Documente Academic
Documente Profesional
Documente Cultură
By: P&D-M&E
Table Of Contents
DEPARTMENT OF MEDICINE...............................................................................................................................................6
SOPS FOR EMERGENCY TRAY................................................................................................................................................6
Emergency Tray Equipment..............................................................................................................................................6
Emergency Medicines.......................................................................................................................................................7
SOPS FOR PRESCRIPTION OF DRUGS......................................................................................................................................8
General Principles for Prescribing of Drugs...................................................................................................................8
Administering intravenous drugs.....................................................................................................................................8
Administering Oral Drugs................................................................................................................................................8
SOPS FOR ADMISSION TO IN PATIENT CARE ON THE WARD..................................................................................................9
Who Can Admit.................................................................................................................................................................9
SOPS FOR DISCHARGING THE PATIENTS..............................................................................................................................10
In patient Consultation Between Different Units of the Hospital...................................................................................10
SOP FOR PRIVATE ROOMS....................................................................................................................................................11
Admission Criteria..........................................................................................................................................................11
Admission Process..........................................................................................................................................................11
Private Rooms Services..................................................................................................................................................11
SOPS FOR CONSULTANT OPD..............................................................................................................................................11
SOPS FOR WARD ROUND.....................................................................................................................................................12
SOPS FOR G.I. ENDOSCOPIES..............................................................................................................................................12
DEPARTMENT OF SURGERY...........................................................................................................................................12
INTRODUCTION...........................................................................................................................................................13
ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................13
Admission to Surgical units:...........................................................................................................................................13
Admission to Private Rooms...........................................................................................................................................14
History Sheets.................................................................................................................................................................14
Duty Rotas......................................................................................................................................................................14
Academic Activities:.......................................................................................................................................................14
Emergency Patients........................................................................................................................................................14
Patient Preparation for Surgeries;.................................................................................................................................15
OPD................................................................................................................................................................................15
OPERATION THEATRE:...............................................................................................................................................17
MINOR OT:....................................................................................................................................................................17
WARD ROUNDS:...........................................................................................................................................................17
DURG ADMINISTRATION:...........................................................................................................................................18
INDENT BOOK:.............................................................................................................................................................18
SAFETY MEASURES:....................................................................................................................................................18
WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................18
DEPARTMENT OF GYNAE &OBSTETRIC.....................................................................................................................19
INTRODUCTION...........................................................................................................................................................19
ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................19
Admission to Gynae Units & Labour Room:..................................................................................................................19
Admission to Private Rooms...........................................................................................................................................20
History Sheets.................................................................................................................................................................20
Duty Rotas......................................................................................................................................................................20
Academic Activities:.......................................................................................................................................................20
Emergency Patients........................................................................................................................................................21
Patient Preparation for Surgeries;.................................................................................................................................21
Postoperative Care:........................................................................................................................................................22
OPD & ANC:..................................................................................................................................................................22
OPERATION THEATRE:...............................................................................................................................................22
WARD ROUNDS:...........................................................................................................................................................22
DURG ADMINISTRATION:...........................................................................................................................................24
DISCHARGE:.................................................................................................................................................................24
Labour Room..................................................................................................................................................................24
CLINICAL AUDIT:.........................................................................................................................................................25
DOCUMENTATION:.....................................................................................................................................................25
INDENT BOOK:.............................................................................................................................................................25
SAFETY MEASURES:....................................................................................................................................................25
WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................25
RESEARCH AND CLINICAL TRIALS:..........................................................................................................................26
DEPARTMENT OF OTO-RHINO-LARYNGOLOGY (ENT)..........................................................................................27
ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................27
Admission to ENT units:.................................................................................................................................................27
Admission to Private Rooms...........................................................................................................................................28
History Sheets.................................................................................................................................................................28
Duty Rotas......................................................................................................................................................................28
Academic Activities:.......................................................................................................................................................28
Emergency Patients........................................................................................................................................................28
Patient Preparation for Surgeries..................................................................................................................................29
OPD................................................................................................................................................................................29
OPERATION THEATRE:...............................................................................................................................................29
WARD ROUNDS:...........................................................................................................................................................30
DURG ADMINISTRATION:...........................................................................................................................................31
INDENT BOOK:.............................................................................................................................................................31
SAFETY MEASURES:....................................................................................................................................................31
WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................31
DEPARTMENT OF OPHTHALMOLOGY........................................................................................................................32
INTRODUCTION...........................................................................................................................................................32
ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................32
Admission to units..........................................................................................................................................................33
Admission to Private Rooms...........................................................................................................................................33
History Sheets.................................................................................................................................................................33
Duty Rotas......................................................................................................................................................................33
Academic Activities........................................................................................................................................................33
Emergency Patients........................................................................................................................................................34
Patient Preparation for Surgeries..................................................................................................................................34
OPD................................................................................................................................................................................35
OPERATION THEATRE................................................................................................................................................35
WARD ROUNDS............................................................................................................................................................35
DURG ADMINISTRATION............................................................................................................................................36
INDENT BOOK:.............................................................................................................................................................36
SAFETY MEASURES:....................................................................................................................................................36
WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................36
DEPARTMENT OF PEDIATRICS & CHILD HEALTH..................................................................................................37
Admission Policy............................................................................................................................................................37
Ward Discharge Policy...................................................................................................................................................37
Ward Round Policy.........................................................................................................................................................38
Patients Investigations & Procedures Policy.................................................................................................................38
Inject able Drug Policy..................................................................................................................................................38
Ward Referral Policy......................................................................................................................................................38
Ward Emergency Policy..................................................................................................................................................38
ACCIDENT & EMERGENCY SERVICES DEPARTMENT...........................................................................................40
Standard Operative Procedures.....................................................................................................................................40
Dog Bite..........................................................................................................................................................................40
Investigations:................................................................................................................................................................59
DECISIONS........................................................................................................................................................................62
DISASTER …………………BE PREPARED -A GENERAL REVIEW................................................................................................63
Steps to be taken.............................................................................................................................................................64
1. Nomination of a focal person...........................................................................................................................................64
2. Formation of Disaster Management Groups (DMGs).......................................................................................................64
3. Medicines......................................................................................................................................................................... 64
4. Equipments....................................................................................................................................................................... 64
5. Blood................................................................................................................................................................................ 65
6. Instruments....................................................................................................................................................................... 65
7. Ambulances...................................................................................................................................................................... 65
Crisis Management Team (CMT)...................................................................................................................................66
Objective.........................................................................................................................................................................66
Group of Surgeons / Anesthetist.....................................................................................................................................67
Doctors to be present at site of Mass Emergency...........................................................................................................69
Diagnostic Services Management Group.......................................................................................................................70
Medicine and Surgical Disposable Management Group................................................................................................70
DMG-6 Information and Registration Group...........................................................................................................70
MASS EMERGENCY AREAS (RED ZONES)...................................................................................................................................71
Logistics..........................................................................................................................................................................71
TELEPHONE NUMBERS OF PROFESSORS...............................................................................................................72
Introduction....................................................................................................................................................................74
Guidelines for the patients..............................................................................................................................................74
Ultrasound......................................................................................................................................................................74
X-ray...............................................................................................................................................................................74
CT Scan..........................................................................................................................................................................74
MRI.................................................................................................................................................................................74
Staff.................................................................................................................................................................................74
Revenue..........................................................................................................................................................................75
Duty Rota........................................................................................................................................................................75
Cleanliness......................................................................................................................................................................75
DEPARTMENT OF MEDICINE
EMERGENCY MEDICINES
3. Atropine Sulphate 5
4. Hypertonic 10
8. Inj. Decadron 10
9. Inj.Lignocaine 5
18. Drips 05
A leading zero may be used( eg. 0.5 mg as 5mg may be read as 5 mg). Avoid using trailing zero
which may be misread ( eg. 5.0mg may be read as 50 mg)
The doctor should know the cost of medicine prescribed & tailor it according to the socio-
economic status of the patient as it may be the only cause of non-compliance.
