Hospital Policy Manual

HOSPITAL POLICY MANUAL General Hospital,

GENERAL HOSPITAL, GANDHINAGAR TABLE OF CONTENTS

GENERAL HOSPITAL, GANDHINAGAR TABLE OF CONTENTS

Section No.

Section / Sub-section

1

Introduction

2

Scope of Services

3

Organisational Structure

4

Hospital Policies

Page No

Access Assessmen Assessmentt and Continuity of Care Patient Rights and Education Care of Patients Management of Medication Hospital Infection Control Continuous Quality Improvement Responsibility of Management Facility Management and Safety Human Resource Management Information Management System 5

Hospital Committees

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GENERAL HOSPITAL, GANDHINAGAR Issue date


POLICY MANUAL

Revision No. Section - 1

INTRODUCTION

Rev. date

Commissioned in 1969, the General Hospital Gandhinagar (GHG) was conceived as a dispensary in sector - 29, later a 16-bedded cottage was sanctioned as hospital in the present location in sector - 21, Gandhinagar. In the year 1972 the hospital was shifted to its present location at Sector – 12. From then on the hospital grew gradually over the last 35 years in the same location to the present status of 157-beds.

The hospital caters to the healthcare requirements of 14 lakh people in the city Gandhinagar and the four Taluks attached to it-Gandhinagar, Mansa, Dehgam and Kalol.

The main objective of the hospital is to provide holistic healthcare servicespreventive, promotive, curative and rehabilitative-under the allopathic system.

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SCOPE OF SERVICES

Rev. date

General Hospital, Gandhinagar is a Government District Hospital providing following services to all irrespective of caste, creed or economic status.

The Hospital shall provide following services: General

Related

Specialty

Services

Additional

General

Time

Remarks

OPD- Morning and Evening as per Schedule

Examination

General Medicine

Basic Cardiology

OPD- Daily Morning IPD- Daily

Diabetes Care

Obstetrics &

High-risk Pregnancy

Gynecology

Family Welfare services

General Surgery

Burns Cases

Pediatrics

Well baby clinic Neonatology

OPD- On designated days IPD- Daily OPD- On designated days IPD- Daily OPD- On designated days IPD- Daily

Immunization Services Orthopedics

Physiotherapy

OPD- On designated days IPD- Daily

ENT Surgery

Ophthalmology

Emergency Examination and admission round the clock all 365 days through Casualty Department ICCU facility available. Cases for interventional cardiology referred to higher centre. 2 D Echo facility available on fixed day.

Laparoscopy surgery facility Complicated neonatal and pediatric surgery cases referred to higher level Joint Replacement surgery facility

OPD- On designated days IPD- Daily Facility for Intra Ocular Lens Implant with Phaco

OPD- On designated days IPD- Daily

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SCOPE OF SERVICES Emulsification Sexually Transmitted

Dermatology

OPD- Daily Morning and Evening

Diseases Clinic Cryodermabrasion Basic Dental services

Dental services

available Anesthesia services

Pain Clinic on fixed day

Neurosurgery

Consultation only

Nephrology Pathology

Consultation only Hematology

Laboratory

Pathology Bio Chemistry

Radiology

Rev. date

X- Rays Sonography Examination CT Scan Colour Doppler 2 D Echo

Integrated

Prevention of parent to

Counseling and

child services also

Testing Centre (for

available

Indoor as and when necessary

OPD- Daily Morning and Evening As per OT Schedule OPD on fixed day OPD on fixed day Investigations as per schedule during OPD hours Investigations not available in OPD are referred to Civil Hospital Ahmedabad, Cancer Hospital Ahmedabad or Private Lab in Gandhinagar as per patient’s choice Routine investigations done during OPD hours Emergency Investigations done round the clock 365 days

HIV and STD testing facility available during routine OPD hours

HIV/AIDS)

Scheduled surgery only Critical investigations available round the clock 365 days

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

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SCOPE OF SERVICES

Rev. date

The above services are provided on both Indoor and Outdoor basis as per the timings fixed by the Hospital.

