze the wound to bleed it
Do not use bleach, chlorine, alcohol, betadine,
iodine or other antiseptics/detergents on the
wound
78
Chapter-8
MANAGEMENT OF MEDICATION
79
Chapter-8
MANAGEMENT OF MEDICATION
1.0 INTRODUCTION
Greater focus is needed on improving patient safety in modern
healthcare systems and the first step to achieving this is to reliably
identify the safety issues arising in healthcare.
Medication Management is essential in Accident and Emergency
(A&E) department as it is considered to be a problematic
environment where safety is a concern due to various factors, such
as the range, nature and urgency of presenting conditions and the
high turnover of patients.
2.2
CART
CRASH
80
A suggestive list of drugs and equipment in the crash cart is given as below:
Top
Defibrillator
Electrodes
Suction machine
Adult and paediatric Ambu bags
Stethoscope
CPR book
On the side of the Crash Cart :
Oxygen tanks with one regulator
First Drawer
Inj. Atropine 1mg/10mL (1)
Inj. Adenosine 6mg/2cc (2)
Inj. Calcium Gluconate 1gm/10mL (1)
Inj. Adrenaline 1:10,000/10mL (2)
Inj. Dexamethasone 4mg/1mL (1)
Inj. Digoxin 0.5mg/2mL (1)
Tongue blades (5)
Oxygen wrench
Thermal paper
Second Drawer
Inj. Dextrose 50gm/50mL (1)
Inj. Amiodarone 150mg/3mL (2)
Inj. Nitroglycerine 50mg/10mL (1)
Inj. Sodium bicarb 8.4%/50mL (1)
Inj. Dopamine 400mg/10mL (1)
Suction tubing (2)
Third Drawer
Inj. Furosemide 40mg/10mL (2)
Inj. Magnesium sulfate 5gm/10mL (1)
Fifth Drawer
Laryngoscope handle
Miller Blade #2 (1)
Miller Blade #3 (1)
Macintosh Blade #2 (1)
Macintosh Blade #3 (1)
ET Tubes 4 (1)
ET Tubes 7 (1)
ET Tubes 8 (1)
Airways 6 (1)
Airways 8 (1)
Batteries C (2)
Fourth Drawer
Gloves 6-1/2 (3)
Gloves 7-1/2 (3)
Tape
IV Canula 22ga (2)
IV Canula 20ga (2)
Tourniquet (1)
Alcohol Swabs
Syringes 60ml (2)
Syringes 20ml (2)
Syringes 10ml (5)
Syringes 5ml (5)
Syringes 3ml (5)
Needles 18ga (10)
Conductivity gel
Inj. Normal Saline 50ml (2)
Sixth Drawer
D5 NS 250cc (1)
Lactated Ringers 500cc (2)
NACL 0.9% 500cc (2)
IV tubing (5)
81
2.4
PURCHASE
EMERGENCY
2.6
NARCOTIC
&
PSYCHOTROPIC DRUGS
DRUG
Diazepam
Paracetamol
FORMULATION
DOSE
Injection,
5 mg / ml
Suppository
5 mg
Injection
150 mg / ml
82
2.8
STANDARD
TREATMENT GUIDELINES
Assess Airway-Breathing-Circulation
Supplement-Oxygen
Secure IV access
Give isotonic crystalloid [(20 ml/kg over 3-5 min) NS, RL]
REASSESS
No improvement
Improved BP
- Peripheral perfusion
- Urine passed
Improvement
- Establish aetiology
- Continue fluids
- REASSESS frequently
- Inotrope
- Reassess
Continue fluid under
CVP monitoring
Consider alternate
aetiology
Consider
- Vasodilator
Diuretics
- Establish aetiology
Dialysis
- Careful fluid replacement
83
2.9
ANTIMICROBIAL
POLICY
2.10
AUDIT
PRESCRIPTION
2.11
MEDICATION
ERRORS/ADR
MONITORING
84
The following are some of the possible errors that can occur either in the prescribing, dispensing or
administration processes, and which should be monitored:
Prescribed medication not given by staff nurse
Administration of a drug that was not prescribed
Medicine given to the wrong patient
Wrong medicine or iv fluid administered
Wrong dose or strength given
Wrong dosage form given, for example eye drops instead
of ointment
Wrong route of administration
Wrong rate of administration, for example iv infusion
Wrong time or frequency of administration
Medicine given for the wrong duration
Wrong preparation of a dose, for example incorrect
dilution of a dose, not shaking a suspension
Incorrect administration technique
Medicine given to a patient with a known allergy.