Drugs available in hospital pharmacy should be given priority.
If a drug is not available in the hospital pharmacy then drugs available at endowment fund
pharmacy should be prescribed
Drugs from outside the hospital should only be prescribed when utterly necessary after
discussion with the team
o Admission after 2 Pm from consultants private clinic should be direct to ward on call with out
going through ( executive admission fee may be levieved)
o Referral from other hospitals should be admitted via casualty
o On admission , detail history should be taken by the house officer on arrival, followed by a
summary of the patient by the TMO on duty
o For medico-legal cases proper official referral & presence of police is mandatory
o Proof of identity should be must for every patient
o Afghans with out registration cards should be separately marked
o RMO must accompany un accompanied & with out identity patients ( Lawaris patient) to the
ward for admission & should arrange all the necessary arrangements for management.
ADMISSION PROCESS
o Private Room admission should be done on single occupancy basis
o Consultant/ SR, can admit patients in private room directly via CMO
o Consultant/ SR, JR can admit in patients from the ward to private room
o After admission , MO of private room should take history, send investigations & start
treatment as directed by the admitting doctor
DEPARTMENT OF SURGERY
INTRODUCTION
The Deptt. Of Surgery, KMC Peshawar consists of five General Surgical Units, Orthopedic &
Trauma Unit, Casualty, Plastic Surgery & burn unit, SICU & a Pediatric Unit. Each unit has 46
beds. Patient care means that the doctors & ancillary staf are not only doing so in the wards but
also are using the OPDs, major OT for doing so. It may be mentioned that the major OT not only
has operating rooms but also a recovery room & endoscopy suite besides other areas such as
staf rooms.
Managing patients does not only mean treating disease but involves making sure that this is
done in a way which comfortable both for the patients and relatives, ethical, logical & cost
efective. It must be kept in mind that all medical personnel are part of a team each having their
own roles in patient care. In dealing with patients & relatives medical personnel should be polite
at all times. White coat, name tags & a professional turnout is emphasized for all doctors.
A concerted efort is needed to prevent errors. Standardized systems are needed to minimize
the need to rely on human nature, which is rather imperfect. Legal issues can come up in patient
management. Following a set protocol can go a long way in protecting medical personnel from a
legal view point.
The following are some guidelines that should be followed by the Medical personnel while
managing patients:
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of relevant systems & a note of chest
findings, BP, Pulse
o TMO notes & plans in writing are mandatory, especially in emergency cases. However
resuscitation of the patient will take priority
o Daily morning & evening progress report should be recorded by the HO & TMO
DUTY ROTAS
o These should be made by the SR or Assistant Professor of the ward & should include duties in
minor OT, recovery room & ward
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
1. Doctors should communicate with each other at the time of change of duty ie they
should inform the next doctor on duty the status of serious patients etc
ACADEMIC ACTIVITIES:
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/ seminars being held in the ward
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments is available
at all times & in working condition
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed.
o Every efort should be made to resuscitate patients if indicated according to ABC protocol
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
o Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, ward and
specimen name.
OPD
o All doctors should be available in the OPD.
o The Dispenser should make sure that the OPD is clean, the instruments sterilized, disposables
available and all equipment and lights etc in working order.
o The staf should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed.
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
OPERATION THEATRE:
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o Swab count should be maintained at all times by one member of the operating team and the
same nurse of OT tech. ideally this should be written on a board.
o A House Officer and Trainee of the ward should be present in the recovery room and ward to
respond to unforeseen mishaps.
o All post op patients should be monitored.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Surgical Department and the administration.
MINOR OT:
o Two trainees should be present in the minor OT on OPD days to carry out minor procedures
like biopsies, nail avulsions etc.
WARD ROUNDS:
o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am
so as to have time for carrying out orders like investigations, calls etc.
o The evening round must be done daily by the Registrar and important entries made.
o The post of and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs one.
o The Registrar should ensure that all orders of the senior teaching staf regarding patients have
been carried out including referrals to medical and other related specialties.
DURG ADMINISTRATION:
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward.
SAFETY MEASURES:
o At no time shall any anaesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bough by the patient should be
kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
This protocol should be reviewed every six months and changes/additions made accordingly.
INTRODUCTION
The Department of Gynecology/Obstetric KMC Peshawar consists of 3 Gynae Units and a Labour
Room. Each Unit has 40 beds, Labour Room has 20 beds & gives 24hrs emergency cover.
Managing patients does not only mean treating disease but involves a coordinated approach to
diagnosis, treatment & care services of all patients. This should be done in such a way which is
comfortable both for the patients and relatives and is ethical, logical & cost efective. It must be kept
in mind that all medical personnel are part of a team each having their own roles in patient care. In
dealing with patients & relatives medical personnel should be polite at all times and should have
professional attitude. White coat, name tags & a professional turnout is emphasized for all doctors.