•

Emergency Services for basic specialties are available round the clock all 365 days to all patients irrespective of their place of residence, paying capacity etc.

•

Medico legal cases are accepted round the clock and post mortem examination performed as and when necessary.

•

•

Registration timings - 8:00 am to 12:00 noon and 4:30 p.m. to 5:30 pm (Summer – April to Oct) 8:30 am to 12.30 pm and 4:00 pm to 5:pm (winter Nov –Mar) OPD consultation o

o

o

•

Summer – (April to October): 8:30 am to 12:30 pm and 4:30 pm to 6:30 pm Winter – (November to March) 9:00 am to 01.00 pm and 4:00 pm to 6:00 pm Saturday – Only morning OPD

Cases requiring higher institutional setup are referred to higher institution after stabilization.

•

The hospital is also responsible for rendering community services as laid by the National Health Programs through outreach programs by Post Partum Unit and Sector Dispensaries such as Ante Natal Clinic, Post Partum Services, Immunization Services, School Health.

•

Yellow Fever Vaccination on designated day and time (Monday at 11 AM)

Auxiliary Services o o o o o o o o o

Dietary services (only for patients) Theatre Sterile and Supplies Department Hospital Laundry Stores (general, medical) Mortuary and Post mortem room Medical gases (Cylinders and piped medical gases) Security Ambulance services Medical record department

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Revision No. Section - 2 o o o

SCOPE OF SERVICES

Rev. date

Human Resource department (Administrative office) Hospital Management Information System Rogi Kalyan Samiti

Other Services Certificate (Medical fitness, Disability certificate, Health Certificates, Age certificate) o AFHS (Adolescence Friendly Health Services Centre) o Emergency Medical Response VVIP and VIP coverage o

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SCOPE OF SERVICES

Rev. date

General hospital, Gandhinagar, is a government district hospital and complies with Gujarat health act and governance policies as issued by state. Other than these following policies as required for internal functioning and in accordance with NABH norms are complied with

A. Policies for Access, Assessment and Continuity of Care (AAC) Policy No. A-1 – Scope of services Refer section 2 Policy No. A-2 - Policy for registration and Admission for outpatients, inpatients and emergency patients, including unidentified patients and situations when beds are not available All the patients are registered with a unique registration number (MRD no). Following timing is followed for registration, OPD consultation and emergency services Summer (April to October) Registration – OPD consultation - 8:30 am to 12:30 pm and 4:30 pm to 6:30 pm • Summer – (April to October)8:30 a.m to 11:30 a.m and 4:30 p.m. to 5:30 p.m •

•

Winter (November to March) Registration – 8:30 am to 12:30 pm and 3:30 p.m. to 5:30 p.m • OPD consultation 9:00 am to 01.00 pm and 4:00 pm to 6:00 pm Summer – (April to October): • •

Saturday – Only morning OPD Emergency services – 24 hrs a day and 365 days a year

Patients are admitted only if the treatment requirement is within the scope of services of the hospital (as detailed in section 2 of this document) and acceptance / advice

of concerned treating consultant In case of non-availability of beds one of the following shall be followed Patient shall be given a later date for admission if urgent admission is not required Patients shall be referred to another hospital (Follow policy No. A - 2 – Transfer and referral) Extra beds shall be arranged only if essentially required and on discretion of concerned doctor •

•

•

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SCOPE OF SERVICES

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Registration and admission of unidentified patients shall be recorded as per medico-legal guidelines in the medico-legal register. Staff involved in registration shall contact RMO if clarification is required. Following procedures to be followed for registration and admitting the patients o o

Document No. A-2.1 – Registration Document No. A-2.2 – Admission

Policy No. A-3 - Transfer & Referral of patients outside the facility Patients who do not match the scope of services of hospital shall be referred and/or transferred to Civil hospital, Ahmedabad or as per patient’s preference