85
Introducing a punishment-free system to collect and record information about medication errors
Developing written procedures with guidelines and checklists for the administration of
intravenous fluids and high-risk drugs
Confirming patients identity before administering a drug
Allowing verbal or telephone orders only in an emergency to prevent errors
Legible handwriting and complete spelling of a drug name
Using of standardized notation
Dose units written in one way only, for example mcg not g or g not gm
Use of leading zeros for values less than 1 (0.2 instead of.2) and avoidance of trailing zeros for
values more than 1 (2 instead of 2.0)
The route of administration and the complete directions (for example daily not OD) be written
on all drug orders (prescriptions)
2.11 PREVENTION OF
MEDICATION ERRORS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Tab.Ondansetron
Tab.Atenolol
Tab.Digene
Tab.Amoxycillin
Tab.Metaclopramide
Tab.Metrogyl
Tab.Dicylomine
Tab Clopidrogril
Tab Phenytoin
Tab Albendazol
Tab Calcium gluconate
Tab.Chlorphenaramine
Tab. Chlortrimazole
Tab.Paracetamol
Tab.Omeprazol
Tab.Mebendazol
Tab.Cotrimoxazol
Tab.Isosorbide mononitrate
Tab. Rantac
Tab. Ondansetron
Tab. Divol
Tab. Paracetamol
86
12.
13.
14.
15.
16.
Inj Vit. K
Inj Drotaverine
Inj Atropine sulphate
Inj Metaclopramide
Inj Lasix
Sound alike medicine: The following is the list of drugs when purchased locally with trade name causes
confusion
1. Tab.Epsoline(Phenytoin)
Tab.Efcorline (hydrocortisone)
2. Inj Syntac
Inj Rantac
3. Tab.PCM
Tab.PAM
4. Inj Tramadol
Inj Haloperidol
Spell alike: The following is the list of drugs commonly causing confusion if name of the Drug is not
written properly.
1. Syrup Azithromycin
Syrup Amoxy, Amoxy clav
2. Tab. Clopidrogril
Tab. Cephadroxil
3. Cap Cephalexin
Cap Cephadroxil
4. Tab. Lasix
Laxative
5. Tab. Pentazocine
Tab Pantoprazol
6. Tab. Diclofenac
Tab. Dicylomine
7. Inj Isolyte P
Inj.Isolyte G, Isolyte M, Isolyte E
8. Duolin Respule
Tab.Duodiline
9. Tab.Dobutamine
Tab.Dopamine
10. Tab.Cefotaxime
Tab.Ceftriaxone
11. Tab.Frusemide
Tab.Fomatidine
12. Tab.Glimipride
Tab.Glibenclamide
13. Tab.Metrogyl
Tab.Metoclopramide
14. Inj Dobutamine
Inj Drotaverine
15. Tab. Domperidon
Tab. Daflon
16. Inj Lupinox
Inj Lasix
17. Tab. Ciplox TZ
Tab. Cebexin Z
b) Drugs with narrow therapeutic window:
A list of drugs with narrow therapeutic window or with known severe adverse effects should
be made and displayed at nursing station in a prominent colour, maybe red, to alert nursing
staff who administers such a drug to be conscious of the dose & route of administration.
c) Electrolyte solution:
The doctors and nursing staff should be trained and supervised for ordering and
administering variety of electrolyte solutions since a wrong electrolyte solution may be
detrimental to patients health.
d) Orders over phone:
A Policy has to be developed regarding receiving orders over phone. In case of emergency if
an order has been given over phone, the nursing staff should repeat the name of the drug &
route of administration. For any drug which is sound alike drug or with narrow therapeutic
window, it should be confirmed by spelling out the name, dose and route of administration.
The verbal orders should be endorsed/ confirmed in the medical records by physician within
a specified time maybe within 12 hours.