A concerted efort is needed to prevent errors. Standardized systems are needed to minimize the
need to rely on human nature, which is rather imperfect. Legal issues can come up in patient
management. Following a set evidence based protocols will protect medical personnel from medico
legal issues.
The following are some guidelines that should be followed by the Medical personnel while managing
patients:
o Elective admission should be done after the patient is seen by a person of SR level and above.
The admission should be justifiable
o Patients who have undergone major surgery should stay in ward for 24hrs postoperative,
before being shifted to private room.
o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as
an emergency case, the patient should be managed accordingly whether the particular
consultant belongs to that ward or not. The patient may be shifted to the ward the consultant
belongs to, only if he/she has requested to shift that patient.
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of relevant systems, Obstetric &
Gynecological examination
o TMO notes & plans in writing are mandatory, especially in emergency cases. However
resuscitation of the patient will take priority
o Daily morning & evening progress report should be recorded by the HO & TMO
DUTY ROTAS
o These should be made by the Registrar/SR or Assistant Professor of the ward & should include
duties in Ward, Labour Room, O.T, OPD, ANC
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
o Doctors should not only communicate, with each other at the time of change of duty ie they
should inform the next doctor on duty the status of serious patients etc but should also
maintain a hand over & take over register
ACADEMIC ACTIVITIES:
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/seminars /journal club/ long cases
being held in the ward
o Regular rehearsal drill of obstetric and Gynaecological emergencies should be done in ward by
the TMO, H.O and supervised by registrar.
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments are available
at all times & in working condition
o Emergency tray should be regularly updated & maintained by the registrar
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed.
o Every efort should be made to resuscitate patients if indicated according to ABC protocol
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
o Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
would prevent unnecessary delays, and wastage of time as well as resentment on the part of
patients for having to be admitted only to be deferred or have a delay.
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, and ward and
specimen name.
POSTOPERATIVE CARE:
o One house officer and TMO must be available in the ward 24hrs a day for care of the patient.
o The TMO Batch on call must come after O.T for postoperative round.
o The registrar on call should do a postoperative round after O.T.
o Postoperative round must be documented with date and time by H.O /T.M.O , registrar &
consultant on call.
o There must be protocol for resuscitation in case of any complication & immediate contact of
senior as per protocol.
OPERATION THEATRE:
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o Swab count should be maintained at all times by one member of the operating team and the
same nurse or O.T tech. Ideally this should be written on a board.
o A House Officer should be present in the recovery room and ward to respond to unforeseen
mishaps.
o All post op patients should be monitored.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Gynae Department and the administration.
WARD ROUNDS:
o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am
so as to have time for carrying out orders like investigations, calls etc.
o The evening round must be done daily by the Registrar and important entries made.
o The post and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs it.
o The Registrar should ensure that all orders of the senior teaching staf regarding patients have
been carried out including referrals to medical and other related specialties.
DURG ADMINISTRATION:
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
DISCHARGE:
o The discharge slip should be prepared a day before the expected discharge of the patient by
the H.O & checked & counter signed by T.M.O, so that undue delay and discomfort of the
patient is avoided.
o Decision of discharge should be done by the registrar, S.R or Consultant.
LABOUR ROOM
o 3rd year TMO & House officer Batch on call will do labour room round at 8:00am along with
Registrar. 1st year PG and H.O batch will stay in the labour room from 8:00am ––– 2:00pm. A
4th year PG along with her batch on call will do round at 1:00pm along with the Registrar
o A 1st year PG along with H.O’s will stay in the labour room and 3rd year / 4th year PG will do
round at 6:00pm. The Registrar /S.R and assistant Prof will do round at 7:00pm on
emergencies & will be on call at night.
o The decision of surgery should be taken only after discussion with registrar.
o All high risk patients should be discussed with the consultant on call.
o The consultant on call should also inform about the progress of high risk patient.
o The Head nurse should make sure that the labour room is clean all the times as it is a place of
quick patient turn over. This includes the delivery rooms, instruments, Autoclave, Drugs,
linens, floors, beds, toilets etc. The registrars of the three units should work in collaboration
for maintenance and cleanliness of the labour room.
o The Head nurse and the registrar of the Gynae unit on call should make sure that the
emergency tray in the labour room is completed and updated all the times in order to face any
sort of emergency.
CLINICAL AUDIT:
o Statistical record of the ward should be maintained and regularly checked by the registrar /
S.R.
o Fortnightly or monthly clinical audit meeting should be conducted in the ward & supervised by
the Professor in charge of the ward.
o Adverse events & near miss events should be discussed in no blame environment to improve
patient outcome & should be notified to the administration.
o Protocols for Obstetric & Gynaecological emergencies should be displayed in the Gynae Units
& Labour rooms & regularly updated.
DOCUMENTATION:
o Adequate documentation should be maintained in the charts. All findings & orders should be
legibly written & signed with date & time. This should be regularly checked by the registrar on
call.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward.
SAFETY MEASURES:
o At no time shall any anaesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bought by the patient should
be kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
This protocol should be reviewed every six months and changes/additions made accordingly.
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of relevant systems & a note of chest
findings, BP, Pulse
o TMO notes & plans in writing are mandatory, especially in emergency cases. However
resuscitation of the patient will take priority
o Daily morning & evening progress report should be recorded by the HO & TMO
DUTY ROTAS
o These should be made by the SR or Assistant Professor of the ward & should include duties in
minor OT, recovery room & ward
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
o Doctors should communicate with each other at the time of change of duty ie they should
inform the next doctor on duty the status of serious patients etc
ACADEMIC ACTIVITIES:
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/ seminars being held in the ward
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments is available
at all times & in working condition
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed.
o Every efort should be made to resuscitate patients if indicated according to ABC protocol
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
SOPs KTH 2010
P&D Cell-M&E 30
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
OPD
o All doctors should be available in the OPD.
o The Dispenser should make sure that the OPD is clean, the instruments sterilized, disposables
available and all equipment and lights etc in working order.
o The staf should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed.
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
SOPs KTH 2010
P&D Cell-M&E 31
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
OPERATION THEATRE:
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o Swab count should be maintained at all times by one member of the operating team and the
same nurse of OT tech. ideally this should be written on a board.
o A House Officer and Trainee of the ward should be present in the recovery room and ward to
respond to unforeseen mishaps.
o All post op patients should be monitored.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Surgical Department and the administration.