Decision of transfer / referral shall be taken by concerned consultant / duty doctor and the same shall be intimated to patient and relatives with reasons. Patients coming in for Emergency shall be provided with first aid treatment and stabilised before transferring. Patient in life threating situation (as decided by doctor on duty) shall be transferred in ambulance with basic life support Patients who are stable shall be transferred through hospital’s ambulance or other mode as decided by doctor on duty Following procedure shall be followed for transfer of stable and unstable patients o

Document No. A-3.1 (Transfer of stable and unstable patients)

Policy No. A- 4 – Policy for patient / family education during the admission process All patients and / or family members shall be explained about the following by Doctor in charge and / or patient care team on advice of Doctor in charge. (i) Plan of treatment as decided by the doctor or the patient care team. (ii) Likely outcomes of the plan of treatment. (iii) Possible complications if any (This shall be communicated in written and patient/attendant signature shall be obtained).

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SCOPE OF SERVICES

Rev. date

(iv) Expected expenses on the treatment, if any (This shall be communicated in written and patient/attendant signature shall be obtained). Doctor in charge may withhold these information from disclosure on his discretion on the basis of situation, kind of disease, pschycological impact or similar other reasons.

Policy No. A – 5 – Initial assessment of patients including outpatients, inpatients and emergency patients All patients registered in the hospital shall undergo an initial clinical assessment by the concerned specialist / treating doctor based on standard norms of medical examination. The initial assessment shall be done by treating doctor / or a nurse on advice of treating doctor and shall be signed, named, timed and dated. Initial clinical assessment shall be completed at the earliest as warranted by the situation, and documentation as per given time frame as follows – o o

Emergency – within 1 hour of registration IPD – within 24 hrs of admission.

Following guideline shall be followed Document No. A – 5.1 (Clinical assessment and its documentation) •

Policy No. A – 6 – Policy for clinical re-assessment of patients Re-assessment shall be done by Medical Officers twice a day and by concerned consultant at least once a day. The frequency can be augmented based on the clinical condition. All clinical re-assessments shall be recorded and signed with name, date and time duly endorsed in the medical record by the assessor. The re-assessment shall faithfully reflect the patient’s clinical condition, response to treatment and inputs to plan further line of treatment or discharge. o

Document No. A-5.1 (Clinical assessment and reassessment)

Policy No. A – 7 - Laboratory Services Laboratory shall provide all services as required generally by the clinical services offered by the hospital. (As detailed in section 2 of this document).

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Laboratory shall employ qualified personnel carrying out lab tests as given below. Pathologist – MD Path Technician – B.Sc / DMLT with 2 years of experience Lab Asst. – B.Sc. Lab attendant – 10 th passed

Sample collection. Following timelines shall be followed for sample collection OPD - 9:00 a.m to 12:00 noon and 4:00 pm to 5:30 pm IPD - 9:00 a.m to 12:00 noon and 4:00 pm to 5:30 pm Emergency cases – Samples will be accepted by the lab at any time on request of the treating physician • • •

Sample identification All samples will be labeled with the name, age, sex and OPD/IPD number of the patient All samples will be accompanied by a written requisition for lab investigation The lab reception receiving the samples will enter the details in register Samples received from wards and departments will be sent to the lab with details on a register which will be in turn signed in acknowledgement at the lab reception •

•

•

•

Sample handling All samples will be handled as per the infection control guidelines Universal precautions are to be observed while handling samples •

•

Safe transportation of samples All samples requiring transportation will be sent as per documented safety guidelines Samples are not to be allowed to deteriorate Necessary precautions are to be taken depending on prevailing environmental factors •

• •

Processing of samples Processing of samples is to be carried out as per the requirements of individual tests Procedure for testing is to be standardized and necessary instructions issued to all concerned personnel •