Some drugs are more prone to cause serious medication errors. So while prescribing,
preparing and administering these drugs, special precautions like checking dose, strength,
dosage form, frequency of administration and strict monitoring after administration should
87
be taken. Following is the list of drugs and should be displayed in the emergency to avoid
errors.
e) High Risk Medication:
List of high risk medication more likely to be involved in serious medication errors
Epinephrine
Phenylephrine
Norepinephrine
Propranolol
Metoprolol
Labetablol
Warfarin
Low-molecular-weight Heparin
IV unfractionated Heparin
Fondaparinux
Chemotheraputic agents
Chloral hydrate
Opiates like morphine
Theophylline
Midazolam
Dextrose, hypertonic, 20% or greater
Concentrated Potassium Chloride
It is required that availability, access, prescribing, preparation, distribution, labelling,
verification, administration and monitoring of these agent be planned in such a way that
adverse effects can be avoided.
f)
Use of Abbreviations:
Use of abbreviations should be discouraged as it may lead to medication errors E.g AZT
may be misunderstood for Azathioprin causing further immune suppression in patients
of AIDS.
88
---------------------------------------------------
Strength
---------------------------------------------------
Time of preparation
---------------------------------------------------
---------------------------------------------------
---------------------------------------------------
Signature
--------------------------------------------------
89
BIBLIOGRAPHY
1. Literature Review of emergency department Staffing Redesign Frameworks
Undertaken for NSW Health, Northern University October 09
2. Policy and Guidelines for Hospital Accident and Emergency Services in Ghana
Ministry of Health A&E Services, GHANA, October, 2011
3. Guidance on safe nurse staffing levels in the UK, Royal College of Nursing
4. Dammam Medical Complex Emergency Department Policy and Procedure
Revised and Compiled, Ministry of Health Saudi Arabia, 2005
5. Operational Guidelines on Quality Assurance for Public Health Facilities, National
Health Systems Resource Centre, 2013
6. Emergency Department Clinical Quality Indicators: - A CEM guide to implementation
7. The College of Emergency Medicine Patron: HRH The Princess Royal Incorporated by
Royal Charter, 2008
8. Hospital emergency response checklist An all-hazards tool for hospital administrators and
9. emergency managers, World Health Organization, 2011
10. Centre for Disease Control and Prevention (CDC) Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Post-exposure Prophylaxis MMWR Recommendations and
Reports, Volume 54, Number RR-9
11. Centre for Disease Control and Prevention (CDC) National Institute for Occupational
Safety and Health, ALERT, Preventing Needle Stick Injuries in Health Care Settings
12. Guidelines for Essential Trauma Care World Health Organization, 2011
13. Emergency care in India: the building blocks, Imron Subhan & Anunaya Jain, 4
August 2010
14. Accidental Deaths and Suicides in India, National Crime Records Bureau,
Ministry of Home Affairs, 2011
15. Adult emergency services: Acute medicine and emergency general surgery
Commissioning standards, September 2011
90
19. Essential Trauma Care Project Checklists For Surveys Of Trauma Care
Capabilities, Injuries and Violence Prevention Department, World Health
Organization and International Association for the Surgery of Trauma and
Surgical Intensive Care (IATSIC), International Society of Surgery / Socit
Internationale de Chirurgie 14-Sept, 2004
20. Prevention of hospital-acquired infections a practical guide 2nd Edition
WHO/CDS/CSR/EPH/2002.12 World Health Organization Department of
Communicable Disease, Surveillance and Response, 2001
21. Guide To Managing an Emergency Service Infection Control Program FA-112 /
United States Fire Administration 2002, Guide To Managing An Emergency
Service Infection Control Program, January 2002
22. Report of the Working Group on Emergency Care in India Ministry of Road
Transport & Highways, Govt. of India, 2010
23. Guidelines on Emergency Department Design, Australasian College of Emergency
Medicine, March 2007
24. Emergency Design Document, Health Authority Abu Dhabi, Emergency Unit, June
2011
91
ANNEXURES
92
Annexure-I
93
Annexure-II
OPD/INITIAL ASSESSMENT FORM
Form No. XYZ/DH/.....
CR No...............................................................Date:-................................Time...................................
Mode of Arrival - Ambulance/ Ambulatory/ Any other......................................................................
Patient Name: ............................................... Age/Sex ( M/F):..............................................................
Address:-.................................................................................................................................................
......................................................................................................................................................
................................................................................................................................................................
Presenting Complaints & History:-....................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Provisional/ Definite Diagnosis:-...................................................................................................