WARD ROUNDS:
o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am
so as to have time for carrying out orders like investigations, calls etc.
o The evening round must be done daily by the Registrar and important entries made.
o The post of and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs one.
o The Registrar should ensure that all orders of the senior teaching staf regarding patients have
been carried out including referrals to medical and other related specialties.
DURG ADMINISTRATION:
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward.
SAFETY MEASURES:
o At no time shall any anesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bough by the patient should be
kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
Note: This protocol should be reviewed every six months and changes/additions made
accordingly.
DEPARTMENT OF OPHTHALMOLOGY
INTRODUCTION
The Deptt. Of Ophthalmology, KTH Peshawar consists of 2 units. Each unit has 46 beds. Patient care
means that the doctors & ancillary staf are not only doing so in the wards but also are using the
OPDs, major OT for doing so. It may be mentioned that the major OT not only has operating rooms
but also a recovery room besides other areas such as staf rooms.
Managing patients does not only mean treating disease but involves making sure that this is done in a
way which comfortable both for the patients and relatives, ethical, logical & cost efective. It must be
kept in mind that all medical personnel are part of a team each having their own roles in patient care.
In dealing with patients & relatives medical personnel should be polite at all times. White coat, name
tags & a professional turnout is emphasized for all doctors.
A concerted efort is needed to prevent errors. Standardized systems are needed to minimize the
need to rely on human nature, which is rather imperfect. Legal issues can come up in patient
management. Following a set protocol can go a long way in protecting medical personnel from a legal
view point.
The following are some guidelines that should be followed by the Medical personnel while managing
patients:
ADMISSION TO UNITS
o All patient needing admission should be ofered admission irrespective of whether they have
been seen in a private clinic or in OPD. Emergency patients will take priority as well as those
needling urgent surgery eg. Trauma etc..
o Elective admission should be done after the patient is seen by a person of SR level and above.
The admission should be justifiable
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of ophthalmic system & a note of chest
findings, BP, Pulse
o TMO notes & plans in writing are mandatory
o Daily morning & evening progress report should be recorded by the HO & TMO & should be
checked by SR
o All emergency cases admitted should have arrival report by TMO & duty with plans of
management
DUTY ROTAS
o These should be made by the SR or Assistant Professor of the ward & should include duties in
OPD, OT,& ward
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
o Doctors should communicate with each other at the time of change of duty ie they should
inform the next doctor on duty the status of serious patients etc
ACADEMIC ACTIVITIES
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/ seminars being held in the ward
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments is available
at all times & in working condition
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed. SR should be on call on every emergency day, if JR feels any difficulty
he can call SR any time.
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
o Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
would prevent unnecessary delays, and wastage of time as well as resentment on the part of
patients for having to be admitted only to be deferred or have a delay.
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, ward and
specimen name in case of biopsy, AC tape for C/S & corneal scraping for microscopy & C/S.
OPD
o One doctor preferably JR should start OPD at 9.00 AM
o All doctors should be available in the OPD.
o The teaching staf (SR & above) on duty along with the HOs/TMOs etc. should be present in
their respective rooms till end of OPD timing
o The technician should make sure that the OPD is clean, the instruments sterilized, disposables
available and all equipment and lights etc in working order.
o The staf should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed with clearly written name
of doctors
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
This process should be supervised by SR
OPERATION THEATRE
o All doctors should be present in concerned OT room as per duty rota
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o All post op patients should be monitored.
o EUA will be done by consultant who has seen the patient before.
o Surgery of a particular case will be given to particular trainee according to his seniority & level
of competence.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Surgical Department and the administration.
WARD ROUNDS
o All morning rounds must be done by a consultant at a set time, preferably starting at 8.30 am
so as to have time for carrying out orders like investigations, calls etc. except on Wednesday
which should be at 9 am(Hospital CPC day)
o The evening round must be done daily by the Registrar and important entries made & pre op it
should be supervised by SR.
o The post op and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs one.
o The Registrar should ensure that all orders of the senior teaching staf regarding patients have
been carried out including referrals to medical and other related specialties.
DURG ADMINISTRATION
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward. He will also check all the maintenance items supplied & used/ installed in the ward.
SAFETY MEASURES:
o At no time shall any anesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bough by the patient should be
kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
ADMISSION POLICY
o There will be alternate emergency cover of each unit
o Patients will be admitted from 9 AM to 2 Pm from OPD while emergency admission through
emergency pediatric services will be open for 24 hours
o Two trainee MOs & 4 HOs will be on duty in such a manner that at any given time , one TMO &
2 HOs have to be present in the ward
o One SR & 2 JRs will be on call for 24 hours for the Department of Pediatrics covering both
units. Evening round on every emergency day will be done by consultant on call .
o Patients will be admitted on assurance that only one female attendants will be allowed in the
ward & the compliance will be checked by staf nurse on duty
o All histories should be completed & signed by the HO on duty, & the arrival rep[ort with full
assessment has to be taken immediately & signed by the TMOs/Mo on duty
o SR & consultant on duty will be informed depending on the nature of the illness if the child
needs to be seen before ward rounds
o Admission can be decided by the MO on duty in all urgent cases
o When the pediatric unit on call becomes full, the EPS beds can be utilized by the unit on call
for every admission except for very sick patients. ( This is done to prevent doubling in the unit)
DOG BITE
o Wound should be washed with copious amount of saline and antiseptic solution.
o Wound should not be sutured.
o Tetanus prophylaxis should be given accordingly.
1. TiG (Tetanus immunoglobulin 250 units) in non immunized patients and 0.5 ml Tetanus
Toxoid at separate sites with separate syringes.
2. Tetanus Toxoid only in previously immunized patients.
Only first dose of Anti Rabies vaccine (ARV) will be issued from hospital for dog bite cases provided
the patient:
o Has an evident puncture wound.
o Presents within 24 hours of dog bite.
o Did not receive any other ARV after dog bile.
o Belongs to the area allocated to Khyber Teaching Hospital.
o Submits photocopy of his computerized national identity card.
The dose will be issued with permission of I/C Casualty, shift DMS and RMO. It will be administered in
the casualty and record be maintained. The site will be marked and documented by the CMO to
prevent mis-use of vaccines.