•

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

Disposal of specimens Disposal is to be carried out in accordance with bio-medical waste handling rules. Precautions in accordance with the hospital infection control manual are to be observed •

•

Results of investigations The time frame for intimating results is as follows Test results of the sample collected in morning shall be available by 4:30 p.m on same day Test results of the sample collected in evening shall be available by 9:30 a.m on next day Result for tests which take longer duration shall be made available within a reasonable time frame and intimated to all concerned Results in emergency cases shall be intimated to the ward / treating physician at the earliest Results intimated verbally are to be recorded by the receiver and reconfirmed, noting the transmitters name Critical results identified from investigation results shall be intimated to the concerned personnel on priority •

•

•

•

•

•

Outsourcing of lab investigations Lab investigations required by the scope of services offered but not available at the laboratory are to be outsourced Laboratory shall outsource tests not available to a laboratory whose quality assurance system has been reviewed by the hospital and approved. Outsourcing of lab investigations shall be carried out as per the Document •

•

•

Following Documents shall be followed to comply with policies of Laboratory services. o o

Document No. A-7.1 (Work instructions for laboratory) Document No. A-7.2 (Outsourcing of lab test)

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SCOPE OF SERVICES

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Document No. A-7.3 (Reporting of critical and noncritical investigation results)

Policy No. A – 8 – Laboratory Quality Assurance Programme Laboratory shall follow Internal and external quality assurance programme as follows

•

Internal quality checks – By daily checks through controls samples, daily in morning before starting the lab work Surveillance – Pathologist / Supervisors shall carry out activities connected with surveillance of test results. External quality check – samples shall be send to Medical college Hospital once every month for external checks The verification and validation of test methods are to be addressed by the quality checks Periodic calibration and maintenance of all test equipments is to be carried out as per manufacturers guidelines (where available) Lab shall maintain a register documenting all corrective and preventive actions consequent to investigation of non-conformity. Records for all the above activities shall be maintained.

•

Document – Quality Assurance Manual (S. No. 10, table 2)

•

•

•

•

•

•

Policy No. A – 9 – Laboratory safety The lab shall follow safe practices to ensure safety of lab personnel from injury, infection and occupational hazards. Standard precautions shall be adhered to. Lab shall ensure that personal protective devices and other safety equipments are available and accessible. Any identified potential hazard for which preventive measures has to be taken shall be brought into the notice of Hospital safety committee, which shall analyse the risk and take necessary steps as precautionary measures

Policy No. A – 10 - Imaging Services Imaging services shall comply with AERB guidelines. Hospital shall provide all Imaging services as required by scope of clinical services. (As detailed in section 2 of this document).

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SCOPE OF SERVICES

Rev. date

Imaging services shall employ qualified personnel as given below. Technician - MRT certified with 1 year experience Asst. Technician - 6 mths ITI / appropriately trained • • •

Any other category of personnel after credentialing and privileging

All activities viz identification and safe transportation of patients to Imaging Services shall be undertaken as per documented procedure.

Imaging results shall be available within the defined time frame as given below

For OPD investigations Reports of investigations done in the morning OPD till 12.30pm shall be made available from 4.30 pm onwards till 6.30 pm. Reports of investigations done during evening OPD shall be made available on the following morning. For Inpatient investigations Wards shall preferably send patients for investigation before 11:00 am for morning tests. Reports for investigations done in morning shall be made available in evening of the same day Reports for investigations done in evening shall be made available in the morning of the following day For CT scan the results shall be made available within half an hour. For Contrast Abdomen a date shall be given for the same.