General Examination:-
Systemic examination:-
Temp:
Pulse
BP:
Pallor:
Icterus:
Rx
94
Annexure-III
95
Annexure-IV
Basic Life Support Protocol
96
ANNEXURE-V
COLOUR OF BIN
TYPE OF WASTE
ACTION/ ATTENTION
BLUE
97
Annexure-VI
CLEANING CHECKLIST
DH NAME ____, DISTRICT NAME FORM NO. ______________
CHECKLIST FOR CLEANING AREAS
Cleaning Areas/
Equipment
Material Used
Responsibility
Daily
1% Sodium
Hypochlorite
2 TIMES
1% Sodium
Hypochlorite
2 TIMES
Ventilators
1% Sodium
Hypochlorite
2 TIMES
Dressing trolleys
1% Sodium
Hypochlorite
2 TIMES OR AS
PER REQRMNT
Crash carts
1% Sodium
Hypochlorite
2 TIMES OR AS
PER REQRMNT
Cardiac Table
1% Sodium
Hypochlorite
2 TIMES OR AS
PER REQRMNT
ECG trolley
1% Sodium
Hypochlorite
ONCE
IV Stands
1% Sodium
Hypochlorite
2 TIMES
Nursing Stations
1% Sodium
Hypochlorite
2 TIMES
1% Sodium
Hypochlorite
Soap and Water
solution
Soap and Water
solution
ONCE
Chairs
Mops
Fans
Mirrors
1% Sodium
Hypochlorite
Cleaning
Done/ Not
Done
Remarks
3 TIMES
Daily
98
ANNEXURE-VII
Quantity
Date checked
99
Capital Outlays
Capped bottle, alcohol based solutions
Sterile gauze dressing
Bandages sterile
Adhesive Tape
Needles, cutting and round bodied
Suture synthetic absorbable
Splints for arm, leg
Urinary catheter Foleys disposable #12, 14, 18 with bag
Absorbent cotton wool
Sheeting, plastic PVC clear 90 x 180 cm
Gloves (sterile) sizes 6 to 8
Gloves (examination) sizes small, medium, large
Face masks
Eye protection
Apron, utility plastic reusable
Soap
Inventory list of equipment and supplies
Best practice guidelines for emergency care
Supplementary equipment for use by skilled health
professionals
Laryngoscope handle
Laryngoscope Macintosh blades (adult)
Laryngoscope Macintosh blades (paediatric)
IV infusor bag
Magills Forceps (adult)
Magills Forceps (paediatric)
Stylet for Intubation
Spare bulbs and batteries for laryngoscope
Endotrachael tubes cuffed (# 5.5 to 9)
Endotrachael tubes uncuffed (# 3.0 to 5.0)
Chest tubes insertion equipment
Cricothyroidectomy
Quantity
Date checked
100
ANNEXURE-VIII
SUGGESTIVE EMERGENCY DRUG LIST
Following medicines should be available in the Emergency department for the patients for effective and
immediate management of their conditions:
The list can be pruned or expanded depending upon the need of the hospital.
Emergency Drug List
Sr.
No.
1
Drug
Formulation
Strength
Inhalation
Thiopentone Sodium
Injection Powder
0.5 g
Lignocaine Hydrochloride
Jelly sterile
2%
Lignocaine Hydrochloride
Injection
2%
Atropine.
Injection (sulphate)
0.5 mg/ml
Diazepam
Injection
5 mg/ml
Diclofenac
Injection
25 mg/ml
Ibuprofen
Tablet
400 mg
Paracetamol
Tablet
500 mg
10
Paracetamol
Syrup
100 mg/5 ml
11
Paracetamol
Injection
150 mg/ml
12
Morphine Sulphate
Injection
10 mg/ml
13
Tramadol Hydrochloride
Tablet
50 mg
14
Tramadol Hydrochloride
Injection
50 mg/ml
15
Cetrizine
Tablet
10 mg
16
Cetrizine
Suspension
5 mg/ml,60 ml
17
Pheniramine maleate
Injection
22.75 mg/ml
18
Dexamethasone Disodium
Injection
4 mg/ml
19
100 mg vial
20
Hydrocortisone Sodium
Succinate
Adrenaline
Injection
1 mg/ml (1:1000)
21
Charcoal activated
Tablet
250 mg
22
Antisnake venom
Injection
10 ml vial
23
Calcium gluconate
Injection
100 mg/ml
24
Naloxone Hydrochloride
Injection
400 mcg
25