MEDICINES IN CASUALTY:
o Victims of bomb blast and terrorist activities will be provided all medicines including
implants from hospital.
o Red patients (i.e. serious emergencies needing admission) will be provided with fee medicines
excluding implants, from hospital for first 24 hours subjected to availability.
o Yellow patients (sub acute emergencies needing observation only) will be provided with some
of medicines from hospital subjected to availability.
o Green patients (outpatients) will be provided with free consultation only.
AIRWAY
o Talk to the patient to assess his airway, breathing and consciousness at the same time.
o Start with chin lift and jaw thrust manoeuvre if not responding.
o Oral cavity is examined for foreign bodies and secretions.
o Gödel’s airway of appropriate size should be passed and suction done.
o ETT and tracheotomy/ cricothyroidotomy are reserved for cases unable to maintain their
airway like unconscious patients or GCS less than 8.
o Cervical spines should be immobilized with spine board or hard collar if the slightest double of
spinal injury exists.
BREATHING:
o All trauma patients should be given supplemental oxygen by face mask till confirmed to have
adequate peripheral oxygen saturation.
o Chest should be auscultated bilaterally.
CIRCULATION:
o Two wide bore canolas should be passed in accessible veins in arms or fore arm. (Like 18 G n
adults, 20 G in adolescents and 22 G in children).
o Venous cut down, central venous lines or interosseus lines can be used wherever indicated by
the attending physician.
o Ring lactate is the fluid of choice for initial resuscitation.
o Blood pressure and pulse rate should be regularly checked and properly recorded.
o Any evident bleeding should be stopped with pressure dressing.
o Patients should be properly exposed for examination preventing hypothermia and over-
exposure.
o All suspected fractures should be simply splinted and open wounds washed and dressed.
o Neurological status of the patient should be assessed according to AVPU or GCS.
AVPU SYSTEM
o A Alert
o V Responds to verbal command
o P Responds to pain only
o U Unresponsive
1 2 3 4 5 6
Eyes Does not Opens eyes Opens Opens eyes N/A N/A
Open eyes Response to eyes in spontaneously
Painful stimuli response
to voice
Verbal Makes no Incomprehensible Utters Confused, Oriented, N/A
sounds Sounds inappropri disoriented converses
ate words normally
ADJUNCTS
o Following investigations should be generously utilized where ever needed:-
1. Radiographs lf chest and pelvis and cross table lateral view of cervical spines
2. ECG
3. FAST (Focal assessment sonography in trauma)
4. CT Scan for Head injury
5. Pulse oximetry
6. DPL (Diagnostic peritoneal lavage)
o Nasogastric tube and urinary catheter help in preventing aspiration of gastric contents and
measuring urinary output and should be used
o After completing primary survey the doctor should start secondary survey only if the vital signs
of the patient are within normal limits.
o At this stage AMPLE history should be recorded as following
VITAL SIGNS include the heart beat, breathing rate, temperature, and blood pressure. These signs
may be watched, measured, and monitored to check and individual level of physical functioning.
Normal vital signs change with age, sex, weight, exercise and condition.
Normal ranges for the average healthy adult vital signs are:
o Blood Pressure: 120/80 mm/Hg
o Breathing: 12-18 beats per minute (at rest)
o Temperature: 97.8-99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit.
o The mass emergencies will be dealt according to the revised Disaster Management Plan
already published.
o Patients will be received and shifted after resuscitation as mentioned on page 2-3 of Disaster
Management Plan.
o The Medical Superintendent will be the focal person for dealing with Media, VIP’s/visitors and
Relatives of the patient.
o In absence of Medical Superintendent the DMS (Admin) and DMS (P&D) will be the focal
person respectively.
o The senior most surgeon available at the scene will triage the patient and label them with tags
as under for further management.
Grey Dead or Insolvagable
Red Patient with Life threatening injuries
Yellow Patient with Non-life threatening major injuries.
Green Walking wounded patients with minor injuries
o Patients will be treated according to ATLS protocols as simplified above for Poly-trauma
patients.
1. INFECTION CONTROL:-
I/V LINE
1. Wash hands
2. Pass by staf nurse/4th year nurse
3. Explain procedure to the patient
4. Take consent
5. Clean area with spirit swab
6. Share the area if needed
7. Spread plastic sheet
8. Pass I/V line in sterilized way, check with saline and stabilize with nichban sticking
9. Change after three days
(See SOP). MO
Staff
(Immediate Rx (Continued) Nurse
3). Monitoring MO
4). Prognosis MO
ON ARRIVAL IN SICU
o Patient will be examined by both HO and M.O.
o Documentation by the HO,M.O separately encompassing time of arrival in the SICU,
o History of illness/injuries/surgery, Past History, drug allergies, drug history, family history,
clinical findings, investigations required and management plan.
o To discuss the new admissions with the Registrar and senior registrar.
o To follow the treatment plans according to the treatment protocols and guidelines.
o To start the management ASAP but not later than 15 minute after the arrival of the patients.
o Ensure to utilize the hospital resources a much as possible and to send all investigations to the
hospital laboratory if available.
o To counsel/inform relatives/attendants of patient and take proper detailed consent with
explanation of any possible procedures if needed as part of the patient’s management.
MORNING ROUNDS
o The HO,MOs and TMOs working (inclusive of those on rotation) will take daily progress report
of the patient after proper examination of the patients and proper documentation with time
and date written clearly.
o The morning round will be supervised by the Sr. Reg. and M.O will present beds, if beds are
allotted then MOs will present their respective beds. HO should be encouraged to present
beds and supervised.
o During rounds The patient, his relatives attendants should be properly informed about the
disease, state/ condition of the patient and prognosis
o If a procedure or referral is planned during the round it must be explained to the patient or his
relatives.
EVENING ROUNDS
o Evening round to be done on regularly basis irrespective of any holidays.
o Senior Rg. must supervise the evening round.
o HO and MO on duty must be present in the evening round and present their respective
patients per SICU protocols.
o All orders, examination findings, unusual findings and treatment plans must be clearly
documented and singed. Name of the responsible doctor should be written clearly under the
signature.
o Any new development or change of plans must be explained to the patient or his relatives.
o Proper handover and take over to be undertaken with clear documentation on the chart of the
patient. This applies to doctors and nursing staf.
o Any defaulters from the rounds must be report per protocol of the hospital.