Critical and non-critical results shall be intimated as per the Document. Following procedures shall be followed to comply with the policies of imaging services. o o

o

o

Document No. A-10.1 (Identification of patient) Document No. A-10.2 (Transportation of patient (internal and external)) Document No. A-7.2 (Reporting of critical and non-critical investigation results) Document No. A-10.3 (Work instructions for radiology investigations)

Policy No. A-11 - Imaging services Quality Assurance Programme

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SCOPE OF SERVICES

Rev. date

Imaging department shall follow Internal and external quality assurance programme as follows •

•

• •

•

•

•

•

Internal quality checks – By surveillance, checks of the output of investigations, assessment of competence of personnel, assessment of calibration, maintenance and performance parameters of equipments. Quality of services shall address safety of staff and patients, timeliness of results, accuracy and validity of results. All investigation reports shall be perused and signed by the radiologist Surveillance –Radiologist / Supervisors shall carry out activities connected with surveillance of test results. External quality check – Random samples of imaging shall be sent to Medical College Hospital once every month for reporting to carry out comparison Periodic caliberation and maintenance of all test equipments is to be carried out as per manufacturers guidelines (where available) Imaging department shall maintain a register documenting all corrective and preventive actions consequent to investigation of non-conformity. Records for all the above activities shall be maintained. o

Document – Quality Assurance Manual ( S. No. 10, table 3)

Policy No. A – 12 – Imaging department safety programme The Imaging department shall follow a safety practice as per guidelines of Atomic Energy Regulatory Board. The safety practices shall address staff and patient safety, safe use of contrast material, radiation safety measures, handling and disposal of radioactive and hazardous materials if any, use of radiation safety equipment and devices, testing and documentation of radiation safety devices and training of personnel in radiation safety measures and imaging / radiation signages. Policy No. A – 13 - Continuity of and Multidisciplinary patient care A suitably qualified physician designated as the treating physician, shall be responsible for the care of the patient. Patient care shall be coordinated in all clinical settings within the hospital. Appropriate clinical information about the patient is to be available to medical, nursing and other care providers, as required.

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SCOPE OF SERVICES

Rev. date

All clinical information is to be documented in the patients’ medical record, exchange of information when required on account of staffing shifts, between shifts, and during transfers between units / departments is to be recorded The patients medical records are to be available to the authorised treating staff to facilitate exchange of information. Inter departmental / inter specialty referral shall be done as and when required as per Document. Following Document shall be complied with o

Document No. A-13.1 (Interdepartmental / inter specialty referral)

Policy No. A – 14 – Discharge of patients Discharge process shall be planned for all admitted patients. All departments / agencies involved in discharge process shall work in coordination. Discharge summary shall be prepared as per the Document. All patients shall receive a copy of the discharge summary on discharge. Patients who want to be discharged against medical advice (DAMA) shall be explained about the consequences of their action and a written statement should be obtained from the patient / attendant / guardian in case of minor or unconscious patients. All DAMA patients shall be given discharge summary as per procedure. If the patient leaves without intimation or informing the ward staff, it shall be recorded on patients medical record as patient absconded. Such patients shall be intimated to RMO and CDMO, and a report made to the local police. Following Documents shall be followed to comply with discharge policy o o

Document No. A-14.1 (Discharge of patient) Document No. A-14.2 (Content of discharge summary)

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SCOPE OF SERVICES

Rev. date

B. Policies for Patients Rights and Education (PRE) Policy No. B-1 - Patient and Family rights

Patient and family rights are as given in document These rights shall be respected and protected by the staff of the hospital. Following shall be done to comply with fulfillment of patient rights and education. o

o

o

o

Display of patients’ rights and citizen charter at convenient places in the hospital. Information of rights of patients shall be communicated to them and their families, if asked, in a format and language that they understand Staff shall be made aware of their responsibility towards protecting of patients and family rights. Violation of patient rights is recorded, reviewed and corrective / preventive measures taken by the designated official in accordance with Gujarat Health Act and record of the proceedings shall be maintained. • •

Document No. B-1.1 (Patient and family rights) Document No. B-1.2 (Citizen Charter)

Policy No. B - 2 - Consent

Consent shall be obtained from patients and family for informed decision making about their care. Consent is to be given by o By the patient, unless he or she is a minor. o If patient is incapable of informed decision making, consent shall be obtained from next of kin / parent / guardian, as per l aw of the land. In case of unidentified patient in unconscious condition, treating doctor o shall take a decision in life saving circumstances. In case the patient incapable of independent decision making is a o prisoner, the consent shall be taken from the Jail Superintendent.