Pralidoxime (PAM)
Injection
1 gm vial
26
Lorazepam
Injection
2 mg/ml
27
Magnesium sulphate
Injection
500mg/ml
28
Phenobarbitone
Injection
200 mg/ ml
29
Phenytoin
Injection (sodium)
50 mg/ml
30
Injection
500 +100 mg
31
Ampicillin Sodium
Injection powder
500 mg
32
Benzathine penicillin
Injection powder
6 lacs IU vial
101
33
Benzathine penicillin
Injection powder
12 lacs IU vial
34
Cefotaxime
Injection
250mg
35
Cefotaxime
Injection
500 mg
36
Injection powder
250 mg
37
Injection powder
1 g vial
38
Amikacin
Injection
500 mg/2 ml
39
Ciprofloxacin
Injection IV
40
Gentamycin Sulphate
Injection
41
Metronidazole
Injection
40 mg/ ml, 2 ml
vial
500 mg/ 100ml
42
Heparin sodium
Injection
5000 IU/ ml
43
Ethamsylate
Injection
250 mg/2 ml
44
Vitamin K
Injection
45
Injection
10 mg/ml, 1 ml
ampoule,
500ml
46
Diltiazem
Injection
5 mg/ml
47
Glycerine trinitrate
Tablet (sublingual)
500 mcg
48
Injection
5 mg/ ml
49
Tablet
20 mg (SR)
50
Isosorbide dinitrate
Tablet (sublingual)
5 mg
51
Adenosine Phosphate
Injection
3 mg/ ml
52
Dobutamine
Injection
125 mg/ 5 ml
53
Dopamine Hydrochloride
Injection
40 mg/ ml
54
Streptokinase
Injection powder
1500000 IU
55
Potassium permanganate
Aqueous solution
1 : 10 000
56
Silver sulfadiazine
Cream
1%
57
Calamine lotion
Lotion
8%
58
Povidone iodine
Solution
5%
59
Povidone iodine
Ointment
5%
60
Furosemide
Injection
10 mg/ml
61
Mannitol
Injectable solution
20%
62
Ranitidine
Injection
25 mg/ml
63
Metoclopramide Hydrochloride
Injection
5 mg/ ml
64
Prochlorperazine
Injection
12.5 mg/ml
65
Ondansetron
Injection
2 mg/ ml
66
Promethazine Hydrochloride
Injection
25 mg/ml
67
Promethazine
Syrup
5 mg/ 5 ml
68
Injection
20 mg/ ml
69
Glycerine Saline
Enema
70
As per IP
71
Insulin (soluble)
Injection
40 IU/ml
72
Intermediate-acting insulin
Injection
40 IU/ml
102
(Lente)
73
Injection
3000 IU /ml
74
Tetanus vaccine
Injection
0.5 ml Ampoule
75
Injection ID
76
Neostigmine
Injection
500 mcg/ ml
77
Ciprofloxacin
Eye Drops
0.3%
78
Atropine Sulphate
Eye Ointment
1%
79
Tropicamide + Phenylepherine
Eye Drops
0.8% + 5%
80
Eye Drops
0.5% w/v
81
Saline
Nasal Drops
0.6%
82
Xylometazoline
Nasal Drops
0.05%,
83
Glycerin
Solution
500 gm bottle
84
Oxytocin
Injection
85
Haloperidol
Injection
5 IU in 1 ml
ampoule
5 mg
86
Alprazolam
Tablet
0.25 mg
87
Aminophylline
Injection
25 mg/ ml
88
Nebulizer Solution
89
Salbutamol Sulphate
Nebulizer solution
5 mg/ ml
90
Etophylline + Theophylline
Injection
91
Budesonide
Nebulizer solution
169.4 mg + 56.6
mg/2 ml
15 ml vial
92
Glucose/dextrose
Injectable solution
5%, isotonic
93
Glucose/dextrose
Injectable solution
10% isotonic
94
Glucose/dextrose
Injectable
25%
95
Injectable solution
96
Potassium chloride
Injectable solution
5% glucose +
0.9% sodium
chloride
11.2% in 20ml
97
Ringer lactate
Injectable IV solution
98
Sodium bicarbonate
Injectable IV solution
7.5%
99
Sodium chloride
Injectable solution
0.9% isotonic
100
Injection
5ml ampoule
101
Artesunate
Injection
60 mg/ml
102
Artemether
Injection
103
Quinine (Dihydrochloride)
Injection
104
Chloroquine phosphate
Injection
80 mg/ml, 1 ml
amp
300 mg/ ml, 2ml
ampoule
40 mg / ml
105
Amiodarone
Injection
106
Digoxin
Injection
50 mg/ml (3 ml
ampoule)
0.25 mg/ml
107
Pantoprazole
Injection
40 mg
103