INFECTION CONTROL
o All entering the SICU must take of their shoes and over alls before entering the SICU.
o Wash hands before examining patients and relatives must wash hands before touching their
patients.
o After examination and procedure, all health care providers must wash their hands.
o Relatives and attendants accompanying the patients must be discouraged and clearly told not
to bring any unnecessary personnel belongings to the SICU.
o Hospital timings regarding visiting hours and rounds must be observed.
I/V LINE
1. Wash hands
2. Pass by staf nurse/4th year nurse
3. Explain procedure to the patient
4. Take consent
5. Clean area with spirit swab
6. Share the area if needed
7. Spread plastic sheet
8. Pass I/V line in sterilized way, check with saline and stabilize with nichiban sticking
9. Change after three days
o Visitor pass must be issued to the attendant accompanying patients admitted in the SICU.
o Rupees 100 (refundable) deposited for each pass with the charge nurse and document in the
register.
o Visitor pass collected by charge nurse when patient is discharged
o Refund Gate pass fee of Rs 100 and clearly document in the register.
10 bedded ICU for most serious patients of the hospital, subject to availability of beds
HIERARCHY
o Senior Registrar
o Registrar
o 6 Medical Officers
o 2 House officers on rotation from medical wards
o 2 staf nurses in each shift
o One student nurse
1. The patients are admitted in MICU from medical & allied as well as surgical & allied
wards with medical problems
2. In MICU the staf present on duty is responsible for all the orders given for medication
& nursing care
DOCUMENTATION
o As soon as the patient is shifted to the MICU, the MO on duty reviews the treatment of the
patient, fully understands the purpose of the patient admission in the ICU and along with the
HO present on duty documents the patient( history taking by the HO while the MO writes the
arrival reports clearly) with in the 30 minutes of the patients arrival
o If already prescribed with any investigations & treatment, the orders must be carried out as
soon as possible. HO being on the front line is fully supervised by the MO & registrar. If the SR
is present then he must supervise all the staf present in MICU and review all the work done
by the staf junior to him
o When a doctor/ consultant from the parent ward visits the ICU , the MO & the HO must
present & discuss the relevant patient in detail with the visiting doctor & properly document
their notes.
o A proper treatment plan to be notified on the chart of the patient, so as to elaborate the line
of action
o Proper , clear, compassionate explanation of what is being done for the patient should be
communicated by the HO/ MO/ Registrar/ SR to the patient after as per protocol of the MICU
& the prognosis dicussed with the relatives with in the ethical limits.
o While changing shifts the doctors, nurses & other staf must ensure proper well documented
hand over & take over
INFECTION CONTROL
IV LINE
a. Wash hands
b. Pass by staf nurse/ 4th year student nurse
c. Explain procedure to the patient
d. Take consent
e. Clean area with spirit swab
f. Shave the area if needed
g. Spread plastic sheet
h. Pass IV line in sterilized way, check with saline & stabilize with nichiban sticking
i. Change after 3 days
PULMONOLOGY UNIT
STANDING OPERATING PROCEDURE FOR BRONCHOSCOPY
DUTIES OF BRONCHOSCOPY TECHNICIAN/REG/TMO
o Patient should be NBM for at least 4-6 hrs.
o Check P.T. It should not be more than 3 sec from control.
o Check, document & share B.P, PULSE, SaO2, and any ECG abnormality. Patient
o Hemodynamically stable and SaO2 at least >90%.
o Check procedure items. (Technician & MO/TMO on duty)
o Explain procedure to the patient. (Duty of MO/TMO responsible for bed in case of admitted
patient and also TMO on duty in OPD cases).
o Take written informed consent from patient/relative.
o Ensure patient / working i/v access (Cannula).
o Re-confirm the indication for bronchoscopy and side of pathology.
o Recheck working oxygen cylinder, oxygen gauge and new/sterilized nasal cannula.
o Properly operating suctioning machine and sterilized bronchoscope confirmed before each
bronchoscopy.
o Re- confirms the availability & expiry date of all possible medications in the resuscitation
trolley.
o Must always checked sputum for AFB result (if available) before bronchoscopy.
o Identify the name, CXR, check relevant investigations and correlate clinically.
o Hand over the valuable of patient like watch, gold rings, bangles etc. to relative.
o Particularly, remove nose ring or clip in female patient.
o Perform procedure in accordance with guidelines.
o Operator must be SR or above to perform procedure independently.
o Specimen must be labeled legibly before handing it over to the patient.
o Document procedure notes.
o Re-check and document post procedure BP, Pulse & SaO2.
o In case of TBB obtain CXR (PA view) & exclude pneumothorax.
o Bronchoscopy call must be discussed with the consultant before giving date and then
animate the date to the bronchoscopy technician well in time to enable him to prepare list.
o If TMO is main operator, he must have authorization from SR/AP/Prof. All others must do
under supervision of consultant /year 3 trainee of Pulmonology.
o Perform procedure in accordance with the guidelines.
o Re – check proper working of chest tube, all connections and under water seal bottle.
o Check Chest X- ray post procedure.
o Document all the procedure notes and any specific order.
o Explain precautions regarding tube care to the patient &/attendant as well.
o Re – check & document post procedure BP, Pulse & SaO2.
o Presence of close relative/female staf should be ensured if procedure is undertaken on female
patient.
o OPD case should be admitted for proper care.
The following rules should be observed and followed. (Duty of Registrar, TMO/MO will look after
to continue implementation).
o Time of arrival and treatment should be written on the treatment charts (Reg /TMO/MO on
duty).
o Patient should get admission number within an hour of arrival (duty of staf nurse and ward
technician) but this should not delay the treatment.
o Medical officers should write medication within half and hour and arrival reports within one
hour of receiving the patient.
o House Officers should write detailed history of the patients within three hours of admission
and all the histories must be completed till 2.00 pm.
o Medical Officers and House Officers on Evening Duty should write Arrival Reports and Detailed
histories of all the patients admitted through Casualty.
o Any medication written on Treatment Charts should be in clear and eligible writing with name
of the advising doctor mentioned.
o Evening Rounds should be documented in the Register by the nurse, signed by the MO and
report should be written in the evening round register and separate report submitted the
Dr.Mukhtiar Zaman Afridi.
o All investigations advised must be sent to the lab on the register and sign should be taken from
the appropriate person from lab. (MEMO needs to go from management of ward to lab for
cooperation.)
o Beds allotted to each HO/TMO/Rotation TMO must be properly displayed on the beside (duty
of registrar) and all needs to be aware of the case and DPR.