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SCOPE OF SERVICES

Rev. date

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

• •

Document B-2.1 – (Obtaining consent) Document B-2.2 – (List of situations where informed consent shall be obtained)

Policy No. B – 3 – Patients right to information on expected cost The policy undertakes to inform patients / families as to the expected cost of treatment via the following measures. o o o o

o

Uniform pricing policy for outpatients and inpatients Availability of rates for various categories of patients, and services Issue of an estimate in writing at the time of admission Whenever there is a change in the patient condition or treatment setting, any change in the financial implications shall be communicated to the patient / family through the treating physician. Provision of emergency treatment or care through the emergency service department shall not be denied due to incapacity to pay.

C. Policies for Care of Patients (COP) Policy No. C - 1 - Provision of uniform care to patients

All patients shall receive uniform health care delivery across all settings that is to say that, the organisation shall ensure that patients with the same problems and care needs receive identical healthcare throughout the organization irrespective of the category of wards. Uniformity of care is to be guided by the applicable laws and regulations and are to be reflected in policies and procedures concerning care of patient accordingly. All patient assessment, care and treatment orders are signed, named, dated and timed by the concerned physician.

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SCOPE OF SERVICES

Rev. date

The plan of care is to be countersigned by the treating physician within 24 hours where applicable. All patient care shall as far as possible conform to evidence based medicine, and clinical practice guidelines. Evidence based medicine is defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Clinical practice guidelines are "quality-improving strategies" systematically developed incorporating validity, usefulness and applicability in medical practice. All healthcare workers shall be trained in Basic Life Support (CPR). Clinical management of the patients shall be on the basis of standard treatment guidelines ‘A manual for Medical Therapeutics’ published by WHO.

Policy No. C - 2 - Emergency Services

All patients attending the emergency services department shall be screened by the physician on duty. Documented triage procedure shall be followed in all cases. The emergency department shall be in readiness for handling disasters and other emergencies as per disaster and emergency management plan of the hospital Medico-legal cases shall be handled as per policy and procedure documented separately. All staff of the emergency department are to be conversant with the policies and procedures concerned with the care of emergency patients Patient attending Emergency services will be handled as per documented procedure. Following Documents shall be followed in the Emergency service department. o o o

Document No. C - 2.1 (Attending patients at Emergency) Document No. C – 2.2 ( Handling of road traffic accidents) Document No. C – 2.3 ( Handling of cases of poisoning)

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Document No. C – 2.4 (Handling of burns cases) Document No. C- 2.5 (Triaging of patients) Document – Disaster Manual

Policy No. C – 3 – Medico Legal Cases Doctor on duty shall decide whether a case is a medico legal one. All MLC shall be notified to the police as per Document. All MLC shall be recorded and marked as MLC. MLC records shall be stored separately under secure custody. Following Document shall be followed to handle MLC. o

Document No. C – 3.1 (Medico Legal Cases)

Policy No. C – 4 – Triage Triage is the process of sorting patients based on their need for immediate medical treatment as compared to their chance of benefiting from such care. Triage is done in the emergency service department, when faced with mass casualties and limited medical resources, which must be allocated to maximize the number of survivors. Triage is defined as "The evaluation and classification of casualties for purposes of treatment and evacuation. It consists of the immediate sorting of patients according to type and seriousness of injury, and likelihood of survival, and the establishment of priority for treatment and evacuation to assure medical care of the greatest benefit to the largest number." Triaging shall classify the sick and injured according to the urgency and type of condition in an order that each casualty receives treatment according to his or her immediate need. Triage shall be carried out as per documented procedure. o

Document No. C – 2.5 (Triaging of patients)

Policy No. C – 5 – Ambulance services

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SCOPE OF SERVICES

Rev. date

The ambulance services available with the hospital are to be commensurate with the scope of services offered at all times. The ambulances shall comprise general ambulance and ambulance with basic life support facility and shall be deployed according to the patient’s condition. The access, entrance and exits to and from the emergency service department shall be kept unobstructed to facilitate easy and smooth movement of ambulance vehicles. Ambulance vehicles which are not engaged in patient related duties are to be kept in the designated parking areas under the control of casualty medical officer, who will authorize necessary movement. The ambulance bay of the emergency department shall be kept unobstructed at all times to facilitate easy movement of ambulance while handling emergencies. The ambulance is to be equipped appropriately and the equipment is to be checked for serviceability and readiness with each shift and record maintained to that effect. The check shall include that of emergency medications also. The personnel manning the ambulance shall comprise a team of medical, nursing, technical / paramedical, driver, and ward boy. The team members shall be deployed as per the circumstances faced in transporting patient, on the instructions of the casualty medical officer. All the ambulance team members shall be deployed in shifts and the duty roster shall be intimated in advance. All the ambulance team members shall be trained in advanced life support and / or basic life support and handling of emergencies as per their responsibilities. They shall receive periodic refresher and competency training. All ambulance vehicles shall carry a cell phone / suitable wireless communication device for communication with the base casualty station. The communication device is to be checked for serviceability with each shift. o

Document No. A – 10.1 (Transport of patient (Internal and External))

Policy No. C – 6 - Cardio Pulmonary Resuscitation (CPR)

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SCOPE OF SERVICES

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Cardiopulmonary resuscitation activities shall be uniformly used as and when required as per documented procedure. A Code Blue Team shall be constituted and trained in BCLS and ACLS. Mock drill of a CPR event shall be held regularly for training. All CPR events shall be recorded in Medical Records and the clinical risk management committee shall do a post event analysis of the same. Corrective and preventive measures shall be taken and communicated to all concerned based on post event analysis. Telephone operator should ensure that they know the code blue team at any given point of time. All medical emergencies shall be immediately communicated to telephone operator. Telephone operator on receiving the emergency call shall call the code blue people through public address system clearly indicating the area where emergency occurred. Code blue team shall reach the location and initiate CPR as per the procedure All patient care areas to be equipped with a crash cart. Contents of crash cart), shall be checked daily by the nurse-in-charge. After any usage for CPR/ ACLS efforts, nurse on duty shall take action to replace the used consumables and all equipment duly decontaminated and resealed. Post event analysis of all CPR cases shall be carried out by the Medical audit Committee, who shall indicate corrective and preventive actions to be instituted if any. Following Document shall be followed in case of medical emergency situation. o o

Document No. C – 6.1 (Code blue response) Document No. C – 6.2 (Management of Medical emergency / Cardiopulmonary arrest).

Policy No. C – 7 - Rational use of Blood & Blood Components Blood and blood products shall be used rationally and only on advice of the treating physician. Informed consent shall be obtained whenever use of blood or blood products is contemplated. Drugs and Cosmetic Act as applicable to blood bank shall be followed (Refer Reference manual) National Aids Control Programme of India, Guidelines For The Appropriate Use of Blood, shall be followed. (Refer – Reference manual) Blood must be available as per given time frame

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Rev. date

Emergency use in less than 1 hour Planned use within 24 hours.