o Registrar should ensure that DPR and ward is ready before starting morning round.
o All HO’s should bring their own stethoscope and BP apparatus.
o All patients’ diagnosis and their ICD 10 coding must be clearly written on their history sheets
as well as on their discharge cards.
o It is the duty of the Reg /MO/TMO to ensure patient is getting all medications as prescribed.
o No discharge card is given to the patient unless it is checked and duly signed by the chest ward
permanent TMO/MO & /Registrar.
o On OPD days chest ward TMO/MO who’s duty is in ward is supposed to see and manage
admitted patients and prepare them for post OPD round.
o Bed numbers and important orders of all serious patients should be clearly written on the
lounge notice board (duty by relevant MO/Registrar).
o Call from other wards should be noted and attended by Reg /Senior MO/TMO and if needed
consult the senior on duty. Call specifically written for the consultant should be noted and
timely informed to the consultant on call. Call register should be maintained by Reg /MO on
duty.
o Bronchoscopy call must be discussed with the consultant before giving date and then intimate
the date to the bronchoscopy technician well in time to enable him to prepare list.
o All MO/TMO should perform their duties in respective places in accordance with the duty Rota
displayed in the ward and doctor’s lounge.
o Monthly morbidity and mortality meetings will be held in last week of the month (SR duty)
and doctors should present all respective cases. List of cases will be developed during the
month.
o All TMO’s should keep their log book updated and get it signed within 1 week of the activity.
o All MO’s keep a record of the procedures performed and their outcome and report will be
presented in the monthly meeting along with record of short cases, long cases and CPC
presented or attended. Etc.
o Any new appointee should go through induction, orientation programme within 1 week of
arrival & all protocols & guidelines will be shared ( duty 0f SR & JR).
o To anticipate potential risk involved by taking a thorough history, physical examination &
laboratory investigations
o To ensure that the patient is prepared to decrease the risk of adverse outcome
o To provide appropriate information to the patient & to obtain consent for a planned anesthetic
technique.
o To prescribe pre medication and prophylactic measure if required.
o To provide satisfactory pre operative care
o Consultation with relevant professional & seniors where required.
ANESTHETIZING A PATIENT
o Setting I/V line & starting I/V fluids
o Setting monitors-SpO2, BP, ECG etc.
o Pre medication
o Induction & maintenance of anesthesia as planned
o Recovery of patient
o Shifting the patient from the recovery to ward or ICU according to the patient clinical status
o Consultation with seniors in difficult situation/complication
INVESTIGATIONS:
o MRI, CT-Scan to indoor patient on the sign of the consultant only.
o Routine investigations to Zakat patient (free)
1. Ailments i.e. diabetic, Asthmatics, HTN, osteoporosis, Thalecemic etc.
o OPD patient, from KTH surrounding area properly referred by district Zakat officer will be
entertained.
o Medicine received must be defaced before issue and sign/thumb impression taken in the LP
ledger for Zakat.
o Zakat indent must be signed & stamped by a consultant;
o Three days dose will be issued to indoor patients and 7-15 days dose to be issued to
o Outdoor patients as per short/long illness in the allowed allocation to ensure
o judicious utilization for efective therapy & quick disposal
o Brand of common drugs will be selected to avoid complications/ ensure judicious utilization of
funds for efective therapy and quick disposal.
a). 60% of total budget will be used for Bulk purpose of some common drugs to
facilitate the patients
b) 20% of total budget will be for investigations.
c) 30% of total budget will be for outdoor patients.
d) 50% of total budget will be for indoor patients.
Casualty KTH
Reception + Resuscitation
Resuscitation
Main O.T
Transfer to Surgical/
Orthopedic Wards etc
IBP Block
Reception
Resuscitation
Transfer to Surgical/
Orthopedic etc
DECISIONS
The Disaster management team which comprises the doctors to be present on the premises in
Casualty KTH and Trauma Unit adjacent to Orthopaedic ward will assess and proceed to treat the
patient. Patient requiring resuscitation will be resuscitated in Casualty and Trauma area. Patients
requiring any minor surgical procedure shall be shifted to the Minor O.T which has been upgraded
with facilities for anaesthesia and sterilization. Patients requiring major surgical procedure shall
be shifted to the Main O.T and the surgeons present at the site shall operate. ENT and Eye cases will
be taken care of by the respective. These patients after having been operated and treated will
be admitted back to the units on call. If the unit on call has become full with patients the other units
should be used for admitting the patients and the staf of that unit will be responsible for their care
and further management of complications.
PETCOT building will be developed as soon as possible to become the designated area for
Emergency reception and treatment. However till such time that PETCOT is not functional
the above protocol mentioned shall be in vogue. PETCOT is being developed for mass emergency
so as to exclude the main hospital as much as possible from the influx of attendants and public
coming with the injured patients.
An area for reception of emergency will be designated in Petcot, and a resuscitation area will
also be designated. The team of doctors and paramedics designated for being present at the site of
emergency shall then function in this area.
The theatre in Petcot will be fully developed with anaesthesia cover and all minor and major cases
which can be operated there will be taken care of in this operation theatre. The cases of serious
nature requiring major surgery will be operated in the Main O.T of KTH. These patients will then be
shifted to the wards on call and if their numbers increase will go to the other allied wards.
2. One TMO from the surgical wards and Medical Wards should be posted to the casualty on
daily basis from the unit on call.
3. The provision of all necessary items like Oxygen Cylinders, masks, suckers, I/C Canulas, I/V
Fluids emergency drug shall be present at the site of emergency resuscitation and these shall
be checked by the focal person i.e the Medical Superintendent.
4. Bulk Store in the basement with resuscitation material for fifty patients shall be present at all
times and will be checked by the focal person.
6. Resuscitation items for at least twenty patients shall be available in the Casualty of KTH and
the focal person shall check its availability.
SOPs KTH 2010
P&D Cell-M&E 66
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
Disaster is a sudden great incidence causing massive destruction and casualties like Bomb blast, Road
Side Accidents, Fire Arm Injuries, Riots and violence, Building Collapse and out break of epidemic
diseases.
Disasters have been classified as natural and man made. There is a complex relationship between the
two.