(i) (ii)

Informed consent shall be taken from donor of blood or blood components, as per documented procedure, and shall include patient and family education about donation. All transfusion reactions (minor and major) shall be reported to the blood bank in writing and record made in the patients medical record also. The Medical Audit Committee shall review and analyze blood transaction reactions for preventive and corrective actions and recorded accordingly for implementation. Following Document shall be followed for donation and transfusion of Blood. o

Document No. B – 2.1 (Obtaining Consent)

Policy No. C – 8 – Provision of Intensive Care and High Dependency unit

facility. Intensive care admission and / or discharge shall be decided by treating doctor and as per admission and discharge criteria document. Intensive care areas shall try to keep 10% of its beds vacant at any given time for emergency cases. This shall be done by discharging stable cases as early as possible. In case of non availability of beds in ICU patient shall be transferred to hospitals as mentioned in Policy no. A-2. Intensive care areas shall follow infection control practices as per procedure o

Document No. C-7.1 (Admission and Discharge criteria for ICU) o

Document No. C-7.2 (Infection control practices in OT)

Policy No. C – 8 – Care of vulnerable patients Children, elderly patients, mentally and physically challenged people are considered as vulnerable group and care of the same shall be taken as per Disability and Mental Act. The vulnerable patients shall be kept in safe and secured environment.

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SCOPE OF SERVICES

Rev. date

Staff shall be trained to care for vulnerable group. The orphans brought by either police or NGOs shall be identified or attempts shall be made to record the person, who can be communicated in case of recovery, discharge or death. When nobody is identified the police shall be intimated for the same. Following Document shall be followed for care of this group. o

Document No. C – 8.1 (Care of vulnerable patients).

Policy No. C – 9 – Obstetric Patients High risk obstetric care shall be provided to required cases. This care shall be provided by Gynecologist and Trained Medical Officers and nurses. Gynecologist shall train medical officers and staff nurses in care of high risk obstetric cases. Maternal nutrition shall be assessed while assessing these cases

Policy No. C – 10 – Paediatric Patients Care of neonatal patients shall be in accordance to IAP guidelines Paediatric and Neonatal patient’s assessments shall include detailed nutritional growth, psychosocial and immunization assessment.

Children’s family members shall be educated by concerned doctor about nutrition need, immunization and safe parenting and this shall also be documented in medical record of the patient. Children without parents brought either by police or NGOs shall be sent to the children home which are Govt. approved and necessary orders shall be obtained either from the court of law or police officer to avoid dispute in future if any. Policy No. C – 11 – Sedation A doctor or a nurse on advice of doctor shall administer sedation. The person administering and monitoring sedation shall be different from person performing the procedure. Intraprocedure monitoring of the patient under sedation shall be done. This shall include monitoring of following

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Rev. date

Heart rate Cardiac rhythm Respiratory rate Blood pressure Oxygen saturation Level of sedation Any other parameter as required

Post sedation, patient’s vitals shall be monitored at regular intervals (as decided by person administering sedation) till the patient recovers completely Documented criteria shall be followed to decide appropriateness of discharge from recovery area Document No. C – 11.1 (Protocols for Operation Theatre and Intensive Care Settings) Document No.C – 11.2 (Criteria for discharge from recovery area) •

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Policy No. C – 12 - Administration of Anaesthesia Indication and type of anaesthesia (other than local anaesthesia) shall be recorded in medical file. Pre-anaesthesia assessment shall be done for all patient requiring anaesthesia (routine and emergency) shall be done before wheeling in the patient Operation Theatre. The pre-anesthesia assessment shall result into an anaesthesia plan, which shall be recorded in medical file Consent shall be taken from patient before anaesthesia (general or local) administration as per Document no. B -2.1. Intra procedure monitoring of the patient under anaesthesia shall be done and recorded. This shall include monitoring of following Heart rate Cardiac rhythm Respiratory rate Blood pressure Oxygen saturation Potency and level of anaesthesia Airway security Any other parameter as required • • • • • • • •

Approved by: - 25 -


POLICY MANUAL


SCOPE OF SERVICES

Rev. date

Post sedation, patient’s vitals shall be monitored at regular intervals (as decided by person administering sedation) till the patient recovers completely

Approved by: - 26 -

Hospital Policy Manual

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