In order to cope with all sorts of emergencies efectively, all health care institutions must devise an
institutional disaster plan of action. Because in the crisis situation, the failure of the authority to warn
people adequately and of people to respond promptly can contribute to the increase loss of life and
damages. Therefore a plan of action should be worked out to efectively manage crisis situation. Every
health care institution must be prepared and ready to tackle the crisis situation developing as a result
of the disaster in its area. The hospital administration must anticipate the crisis. It can save death and
misery. The sudden increase in demand on the services of the health care must be met. Absence of a
plan will add to chaos and confusion, which come on when ever large numbers of people are afected.
That will paralyze the services to be provided by the institution- what would have been possible
ordinarily would be come almost impossible. All the concerned people, the hospital administration,
doctors, nurses and other paramedical staf, the victims, the relatives and the public become
frustrated. Lives may be lost unnecessarily because of lack of preparedness.
STEPS TO BE TAKEN
1. Nomination of a focal person
In all kind of crisis situation there is need for a unified authority. One focal person should be
identified, who will issue instructions. These instructions must be followed otherwise there will be
confusion and conflict.
It is also necessary to decide before hand who will be the next focal person in the absence of the
designated focal person. The focal person should be available at the control room always. His duty is
to coordinate and supervise the activities, ensuring that the plan is being carried out efficiently. He
should be available to give advice and instructions. The focal person motivates and encourages the
crisis team to give their best.
These groups should be capable of being assembled quickly, at any time of day or night, hence, in he
selection of people, priority should be given to those who are available easily and live close by in the
campus, in the neighbor hood , having telephone connections and own transport.
3. Medicines
All kind of life saving drugs should always be made available in the accident and emergency
department insufficient quantity to provide emergency care to a maximum of 500 patients.
4. Equipments
Certain equipments and materials should be earmarked for dealing with disasters. They must
be checked periodically. It must be ensured that they can be used without any delay.
5. Blood
About 500 bags of screened blood should be made available in the blood bank all the time. A
donor list of people willing to donate blood at short notice be ready, with their correct address and
telephone numbers. Formation of donors desk in the hour of need .
6. Instruments
To ensure the availability of sterile instruments for mass emergency use.
7. Ambulances
Ambulances must be well equipped with emergency drugs , equipments and trained medical
staf.
11. The focal person who is the Medical Superintendent should check the medicines and
relevant equipment on weekly basis to be ready for emergency situations.
OBJECTIVE
To ensure timely organized Trauma care in order to decrease mortality, morbidity & disability due to
injury.
-CMT will hold regular meetings to check the preparations of the hospital in order to cope with all
sorts of emergencies efectively.
1. Dr. Mohammad Zafar Chief Coordinator
Chief Executive KTH/KMC/KCD
Office: 091-9216362
Resident: 091-5861627
Cell No. 0300-5949517
2. Dr. Khizar Hayat Khan
Medical Superintendent Focal Person
Office: 9216832 Residence: 9211196
Cell No. 03339155129
3. Dr. Farman Ali Coordinator DMGs
DMS (P&D)
Office: 1208 Mobile: 0333-9166402
4. Dr. Mohammad Zafar Afridi
Dy: Medical Superintendent (Admn) Coordinator DMGs
Office: 2003 Mobile:03339120753
4. Dr. Ghulam Rasool Main Operation Theatre Coordinator
Office No. Cell No. 03219093747
6. Dr. S.Mujtaba
Resident Medical Officer Member
Office: 2004 Mobile 0300-5940821
7. Dr. S. Asad Maroof Member
Senior Registrar Casualty/Trauma
Office No. 2042
8. Dr. Akbar Shah
I/C A & E Deptt. Member
Contact # Office: 9216363
Mobile: 03465114449
9. Mr. Jalil Anwar Member
Chief Pharmacist
Contact #03339138784
10. Mrs. Naseem Himayat Member
Chief Nursing Supdt:
Office No. 2167
The Blood Bank of KTH has a capacity to store 500 bags of blood.
All the emergency drugs have been stocked in the Casualty Satellite pharmacy. These are sufficient to
provide health care to a maximum of 500 patients. (List of medicine is given below):
All these areas have been equipped with beds, linens, staf, emergency trays and medicines.
LOGISTICS
In case of power failure alternate mechanisms have been ensured working in collaboration
with WAPDA authorities.
Stand by diesel generators along with sufficient diesel for emergency ensured.
Provision for continuous supply of water.
Fire extinguishers to all vulnerable areas.
Emergency Nos have been provided to the telephone operators.
Hot line No. 9216348 communicated to Police and DCO Peshawar.
Measures taken to ensure that the hotline is not kept busy.
Six Ambulances have been equipped for Primary Care with sufficient Diesel and round the
clock provision of drivers.
At least ten trolleys and Ten Wheel Chairs are available for patient transport.
Blood Bank Officer and Social Welfare Officer are working in close liaison with Social welfare
society of KMC to ensure sufficient blood.
DEPARTMENT OF RADIOLOGY
INTRODUCTION
Radiology department is now changed into an imaging department and gives services round the clock.
Department has facilities of conventional X-ray, fluoroscopic examinations, ultrasound and Doppler
studies. The endowment fund has provided CT and MRI.
ULTRASOUND
Department runs in three shifts. Morning: 8am to 1pm. It is for all cold cases of the OPD, wards and
also for emergency cases. Ward cases are by appointment. Evening: 1pm to 8pm. Night: 8pm to 8am.
Evening and night shifts provide cover to casualty and ward emergency cases.
X-RAY
X-ray are done round the clock and the shifts are the same as for the ultrasound.
CT SCAN
CT scan is done up to 3pm and reported daily. After this the emergency services are provided round
the clock.
MRI
MRI is done daily up to 3pm and reported on the same day except few cases kept for teaching
purpose.
STAFF
There are diferent cadres of staf working in the department, the included are
KMC teaching staf.
Provincial Health Services Doctors.
REVENUE
Radiology department is also the earning hand of the institution. Most of the services provided are on
charge basis.
The revenue then generated is deposited with the Almoner of KTH. Revenue generated from CT and
MRI is deposited in the account of Endowment fund project and later distributed between Provincial
Endowment fund, KTH and staf of radiology department.
DUTY ROTA
Duty Rota is made by registrar in consultation with the head of department. The doctor on duty has to
be present in the department. House officers and TMO’s also perform the duties on rotation bases.
Duties are assigned in three shifts.
Registers are maintained in the department by senior technician and supervised by JR/SR along with
head of department.
CLEANLINESS
Department cleanliness and maintenance is checked daily.